Migraine is a form of headache, usually very intense and disabling. It is a neurologic disease of vascular origin. The word "migraine" comes from the Greek construction hemikranion.

Symptoms

Migraine is characterized by attacks of sharp pain typically involving one side of the head and often accompanied by nausea, vomiting, photophobia and phonophobia. The symptoms and their timing vary considerably among migraine sufferers, and to a lesser extent from one migraine attack to the next. Migraine has been thought to be caused by vasodilation in the head and neck, however newer research suggests the cause may be overactivity of nerve cells in certain areas of the brain, leading to vasodilation only as a side effect.

Classical migraine or migraine with aura is preceded by a group of symptoms called aura, most commonly experienced as a visual disturbance. Common migraine or migraine without aura, in contrast, lacks any indicator of the impending headache. Some experience aura without migraine, a condition called amigrainous migraine. Although sometimes comparable in severity, the symptoms of migraine differ from those of cluster headache.

The aura preceding a migraine attack usually manifests itself as a multicolored zig-zag pattern which grows from a small dot until it covers a large part of the field of vision of one eye. The aura disappears within 15 to 45 minutes, and the headache begins between 15 and 30 minutes afterward. Some sufferers experience tingling sensations called paresthesias or disturbances of other regions of the brain instead of a visual aura, either as an occasional alternate or their normal aura.

Migraine can accompany, in many cases, another type of headache called tension headache. Since the treatment differs from that of migraine, it is important to recognize when tension headache is occurring. In some cases, migraine can cause seizures. Stroke symptoms are seen in very severe subtypes.

Migraine often runs in families and starts in adolescence, although some research indicates that it can start in early childhood or even in utero. Migraine occurs more frequently in women than men, and is most common between ages 15-45, with the frequency of attacks declining with age in most cases.

Because their symptoms vary, an intense headache may be misdiagnosed as a migraine by a layperson. Where possible, see a doctor to determine if the headaches are a symptom of something else.

Treatment

Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs.

Elimination of triggers

In a minority of patients the incidence of migraine can be reduced through dietary changes to avoid certain chemicals present in such foods as cheddar cheese, chocolate and most alcoholic beverages. Some triggers may be situational and can be avoided through lifestyle changes. However, other triggers such as particular points in the  menstrual cycle or certain weather patterns are impossible or impractical to avoid.

Avoid bright flashing lights if you notice these trigger attacks; most migraineurs are sensitive and avoid bright or flickering lights. Relaxation after stress, notably weekends and holidays, is a potent trigger; wind down gradually if possible.

Symptomatic control to abort attacks

For patients who have been diagnosed with recurring migraines, doctors recommend taking painkillers to treat the attack as soon as possible. Many patients avoid taking their medications when an attack is beginning, hoping that "it will go away". However in many cases once an attack is underway, it can become intensely painful, last for a long time, and become somewhat resistant to medical treatment. In contrast, treating the attack at the onset can often abort it before it becomes serious, and can reduce the frequency of subsequent attacks in the near-term.

The first line of treatment is over-the-counter medications. Doctors start patients off with simple analgesics, such as paracetamol (acetaminophen), aspirin and caffeine. They may provide some relief, although they are not effective for most sufferers.

Narcotic pain killers (for example, codeine, morphine or other opiates) provide variable relief, but their side effects and high risk of addiction contraindicates their general use.

If over-the-counter medications do not work, the next step for many doctors is to prescribe fioricet or fiorinal, which is a combination of butalbital (a barbituate), acetaminophen (in fioricet) or acetylsalicylic acid (in fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches.

Anti-emetics by suppository or injection may be needed in cases where vomiting dominates the symptoms. The earlier these drugs are taken in the attack, the better their effect.

Sumatriptan and related serotonin agonists are now the therapy of choice for severe migraine attacks that cannot be controlled by other means. They are highly effective, reducing the symptoms or aborting the attack within 30 to 90 minutes in 70-80% of patients. Some patients have a rebound migraine later in the day, and only one such rebound in a day can be treated with a second dose of a triptan. They have few side effects if used in correct dosage and frequency. Some members of this family of drugs are:

• sumatriptan
• zolmitriptan
• naratriptan
• rizatriptan 
• eletriptan 
• frovatriptan 
• almotriptan 

Evidence is accumulating that these drugs are effective because they constrict certain blood vessels in the brain by acting on serotonin receptors in nerve endings. This leads to a decrease in the release of a peptide known as CGRP. In a migraine attack, this peptide is released and may produce pain by dilating cerebral blood vessels.

These drugs are available only by prescription (US and UK). Many migraine sufferers do not use them only because they have not sought treatment from a physician.

Preventive drugs

Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. It is used only if attacks occur more often than every two weeks. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next.

 Beta blockers such as propranolol and atenolol are usually tried first. Antidepressants such as amitriptyline may be effective. Antispasmodic drugs are used less frequently. Sansert was effective in many cases, but has been withdrawn from the U.S. market.

Migraine sufferers usually develop their own coping mechanisms for intractable pain. A cold or hot shower directed at the head, less often a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients, but both should be used when needed.

Alternative approaches

Some migraine sufferers find relief through acupuncture which is usually used to help prevent headaches from developing. Sometimes acupuncture is used to relieve the pain of an active migraine headache.

Biofeedback has been used successfully by some to control migraine symptoms through training and practice.

Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines.

The plant feverfew is a traditional herbal remedy believed to reduce the frequency of migraine attacks. Clinical trials have been carried out, and appear to confirm that the effect is genuine (though it does not completely prevent attacks).

Kudzu root (Pueraria lobata) has been demonstrated to help with menstrual migraine headaches and cluster headaches. While the studies on menstrual migraine assumed that kudzu acted by imitating estrogen, it has since been shown that kudzu has significant effects on the serotonin receptors. Kudzu Monograph at Med-Owl.

 Diet,  visualization, and self-hypnosis are also important alternative treatment and prevention approaches.