Gennie Hamilton BIO 235 April 14, 2012 Term Paper Reoccurring Migraines

Reoccurring migraine headaches are a commonly misunderstood ailment that affects an estimated 2% of adults in Western countries, one with a limited medical history and one that can only be clinically diagnosed. The condition known as a migraine can be found in a category of headaches known as primary headaches, along with tension headaches and cluster headaches. Though the research is limited, there is a consensus that both genes and the environment of the patient play a part in the presence (or lack thereof) of their migraines. According to the MayoClinic, some of the major triggers of migraines include estrogen fluctuation (in women), which are most common right before menstruation, during pregnancy or during menopause. Certain foods such as alcohol most often beer or red wine chocolate, aspartame (a chemical found in Diet Coke), large quantities of caffeine, MSG and a lack of food can also trigger migraines. Other factors can include (but are not limited to), stress, drastic changes in ones sleep cycle, extreme physical exertion, extreme changes in weather, bright lights, loud noises, strong smells and certain medications (Migraines, MayoClinic). Certain attributes of a patients family history can also lead to a diagnosis of a migraine given that around 90% of those who suffer from migraines have a family history of migraines. Gender is another factor in migraines, as women have more migraines than men (largely because of the aforementioned hormone fluctuation). The effects of migraines are widespread and can range from pain due to the pain killers taken to control migraine pain such as Advil to a condition referred to as serotonin syndrome which occurs when a patient with migraines is being treated with a triptan, such as the popular Imitrex, while taking an SSRI (selective serotonin reuptake inhibitors) or SNRI (serotonin-norepinephrine reuptake inhibitors) like the SSRIs Zoloft or Prozac, or the SNRI Cymbalta. However, because this potentially fatal condition occurs through fault of the doctor, serotonin syndrome is rare. To understand migraines and its subcategories, one must understand the symptoms of migraines precursors, warnings and signs of the onset of a migraine. Comprehending exactly what is occurring in the

brain during a migraine is also important; this involves knowing what chemicals and electrical currents are making their way through the brain that make the pain receptors in the brain respond the way they do, as well as factors that determine how frequently and how severely one experiences migraines. Finally, the medical part of migraines must be understood, including the diagnosis of migraines and the treatments of migraines throughout history, as well as future research that is being proposed for migraines and migraine treatment. However, before one can understand any of these things, the classification and categorization of migraines and the subcategories of migraines must be known. The category under which migraines are found (primary headaches), branches off to episodic headaches (those occurring sporadically or infrequently) and chronic daily headaches, which are primary headaches occurring for a minimum of fifteen days per month, for four or more hours per day, for at least three consecutive months. (The differential diagnosis of chronic daily headaches). To be classified as a chronic migraine the occurrence of migraines must fit these guidelines and then display the clinical features of a migraine without an aura for at least eight of the fifteen days. Separate from chronic migraines is the diagnosis of transformed migraines, which requires a minimum of twenty days with headaches per month for at least one year, with no more than five consecutive days free of symptoms, same clinical features of migraine without an aura for at least ten of those twenty days (Chronic migraine classification). The previously mentioned clinical features of migraine headaches encompass a variety of symptoms, all of which vary in severity (if they are even present) from patient to patient. These symptoms tend to follow a timeline in occurrence, beginning with prodrome symptoms, which occur one or two days prior to a migraine. Next are the subtle and not always present, postdrome symptoms include changes in waste elimination (constipation and diarrhea), depression, food-specific cravings (which may be attributed to the drastic hormone changes that are so commonly a cause of migraines in women), hyperactivity, irritability and neck stiffness (Migraines, MayoClinic). Next on the symptom timeline is one of the most well known symptoms, the aura. While many people can experience migraines without the warning provided by an aura, this is one of the best indicators that a migraine will soon follow, as it is specific to migraines alone. Auras are classified sensory abnormalities that crescendo for an average of twenty minutes. These abnormalities are often ocular eye pain, blurred vision, tunnel vision, blind spots and seeing shapes, spots or flashes but can also present through nausea, the pins and needles sensation

in extremities and in rare cases, aphasia, the complete loss of ability to speak or understand speech (Migraine, National Library of Medicine). Once the prodrome migraine symptoms have occurred, the migraine attack can happen anywhere from 20 minutes to twenty-four hours later and can last anywhere from six to forty-eight hours. The bestknown migraine symptoms are extreme sensitivity to light and sound (bright lights and loud noises will result in excruciating pain and irritability for the sufferer) and pain in one side of the head with a throbbing quality. The lesser-known symptoms are comprised of extreme body temperature (chills or sweating), blurred vision, numbness, lightheadedness and occasionally fainting and nausea and vomiting, which may be due to the patients inability to handle the high levels of pain (Migraines, National Library of Medicine). Once the migraine attack itself has passed, the patient will usually still endure another stage of symptoms, known as postdrome symptoms. This stage of a migraine can often include feeling mentally dull, exhaustion and neck pain (Migraine, National Library of Medicine). In some cases, however, patients reported a mild euphoria, likely due to the relief of pain (Migraines, MayoClinic). The activity occurring in the brain during the postdrome symptoms and the migraine attack itself are still incompletely understood, in part because in depth research on migraines is a recent development, as well as the relatively small percentage of the population that not only experiences regular migraines, but seeks treatment for them. The area of the brain in which the migraine occurs is currently thought to be the trigeminovascular system (TVS), a part of the brain that is largely associated with pain, and has only begun to be studied in the last two decades (The pathophysiology of migraine). From this understanding comes multiple theories on what is occurring in the brain during a migraine attack. The original theory, the vasoconstriction-vasodilation theory, hypothesizes that during the migraine aura the vessels in the brain are tightened (thus vasoconstriction), and that the following pain known as a migraine is a result of the sudden dilation and rush of blood back into these vessels (Headache: lessons learned from functional imaging). A newer theory places focus on the brainstem, the cortex of the brain and electrochemical signals. A study done on migraine sufferers showed a suppressing of neuron activation and a drastic increase in oxygenation in the occipital cortex that resulted in the migraine aura. Then during the actual migraine attack neurologists saw that the velocity in the middle cerebral artery (one of the three major arteries responsible

for supplying blood to the cerebrum) on the side that the patients headache was occurring was significantly lower than the side of the brain that the migraine was not felt (Advances in the understanding of headache). Both are theories as to what goes on in the brain during a migraine, done through MRIs and PET scans and neither has been completely validated yet. Despite the contradicting theories on migraine causes, the medical equipment used to develop these theories (in tandem with the patients description of their headaches) play a major role in the diagnosis of migraines. Brain MRIs, CTs, sinus X-rays, sinus CTs, cervical spine X-rays and EEGs are among some of the most common diagnostic techniques used by medical professionals in the diagnosis of migraines (The role of instrumental examinations in delayed migraine diagnosis). However, before using these techniques, neurologists must exclude the possibility that the ailment is a secondary headache disorder (brain tumor headache, cervicogenic headache or infection-related headache) as well as determine which specific subset of primary headaches the patient is experiencing. Next, because chronic migraines often develop as a complication of episodic migraines after a period of increasing headache frequency, the doctor must determine what risk factor caused the initial episodic migraines (if a cause exists), such as the risks that can be fixed obesity, snoring, cranial injury, high levels of stress or abuse of opiates or drugs that suppress the central nervous system (barbiturates). The doctor in question must also take note of any anxiety, cardiovascular risk, stroke risk, chronic pain or depression and while chronic migraines and these conditions do not have a cause-effect relationship established, there is a clear correlation (Chronic migraine, classification, differential diagnosis and epidemiology). Then, to diagnose the migraine itself the patient will often undergo examination of vital signs, a cranial exam to look for any previous trauma, a neck and shoulder exam to look for trigger points, range of motion and the result of stressing the muscles and discs in the neck. The patient will also undergo a neurological examination in which the neurologist will observe the reflexes, motor system, coordination, gait, sensory system and mental status of the patient. Finally, if the neurologist has not diagnosed the patient with chronic migraines based simply upon the patients description of their headaches and the physical and neurological examinations, the patient may have an MRI or CT done to view what is occurring within the brain. CTs are used to look for brain abnormalities, however the more popular MRI will show hemorrhages, trauma, bone abnormalities, and

vascular, neoplastic, cervicomedullary and infectious disorders that would go unnoticed with a head CT alone (Jefferson Headache Manual). Once the patient has been diagnosed with migraines, there are an infinite number of methods that can be used to treat the migraines. A method that has become very popular recently is the treatment of chronic migraines with tricyclic antidepressants, which are used to treat clinical depression but have been discovered to prevent migraines. A few are Amitriptyline, Clomipramine and Doxepin (Prophylactic treatment of migraine). These medications work as preventatives by inhibiting excitement in the cortex, acting on the theory that migraines occur after an increase in oxygen in the occipital cortex (Antidepressants for Migraine Prophylaxis). A few more pharmaceutical treatment options include betablockers a treatment where it is not yet understood how it can help chronic migraines , calcium channel blockers, which induce vasodilation and would prevent the initial vasoconstriction that leads to a migraine. Estrogen has also been used to treat migraines in patients where it has been determined that hormones are the antagonizing factor leading to migraines (Prophylactic treatment of migraine). A more radical method is occipital nerve stimulation which generally involves a small device being placed at the base of the skull (near the occipital nerve), which is then connected to a source of power and transfers electrical impulses to the occipital nerve, and works based on the theory that the cause of migraines occurs in the occipital cortex. This treatment, however, is highly experimental and has only been performed a select number of times (MayoClinic: Occipital Nerve Stimulation). There have also been treatments found that provide an alternative to pharmaceutical treatment, which include mind-body therapies (yoga, meditation and deep breathing exercises) and acupuncture. The use of mind-body therapy to treat migraines likely aided in treatment by lowering stress (a major factor for migraines) and was utilized most commonly by patients who also experienced anxiety and joint or low back pain (Complementary and alternative medicine use among adults with migraines/severe headaches). Future research is needed to fully understand how mindbody therapy works to relieve or prevent migraines. Patients who participated in a study where acupuncture was used to relieve migraines reported at least a 50% reduction in the number of migraine days and a decrease in the intensity of pain (Efficacy of acupuncture for migraine prophylaxis). This method of treatment has been used in Asia for centuries, but is also not fully understood and will require further research.

To understand migraines to the extent that so many other diseases are, the most important requirement will be time. Most diseases have been the subjects of studies for up to a century, whereas migraines have only been under a microscope for a decade or so. There will also have to be an increase in the quantity of studies and research done to make definitive conclusions in the medical community. The migraine what was once thought of as just a headache has become the focus of many studies in the past few years, yet is still not entirely understood. The categorization of migraines has resulted in more efficient diagnoses and in turn, a wider range and more radical treatments for patients who suffer from migraines. The advances medical technology has made in the last few decades has also had a major impact on the ability of neurologists to understand what happens within the brain during postdrome symptoms and migraine attacks. With time will come more studies and experiments done around migraines, and inevitably, a greater understanding.