Migraine Headache

by Kerry Hite

Description

Migraine headaches are a type of headache associated with debilitating pain and sensitivity. The general symptoms are pulsating/throbbing head pain, usually unilateral, sensitivity to light and sound, vomiting and paresthesia¹.Patients with Migraine headaches can experience many combinations of the symptoms listed above, some times in response to known environmental or systemic triggers².Typically patients experience a prodrome before the headache, which are feelings of hyperactivity and inability to concentrate that allow the patient to predict that they will soon experience a migraine.

Migraines may or may not be associated with an aura, which is a visual disturbance resulting in unfocused vision or spots in the visual field¹.The onset of Migraines usually occurs in childhood, at puberty or in adulthood before the age of 40. The exact etiology and pathogenesis is unknown, however the medical field believes there to be several contributing factors¹. These factors and a brief description are listed below.

Factors

Genetic inheritance¹

Cerebrovascular changes:
- Vasoconstriction followed by vasodilation
- Vasoconstriction causes hypoxia
- Vasodilation stimulates nociceptors in cerebrum¹

Increased platelet aggregation:
- Mediated by neurotransmitters
- Associated with anxiety/stress¹

Excitation of Trigeminal pain pathway¹

Serotonin level alteration
- Leads to neuronal excitation
- Possibly caused by stress²

Metabolite and Chemical changes in the brain:
- Affecting cerebral blood flow¹

Cortical Spreading Depression
- Potassium, Calcium level disruption
- Associated with increased local vascular response
- Increased Nitric Oxide¹

Nociceptor input from muscles

Diet high in tyramine-o-sulfatase
- Associatied with vasoconstriction²

Migraine Classification:

There are several types of Migraines most present with similar headache symptoms as previously described, below are further descriptions to identify the different types.

Migraine with Aura (previously called classic migraine):
- Described in detail below
- Type of aura can change from episode to episode³

Migraine without Aura (previously called common migraine):
- Described in detail below³

Hemiplegic Migraine:
- Presents like transient ischaemic attack or mild stroke, but without residual damage
- Numbness, weakness, dysphasia, contra or ipsilateral to symptoms
- Age of onset: 10-15 yrs¹

Basilar Migraine:
- Similar sxs as Hemiplegic but is associated with Ataxia or Double vision
- Bilateral sxs¹

Ophthalmoplegic Migraine:
- Paralysis of 3rd, 4th or 6th Cranial nerve resulting in double vision
- Pain around the eye
- Headache usually precedes eye dysfunction
- Eye dysfunction can become permanent¹

Vertiginous Migraine:
- Dizziness, vomiting, nausea, motion hypersensitivity¹

Status Migrainous:
- Lasts longer than 72 hours
- Associated with severe vomiting and dehydration
- May require hospitalization¹

Comparison of Migraine with and without Aura

According to the International Classification of Headache disorders

Migraine without Aura	Migraine with Aura
At least 5 attacks w/ following criteria:	At least 2 attacks w/following criteria:
- Lasts 4-72hrs	Aura Consisting of 1 of the following w/out motor dysfunction
- 2/3 Symptoms	- Fully reversible visual disturbance
Unilateral Pain	- Fully reversible abnormal sensation
- Pulsating/Throbbing sensation	- Fully reversible dysphasic speech
Moderate to severe pain	At least 2 of the following:
Aggravated by Physical Activity	- Homonymous visual sxs &/or unilateral sensory deficits
Experiences 1 of the following	At least 1 aura symptom develops over time > 5 min.
- Vomiting/Nausea	Each symptom lasts from 5-60 minutes
- Light/Sound Sensitivity	Headache meeting criteria for migraine without aura occurring within 1 hour of aura experience
Headache is not secondary to other disorders

Common Triggers:

Under certain environmental and systemic conditions patients are more likely to experience a migraine. The specific conditions are different for every individual and can vary from episode to episode. Some examples are listed below.

Hormonal Changes specifically a drop in Estrogen level³^,⁴
Changes in Sleep pattern, too much or too little sleep^3,4
Relaxation after Stress^3,4
Alcohol^3,4
Weather changes^3,4
Odors^3,4
Changes in sensation, bright lights or loud noises^3,4
Irregular meals^3,4

Diagnosis:

Diagnoses of migraines are usually made by physicians based on the subjective history of the patient and description their headaches.^1,2,3,4,⁵

Certain tests like electroencephalogram can show increased activity during a headache, but they have not been shown to be necessary or cost effective to use to diagnose migraines.⁵

Transcranial Doppler tests are most commonly used to rule out other disorders that could cause headaches secondarily. They have not been shown definitive for recognizing vascular velocity changes that directly cause migraines.⁶

-Other tests that could be used to rule out other causes of headache are MRI, CT & Lumbar punctures.²

Red Flags:

If a patient presents with any of the following conditions, it is recommended that the physician should be notified and further investigation may be necessary. These red flags are listed below⁵:

Headache that wakes the individual up or is present when the individual awakes
New onset of a headache with neurologic symptoms like motor disturbances and mood changes
New onset of headache with systemic symptoms like fever, chills, sweats
Episodes of blacking out during a headache
Headache accompanied by elevated blood pressure changes
Insidious onset of headache
Sudden severe headache and flu-like symptoms, muscle and jaw pain
No family history of Migraines⁵

Treatment:

The American Academy of Neurology established for the treatment of Migraines practice guidelines. According to these guidelines, treatment should focus on educating the patient, treating acute attacks and preventing further attacks. Treatment falls into two categories pharmacological and non-pharmacological.⁷

Pharmocological:

Descriptions available from the Mayo Clinic

NSAIDs
- Only for mild to moderate migraine pain^2,7

Triptans
- Best evidence for severe migraine relief
- Serotonin Receptor agonists
- Not appropriate for patients at risk of stroke or heart attack^2,7

Ergot
- Alkaloid
- Used for patients with moderate-severe migraines^2,7

Anti-Nausea Medications
- Usually combined with other medication to treat nausea symptomatically^2,7

Butalbital Combinations
- Sedative in combination with aspirin or acetaminophen
- Danger of addiction
- Risk of side effects^2,7

Opiates
- Narcotics
- Danger of addiction
- Risk of side effects^2,7

Non-Pharmacological:

The American Academy of Neurology does not at this time support the use of acupuncture, cervical manipulation, hypnosis or TENS for the prevention or treatment of Migraine headaches due to lack of research⁷. Specific relaxation training techniques are currently supported, these are listed below.

Relaxation Training
- EMG Biofeedback
- Thermal Biofeedback
- Cognitive Behavioral Therapy⁷

Key Evidence for Physical Therapists:

While PT is not currently a regularly accepted treatment for Migraine headaches there is some research to support physical therapy modalities. Massage, cervical mobilization and aerobic exercise have been shown to decrease the severity, frequency or duration of migraine headaches.^4,⁸^,⁹^,¹⁰ This research is very limited. Clinical judgment should be used when working with patients with Migraines; they should be treated based on impairments within the scope of practice of Physical Therapy and at this time not with the intention to cure their Migraines. However, based on the research it is possible that the treatment of those impairments may or may not lead to a positive effect on the patients migraines.