Migraine
Disease Details
Family Health Simplified
- Description
- A migraine is a neurological disorder characterized by intense, throbbing headaches, often accompanied by nausea, vomiting, and sensitivity to light and sound.
- Type
- Migraines are a type of primary headache disorder. The genetic transmission of migraines is complex and often follows a polygenic pattern, meaning multiple genes are involved. In some cases, migraines can show a familial aggregation, suggesting a hereditary component, and certain rare forms of migraine, such as familial hemiplegic migraine, follow an autosomal dominant inheritance pattern.
- Signs And Symptoms
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Migraine typically presents with self-limited, recurrent severe headache associated with autonomic symptoms. About 15–30% of people living with migraine experience episodes with aura, and they also frequently experience episodes without aura. The severity of the pain, duration of the headache, and frequency of attacks are variable. A migraine attack lasting longer than 72 hours is termed status migrainosus. There are four possible phases to a migraine attack, although not all the phases are necessarily experienced:
The prodrome, which occurs hours or days before the headache
The aura, which immediately precedes the headache
The pain phase, also known as headache phase
The postdrome, the effects experienced following the end of a migraine attackMigraine is associated with major depression, bipolar disorder, anxiety disorders, and obsessive–compulsive disorder. These psychiatric disorders are approximately 2–5 times more common in people without aura, and 3–10 times more common in people with aura. - Prognosis
- "Migraine exists on a continuum of different attack frequencies and associated levels of disability." For those with occasional, episodic migraine, a "proper combination of drugs for prevention and treatment of migraine attacks" can limit the disease's impact on patients' personal and professional lives. But fewer than half of people with migraine seek medical care and more than half go undiagnosed and undertreated. "Responsive prevention and treatment of migraine is incredibly important" because evidence shows "an increased sensitivity after each successive attack, eventually leading to chronic daily migraine in some individuals." Repeated migraine results in "reorganization of brain circuitry," causing "profound functional as well as structural changes in the brain." "One of the most important problems in clinical migraine is the progression from an intermittent, self-limited inconvenience to a life-changing disorder of chronic pain, sensory amplification, and autonomic and affective disruption. This progression, sometimes termed chronification in the migraine literature, is common, affecting 3% of migraineurs in a given year, such that 8% of migraineurs have chronic migraine in any given year." Brain imagery reveals that the electrophysiological changes seen during an attack become permanent in people with chronic migraine; "thus, from an electrophysiological point of view, chronic migraine indeed resembles a never-ending migraine attack." Severe migraine ranks in the highest category of disability, according to the World Health Organization, which uses objective metrics to determine disability burden for the authoritative annual Global Burden of Disease report. The report classifies severe migraine alongside severe depression, active psychosis, quadriplegia, and terminal-stage cancer.Migraine with aura appears to be a risk factor for ischemic stroke doubling the risk. Being a young adult, being female, using hormonal birth control, and smoking further increases this risk. There also appears to be an association with cervical artery dissection. Migraine without aura does not appear to be a factor. The relationship with heart problems is inconclusive with a single study supporting an association. Migraine does not appear to increase the risk of death from stroke or heart disease. Preventative therapy of migraines in those with migraine with aura may prevent associated strokes. People with migraine, particularly women, may develop higher than average numbers of white matter brain lesions of unclear significance.
- Onset
- The onset of a migraine often involves a prodrome phase that can begin hours to days before the headache itself. Symptoms during this phase may include mood changes, food cravings, neck stiffness, and increased urination. The headache phase typically starts gradually and can last from a few hours to several days.
- Prevalence
- The prevalence of migraine varies globally, but it is estimated to affect approximately 12% of the population worldwide. This includes around 18% of women and 6% of men. Migraine is most common in individuals aged 25 to 55 years.
- Epidemiology
- Migraine is common, with around 33% of women and 18% of men affected at some point in their lifetime. Onset can be at any age, but prevalence rises sharply around puberty, and remains high until declining after age 50. Before puberty, boys and girls are equally impacted, with around 5% of children experiencing migraines. From puberty onwards, women experience migraines at greater rates than men. From age 30 to 50, up to 4 times as many women experience migraines as men.Worldwide, migraine affects nearly 15% or approximately one billion people. In the United States, about 6% of men and 18% of women experience a migraine attack in a given year, with a lifetime risk of about 18% and 43% respectively. In Europe, migraines affect 12–28% of people at some point in their lives with about 6–15% of adult men and 14–35% of adult women getting at least one yearly. Rates of migraine are slightly lower in Asia and Africa than in Western countries. Chronic migraine occurs in approximately 1.4 to 2.2% of the population.In women, migraine without aura are more common than migraine with aura; however in men the two types occur with similar frequency.During perimenopause symptoms often get worse before decreasing in severity. While symptoms resolve in about two-thirds of the elderly, in 3–10% they persist.
- Intractability
- Migraine can be intractable, meaning it does not respond to standard treatments. This condition is often referred to as refractory or chronic migraine and requires specialized management approaches.
- Disease Severity
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Migraine severity can vary significantly from person to person and even from one episode to another. It is classified into different categories based on the frequency and intensity of the headaches:
1. **Episodic Migraine**: Occurs fewer than 15 days per month. Severity can range from mild to severe.
2. **Chronic Migraine**: Occurs 15 or more days per month for more than three months, with at least eight days featuring migraine headaches. This form is usually more severe and can be debilitating.
The intensity of an individual migraine attack can vary, typically including symptoms such as throbbing pain, often on one side of the head, nausea, vomiting, and sensitivity to light and sound. Severity for each person can be influenced by various triggers, including stress, hormonal changes, certain foods, and environmental factors. - Healthcare Professionals
- Disease Ontology ID - DOID:6364
- Pathophysiology
- Migraine is believed to be primarily a neurological disorder, while others believe it to be a neurovascular disorder with blood vessels playing the key role, although evidence does not support this completely. Others believe both are likely important. One theory is related to increased excitability of the cerebral cortex and abnormal control of pain neurons in the trigeminal nucleus of the brainstem.Sensitization of trigeminal pathways is a key pathophysiological phenomenon in migraine. It is debatable whether sensitization starts in the periphery or in the brain.
- Carrier Status
- Migraine is a type of headache characterized by intense, throbbing pain, often accompanied by nausea, vomiting, and sensitivity to light and sound. Carrier status is not applicable to migraines. The condition can have a genetic component, meaning it may run in families, but it is not something that one can be a carrier for in the way that one can be for genetic disorders like cystic fibrosis or sickle cell anemia. Instead, multiple genes and environmental factors contribute to an individual's susceptibility to migraines.
- Mechanism
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Migraines are a type of primary headache disorder characterized by recurrent, moderate to severe headaches often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light and sound.
**Mechanism:**
The exact mechanism of migraines is not completely understood, but it is believed to involve a combination of genetic, environmental, and neurovascular factors. Migraines are thought to originate in the brain and involve a cascade of neurological events.
**Molecular Mechanisms:**
1. **Cortical Spreading Depression (CSD):** A wave of neuronal and glial depolarization starts in the occipital lobe and propagates slowly across the cortex. This event is believed to be linked to the aura phase of migraines and contributes to the release of inflammatory mediators.
2. **Neurotransmitters and Ion Channels:**
- **Serotonin:** Serotonin (5-HT) levels fluctuate during a migraine attack. The role of serotonin is complex, but it is known to influence blood vessel constriction and dilation.
- **Calcitonin Gene-Related Peptide (CGRP):** CGRP is a potent vasodilator released from trigeminal nerve endings. Elevated levels of CGRP are associated with migraine attacks. CGRP antagonists and monoclonal antibodies targeting CGRP receptors are recent advances in migraine therapy.
- **Ion Channels:** Mutations in ion channels (e.g., calcium and sodium channels) have been linked to familial hemiplegic migraine, a rare form of migraine with aura.
3. **Trigeminovascular System:**
- The trigeminal nerve plays a critical role in migraine pathophysiology. Activation of the trigeminal ganglion leads to the release of neuropeptides such as CGRP, substance P, and neurokinin A, which cause inflammation and dilation of meningeal blood vessels, contributing to pain.
4. **Central Sensitization:**
- Repeated episodes of migraine can lead to central sensitization, a condition where the nervous system becomes more responsive to stimuli. This can result in increased pain sensitivity and chronic migraine.
Understanding these mechanisms has led to the development of targeted therapies, including triptans (which act on serotonin receptors), CGRP antagonists, and preventive medications aimed at stabilizing neural excitability. - Treatment
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Treatment for migraines can include both acute and preventive strategies.
1. **Acute treatment**:
- **Over-the-counter pain relievers**: such as ibuprofen, aspirin, or acetaminophen.
- **Triptans**: such as sumatriptan and rizatriptan, which can help to relieve the migraine by narrowing blood vessels and blocking pain pathways in the brain.
- **Ergots**: such as ergotamine and caffeine combination drugs, which can also be effective.
- **Anti-nausea medications**: such as metoclopramide, especially if nausea and vomiting are present.
- **Ditans**: a newer class of medication, like lasmiditan, for those who cannot use triptans.
2. **Preventive treatment**:
- **Beta-blockers**: such as propranolol and metoprolol, which help to reduce the frequency and severity of migraines.
- **Antidepressants**: such as amitriptyline, which can help to prevent migraines.
- **Anticonvulsants**: such as valproate and topiramate, which may be effective in reducing migraine frequency.
- **CGRP inhibitors**: such as erenumab and fremanezumab, which target a specific molecule involved in migraine pathways.
- **Lifestyle changes**: including stress management, regular exercise, and avoiding known migraine triggers.
Consultation with a healthcare provider is essential to determine the most appropriate treatment plan based on individual needs and medical history. - Compassionate Use Treatment
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Compassionate use treatment and off-label or experimental treatments for migraines can be considered when standard treatments are ineffective or unsuitable. Here are some options that fall under these categories:
**1. Compassionate Use Treatments:**
- **Erenumab (Aimovig)**: Primarily approved in many countries, it may be used under compassionate use programs for patients who don't have access through standard channels.
- **Fremanezumab (Ajovy)**: Similar to Erenumab, it might be provided compassionately for those requiring it.
**2. Off-Label Treatments:**
- **Candesartan**: Typically used for hypertension, it's sometimes prescribed off-label for migraine prevention.
- **Memantine (Namenda)**: Usually prescribed for Alzheimer's disease, it's being explored for migraine management.
- **Topiramate**: Though approved for epilepsy and migraine prevention, it can be used off-label in varying dosages or cases.
**3. Experimental Treatments:**
- **Psilocybin**: The active ingredient in certain hallucinogenic mushrooms is being researched for its potential to reduce the frequency and severity of migraines.
- **Ketamine**: Known for its use in anesthesia and treatment-resilient depression, ketamine is being studied for its benefits in chronic migraine management.
- **Transcranial Magnetic Stimulation (TMS)**: A non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain, showing promise in early-stage trials.
It is important that any such treatments be closely monitored by a healthcare professional to assess efficacy and manage potential risks. - Lifestyle Recommendations
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For managing migraines, several lifestyle recommendations can be helpful:
1. **Regular Sleep Schedule:** Maintain a consistent sleep routine by going to bed and waking up at the same time every day, even on weekends.
2. **Hydration:** Drink plenty of water throughout the day to stay hydrated, as dehydration is a common migraine trigger.
3. **Balanced Diet:** Eat regular, balanced meals and avoid known food triggers such as caffeine, alcohol, aged cheeses, and processed foods.
4. **Stress Management:** Practice stress-reducing techniques such as yoga, meditation, deep breathing exercises, or engaging in hobbies.
5. **Exercise:** Engage in regular physical activity like walking, swimming, or cycling to reduce the frequency and severity of migraines.
6. **Limit Caffeine and Alcohol:** Both substances can trigger migraines in some individuals, so moderating intake is advisable.
7. **Avoid Triggers:** Keep a migraine diary to identify and avoid personal triggers, which might include certain foods, odors, or environmental changes.
8. **Proper Lighting and Screen Time:** Minimize exposure to bright or flickering lights and take breaks from screens to reduce eye strain.
9. **Medication Adherence:** Follow your healthcare provider's recommendations regarding medications and avoid overuse of over-the-counter painkillers, which can lead to rebound headaches.
10. **Healthy Weight:** Maintain a healthy weight through diet and exercise, as obesity is linked to more frequent and severe migraines.
Adopting these lifestyle adjustments can help manage and reduce the impact of migraines. - Medication
- Preventive migraine medications are considered effective if they reduce the frequency or severity of the migraine attacks by at least 50%. Due to few medications being approved specifically for the preventative treatment of migraine headaches; many medications such as beta-blockers, anticonvulsive agents such as topiramate or sodium valproate, antidepressants such as amitriptyline and calcium channel blockers such as flunarizine are used off label for the preventative treatment of migraine headaches. Guidelines are fairly consistent in rating the anticonvulsants topiramate and divalproex/sodium valproate, and the beta blockers propranolol and metoprolol as having the highest level of evidence for first-line use for migraine prophylaxis in adults. Propranolol and topiramate have the best evidence in children; however, evidence only supports short-term benefit as of 2020.The beta blocker timolol is also effective for migraine prevention and in reducing migraine attack frequency and severity. While beta blockers are often used for first-line treatment, other antihypertensives also have a proven efficiency in migraine prevention, namely the calcium channel blocker verapamil and the angiotensin receptor blocker candesartan.Tentative evidence also supports the use of magnesium supplementation. Increasing dietary intake may be better. Recommendations regarding effectiveness varied for the anticonvulsants gabapentin and pregabalin. Frovatriptan is effective for prevention of menstrual migraine.The antidepressants amitriptyline and venlafaxine are probably also effective. Angiotensin inhibition by either an angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist may reduce attacks.Medications in the anti-calcitonin gene-related peptide, including eptinezumab, erenumab, fremanezumab, and galcanezumab, appear to decrease the frequency of migraines by one to two per month.
- Repurposable Drugs
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Several repurposable drugs have shown potential for treating migraines. These include:
1. **Amitriptyline** - Originally an antidepressant, it is often used for its ability to prevent chronic migraines.
2. **Propranolol** - A beta-blocker primarily used for hypertension, it can help reduce the frequency and severity of migraines.
3. **Topiramate** - An anticonvulsant, it is also effective for migraine prevention.
4. **Candesartan** - An angiotensin II receptor blocker initially used for hypertension, it has been found to help with migraine prevention.
5. **OnabotulinumtoxinA (Botox)** - Used for muscle spasms and cosmetic purposes, it is approved for chronic migraine prevention.
There is limited information specific to "nan" in this context. If "nan" refers to a specific treatment or term, please provide further clarification. - Metabolites
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Migraine is associated with distinct metabolic changes in the brain and body. Key metabolites involved include:
1. **Serotonin (5-HT)**: Altered levels are linked to migraine pathophysiology.
2. **Glutamate**: Elevated levels can lead to increased neuronal excitability and migraine.
3. **CGRP (Calcitonin Gene-Related Peptide)**: Prominent in migraine mechanisms, contributing to vasodilation and inflammation.
4. **Lactate**: Increased levels during migraine suggest altered energy metabolism.
5. **Nitric Oxide (NO)**: Overproduction is implicated in vasodilation and migraine headache.
Understanding these metabolites helps in developing targeted treatments for migraine. - Nutraceuticals
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Nutraceuticals refer to food-derived products with potential health benefits. For migraines, certain nutraceuticals have shown promise in prevention and reduction of symptoms. Key examples include:
1. **Riboflavin (Vitamin B2)**: High doses, typically 400 mg daily, may reduce migraine frequency and duration.
2. **Magnesium**: Deficiency in magnesium is common in migraine sufferers, and supplements may decrease the frequency of attacks. Typical doses range from 400-600 mg per day.
3. **Coenzyme Q10 (CoQ10)**: Taking 100-300 mg daily may help lower the occurrence of migraines.
4. **Feverfew**: An herbal remedy that has been reported to reduce the frequency and severity of migraines.
5. **Butterbur**: Extracts from the butterbur plant may help decrease migraines, but it's crucial to use products free of harmful pyrrolizidine alkaloids.
6. **Omega-3 fatty acids**: Found in fish oil, may have anti-inflammatory effects useful for migraine management.
Consultation with a healthcare provider before beginning any nutraceutical regimen is advised to ensure safety and appropriateness for individual conditions. - Peptides
- Migraines have been linked to the role of peptides, particularly the Calcitonin Gene-Related Peptide (CGRP). CGRP is a powerful vasodilator and is thought to play a significant role in the pathophysiology of migraine headaches. Treatments targeting CGRP or its receptor can help alleviate migraine symptoms. These include monoclonal antibody therapies that either inhibit CGRP itself or block its receptor, offering new preventive treatment options for chronic and episodic migraines.