Migraine – Symptoms, Diagnosis, Treatment
A migraine is defined as a paroxysmal headache, recurrent, unilateral, associated with ocular phenomena and autonomic disorders, which start in adolescence and in most cases, can have a family character. It affects 7-10% of the adult population. The onset is most often between late teen years and the 40s. Women are 3 times more affected.
Clinical manifestations of migraine: a succession of four distinct phases.
1.Prodromal: is present in up to 50% of cases, in the form of some symptoms with insidious onset, slow progression, lasting up to 24 hours before the crisis.
– Feeling irritable
– State of hyper reactivity
– Desire for solitude
– Food craving (sweets)
– Speech disorders
- Aura: precedes hemicranias (pain on a hemicranium) by 5-60 minutes. It occurs in 20% of cases. May occur:
– Eye phenomena: sparkling scotoma, hemianopsia, amaurosis (vision loss).
- Headache: the only constant element in 100% of cases, defining the migraine.
– Severe, with throbbing
– Most often unilateral
– Accompanied by nausea, vomiting, photophobia
– Aggravated by motion, light
– Determines the patient’s self-isolation in closed rooms
– Takes 2 -72 h
- Postdromal (postictal state):
– Sometimes euphoria
– Can last up to 24 hours
Crises are separated by free intervals. A daily headache is not a migraine.
Diagnosis: on the basis of some criteria introduced by the International Headache Society. It is a diagnosis of exclusion, finally, in terms of a negative neurological exam! The following forms can be recognized:
- Migraine without aura: seizures lasting 4-72 hours, which meet at least two of the following conditions:
– Pain is unilateral
– Pain is pulsatory
– The intensity of the pain is moderated or severe
– The pain is aggravated by physical activity
– The pain is associated with one or more of the following:
- Migraine with aura: two or more seizures preceded by aura, symptoms of which should not take more than 60 minutes and completely reversible. Pain can take 4-72 hours and must meet at least two of the conditions described above.
Differential diagnosis of migraine
- associated headaches, secondary or symptomatic from trauma, vascular disturbances, metabolic septic, skull pathology, pathology of the eye, nose, throat, ears, sinuses, teeth, mouth.
- Migraine-like symptoms but with objective signs during the neurological exam:
-cerebral malformations-> angioma, aneurysms, carotid-cavernous fistula
– recurrent vascular acute cerebral-vascular insufficiency
-tumor of the lateral ventricles, third ventricle, occipital tumors
- I) Using drugs – it is initiated only when the diagnostic is of certainty; therapy has many side effects and low efficiency (there is no ideal therapy for this).
- A) In the acute phase:
- Simple analgesics:
– Acetylsalicylic acid (Analgin) -> central mechanism (thalamic) and peripheral (COX irreversibly blocking> inhibiting PG) -> 2 g / 24 h
– Paracetamol (Panadol) -> 1-2 g / 24 h
– Metamizol (Algocalmin, Novalgin) -> 1-2 g / 24 h
- Ergot derivatives: they couple with the receptors of 5HT, which mediate the neurogenic inflammation in the brain arterioles and have serotonergic action. Chronic use at high doses can lead to ergotism and may turn the migraine into a daily headache. They are augmented by caffeine, which increases the absorption and with which they mix.
- Selective 5HT1 receptor antagonists: sumatriptan (Imigran)
- B) Prevention: for crisis lasting more than 3 days per month, interrupting normal activity, with long-lasting attacks (over 72 hours) or extreme intensity, for which acute phase therapies do not work, have side effects or are contraindicated:
- Beta-blockers: propranolol, etc.
- Calcium channel blockers: verapamil, nifedipine
- 5HT2 antagonists: pizotifen (Sandomigran), methysergide (Deseril), lisuride (Lisenil), dimetotiazin (Migristen), oxetorone (Nocertone), etc.
- Antidepressants: imipramine, doxepin, amitriptyline.
- Tranquilizers: oxazepam, clorazepate (Tranxene), chlordiazepoxide, diazepam.
- Hormonal: estradiol.
- Magnesium preparations.
- Vitamin preparations.
- II) Surgical: only in cases which are not responding to treatment. It aims to break the trigeminal afferents, arterial occlusion, disruption of vasodilator pathways, and disruption of the efferent pathways of pain.
III) Psychotherapy: fighting panic attacks, anxiety.