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Migraine—a complex neurological disease

If you ask someone what migraine is, chances are they will tell you it’s a kind of severe headache. While partially true, this is an oversimplification. In this article, we explore the stages, symptoms, and myths associated with migraine, and discuss various coping strategies that help mitigate symptoms.

Navigating Migraine Complexity - Understanding the Layers of a Neurological Disease.

To successfully manage migraine it is important to understand the different stages of the process and to be able to identify what triggers your migraine. A healthcare professional may be able to recommend medication suited for your symptoms. Some types of migraine are more common than others, so more treatments have been developed to ease them.

The five stages of a migraine attack

A migraine attack can last from a few hours to several days. The associated symptoms can be categorised into five stages. Not everyone experiences all five and the symptoms differ from person to person.

The stages of a migraine attack typically occur in the following order:

  1. The premonitory stage, as the name implies, is when you feel a premonition of what is to come. This can last for as long as three days before the onset of a headache, and commonly manifests as fatigue, food cravings, sensitivity to light, irritability, and stiffness in the neck.
  2. The aura stage can last up to an hour before the onset of a headache and commonly manifests as visual disturbances such as spots, lines, lights, stars or temporary blindness. Additional symptoms include weakness on one side of the body, dizziness, numbness, and a tingling sensation. Some people report experiencing an aura without suffering a full blown headache.
  3. The headache or ‘main attack’ stage is the most well-known symptom of migraine—severe pain in the form of a throbbing headache. It can be localised or felt all over the head, and may be accompanied by nausea or vomiting and sensitivity to light and/or sound.
  4. The resolution stage is when the pain recedes. This usually happens gradually, but can be experienced as a sudden ‘release’. For some, vomiting or crying works this way, and many report sleeping to be helpful.
  5. The recovery or postdrome stage comes last and is sometimes referred to as ‘migraine hangover’. Migraine is a traumatic experience, so it should come as no surprise that the body and mind need time to recover. Symptoms often mirror those experienced during the premonitory stage, but this is not always the case.

Until recently, the word ‘migraine’ was used to name the painful symptoms of migraine. This has been revised in the interest of accurately describing the disease. Now the correct way to use the word ‘migraine’ is the way you would use the word ‘asthma’. Don’t say: ‘This person suffers from migraines’ (you wouldn’t say ‘This person suffers from asthmas’). Instead, say ‘migraine attacks’ or ‘migraine headaches’.

Warning! Some symptoms of migraine overlap with those of stroke. A stroke is a sudden, severe, and potentially fatal medical condition where the blood supply to the brain is interrupted or reduced, preventing brain tissue from getting the oxygen and nutrients it needs. If you suddenly get a severe headache, have difficulty speaking or understanding speech, the corner of your mouth droops on one side, or you experience sudden numbness or weakness in your face, arm, leg—especially on one side of the body—call an ambulance immediately!

What causes migraine?

Most people who suffer from migraine are genetically predisposed to it. Migraine can skip a generation, so in most cases, transmission is likely based on a defect or mutation in more than one gene.

In 2010, a mutation in a gene called TRESK (which normally plays a key role in nerve cell communication) was discovered to be directly linked to migraine with aura.

However, genetics alone do not determine our health and wellbeing—you may be genetically predisposed to migraine, yet still not suffer from it.

Migraine is not a hormonal disease (a person with migraine isn’t more likely to have abnormal hormone function), but migraine is influenced by fluctuations in hormonal levels. The hormonal fluctuations women experience during the course of their lives may explain why migraine is three times more common in women than in men:

  • migraine begins at puberty in 10–20% of women with migraine;
  • puberty is likelier to trigger migraine without an aura;
  • there is often a link between menstrual periods and the onset of migraine attacks;
  • pregnancy generally causes a reduction in the frequency of migraine attacks and can even eliminate them altogether;
  • although worse in the preceding time-period, migraine attacks tend to diminish post-menopause.

Some people suffer migraine attacks exclusively during menstruation. This is called a catamenial migraine or menstrual migraine, and has been linked to the drop in estradiol that occurs during the perimenstrual period. A migraine attack can start two to three days before one’s period and last three to four days after it. This type of migraine is often enduring, intense, and fairly resistant to treatment.

Attention! Hormonal contraception affects hormone production, and can influence migraine attacks (both positively and negatively). If you suffer from migraine, avoid possible complications by consulting your family doctor or gynaecologist about the method of birth control best suited for you.

Unraveling Triggers - Sensitivities in Migraine Sufferers and the Onset of Attacks

Triggering factors

Migraine sufferers will typically be sensitive to a number of stimuli that appear to ‘set off’ a migraine attack, but don’t cause the condition itself.

Identifying triggers isn’t easy. The list of potential culprits is very long, and it may take up to eight hours for a trigger to set off a migraine. And if that wasn’t tricky enough, triggers can change over time—an environmental factor may be triggering at one point in life and not another.

Keeping a detailed diary of what you do, what you eat, and how you sleep can be very helpful. It is time consuming, but will provide data about your experiences before each migraine that can be compared to identify your triggers. With enough information, you may be able to reduce the frequency and severity of attacks.

Sensory and environmental stimuli such as intense or flickering lights, loud noises, extreme temperatures, high altitudes, changes in the weather, and strong smells or flavours may trigger an attack. Triggers aren’t necessarily sudden, e.g. looking at a computer screen for too long is a common trigger.

Hunger and lack of proper nutrition are also common triggers. Try avoiding unhealthy foods, foods with certain additives—MSG, glutamate, tyramine, nitrates, and aspartame in particular—if you think your triggers are food-related. Too much caffeine or going cold turkey to quit caffeine can be triggering. Even mild dehydration can have a notable impact.

A lack of exercise or overexercising might trigger a migraine attack, especially if either is unusual for the person in question. In contrast, regular and properly managed exercise is beneficial for pain management of all kinds.

Physical conditions such as head trauma, sickness that involves coughing, and  muscle tension (all too often caused by bad posture) can trigger attacks.

Hormonal factors, such as menstruation, taking hormonal contraceptives, and even sexual intercourse are potential triggers.

The amount of sleep you get is very relevant, as is the consistency of your sleep schedule. Staying up late, sleeping in, and napping when you usually wouldn’t are potential triggers. If you think your triggers are sleep-related, decide on a sleep-wake rhythm that is feasible (and healthy) for you, and follow it as closely as possible.

Stress and tension are commonly associated with head pain, and migraine attacks are no exception. One can also experience what is called a weekend headache which is triggered not by the stress itself, but by it's sudden absence. In both cases, reducing your overall level of stress is advisable.

Changes in routine can trigger an attack, even relaxing and positive changes such as going on holiday. Traveling across time zones generally impacts your sleep, compounding the problem.

Some of us unwittingly create destructive routines for ourselves. For instance, the overuse of analgesics can promote chronic headache. If you plan to self-medicate, do your research on both the short-term and long-term effects of the medications you use via reputable sources, then stick to the recommended doses.

Anxiety and depression are often associated with migraine. Those suffering from migraine tend to be more vulnerable to anxiety and depressive disorders, which, in turn, can trigger migraine attacks. Consulting a psychotherapist or psychiatrist can be very helpful. 

Migraine misconceptions

The causes and function of migraine and its symptoms are not yet fully understood, and unfortunately we have many misconceptions about the disease. It is not uncommon to draw connections between the symptoms that accompany migraine and different illnesses.

It’s not a digestive disorder

Nausea and vomiting are among the diagnostic criteria for migraine. They are also common side effects of severe pain. Since the nausea and vomiting symptoms of migraine attacks are typically only present during an attack, we can conclude that this is caused by the pain, and symptomatic of a digestive disorder.

It’s not an ophthalmic disorder

Those who have suffered migraine accompanied by a visual aura report seeing lights or streaks, or experiencing temporary blindness and other abnormalities in their vision. Non-migraine headaches can be caused by visual disturbances, but these tend to be less intense than migraine headaches, and aren’t associated with throbbing pain or additional symptoms.

It’s not sinusitis

Migraine is commonly misdiagnosed as a sinus headache. Along with nasal congestion and pressure in the face and nose (also symptoms of migraine), sinusitis manifests as fever, foul breath, thick discoloured nasal discharge, and sometimes an altered sense of smell (exclusive to sinusitis). Medications used to treat sinus headaches can make migraine attacks worse.

If you suffer from migraine and suspect you may have an additional illness or disorder with overlapping symptoms, don’t hesitate to visit a doctor for an official diagnosis.

Diagnosis & treatment

First and foremost, you want an accurate diagnosis. If you experience migraine attacks or have a family history of migraine, a doctor trained in pain management (likely a neurologist) will come up with a diagnosis based on a physical and neurological examination, your symptoms, and your medical history.

Tests that can potentially rule out other causes of pain include:

  • MRI. An MRI scan is used to diagnose tumours, strokes, bleeding in the brain, infections, and other brain and neurological conditions.
  • CT scan. A CT scan is used to diagnose tumours, infections, brain damage, bleeding in the brain, and other possible medical problems that may cause headaches.

Many medications have been designed specifically to combat migraine; these fall into two broad categories:

  • Pain-relieving medications. These are taken during migraine attacks and are designed to stop or reduce symptoms.
  • Preventive medications. These drugs are taken on a regular basis, often daily, to reduce the severity and frequency of migraine attacks.

The treatment you choose must take into consideration the frequency and severity of your headaches, whether nausea or vomiting are part of your experience, and any other medical conditions you might have. By identifying and eliminating triggers, making the necessary lifestyle adjustments, and discovering the medications that work for you, your migraine attacks can be managed and possibly even prevented altogether.

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