Migraine: Symptoms, Causes & Treatment

Migraine is a chronic neurological disorder characterized by recurrent episodes of moderate to severe headaches, typically on one side of the head. It is one of the most common and debilitating neurological conditions worldwide, affecting millions of people, including those in the Middle East and Jordan. Migraine attacks feature throbbing head pain, nausea, and heightened sensitivity to light, sound, and smells.

Migraine occurs due to a complex interaction between blood vessels and nerves in the brain, believed to be triggered by blood vessel dilation around the brain and spinal cord and the release of neurochemical substances such as serotonin and calcitonin gene-related peptide (CGRP). Approximately 12% of the world's population suffers from migraine, with a higher prevalence in women than men at a ratio of roughly 3:1. It can begin at any age but most commonly occurs during teenage years and the twenties.

Migraine is not merely a common headache but a complex medical condition that can last from hours to several days and significantly impacts work, study, and daily life. Migraine is classified into two main types: migraine with aura (accompanied by sensory warning symptoms) and migraine without aura (the most common type).

Migraine symptoms vary from person to person and may develop gradually. An attack may be preceded by warning signs (aura) hours or days in advance, followed by the severe headache phase and associated symptoms. Attacks typically last 4 to 72 hours. Symptoms may differ between men, women, and children, with milder presentations sometimes occurring in young children.

• Severe throbbing headache: Usually on one side of the head (temple and forehead area), may shift to the other side as the attack progresses.
• Nausea and vomiting: Feeling of nausea that may progress to vomiting; sometimes more distressing than the headache itself.
• Photophobia (light sensitivity): Avoidance of bright or even natural light due to pain and discomfort.
• Phonophobia (sound sensitivity): Normal sounds appear bothersome and may intensify the pain.
• Smell sensitivity: Strong odors may trigger nausea or worsen symptoms.
• Visual aura: Visual symptoms such as zigzag lines, blind spots, or flashing lights may occur 20-60 minutes before the headache.
• Other sensory disturbances: Numbness or tingling in the face or extremities, weakness in the arms or legs may accompany aura.
• Difficulty concentrating and speaking: The person may experience difficulty speaking or inability to focus.
• Facial pallor and sweating: The face may become pale and excessive sweating may occur.
• Fatigue and exhaustion: Severe tiredness during the attack and even after it ends (postdromal phase).
• Pre-attack symptoms: 24-48 hours before the headache, the person may experience mood changes, hunger changes, or constipation.
• Movement sensitivity: Even minor movements may intensify the headache pain.

• Genetic factors: The probability of developing migraine increases by 50-90% if a parent or sibling is affected, indicating the strong hereditary component.
• Hormonal fluctuations: Clear association with estrogen fluctuations, particularly in women during menstrual cycles or when using hormonal contraceptives.
• Stress and emotional tension: Psychological stress and anxiety are among the most common migraine triggers, as well as relaxation periods following intense stress.
• Triggering foods: Such as chocolate, aged cheese, products containing nitrates or monosodium glutamate (MSG), and caffeine.
• Weather changes: Sudden changes in temperature, barometric pressure, and humidity may precipitate attacks.
• Sleep disruption: Irregular sleep patterns, insufficient sleep, or oversleeping are common triggering factors.
• Light and noise sensitivity: Bright or flickering lights and loud sounds may trigger attacks, especially in those with neurological sensitivity.
• Medication overuse: Using pain relievers more than 10 days per month may lead to rebound headache and disease exacerbation.

• Female gender: Women are 2-3 times more likely to develop migraine than men, particularly during reproductive years.
• Family history: Having first-degree relatives with migraine significantly increases the risk of developing the condition.
• Age: Migraine typically occurs between ages 15-55, with peak incidence in the 30s and 40s.
• Comorbid conditions: Conditions such as depression, anxiety, and insomnia increase the risk of severe and recurrent migraine.
• Hormonal contraceptive use: Women using estrogen-containing contraceptives have a higher risk of migraine.
• Cardiovascular disease: History of hypertension or heart disease may increase migraine complications.
• Obesity: Excess weight is associated with increased frequency and severity of migraine attacks.
• Environmental and occupational factors: Working in high-stress environments or continuous exposure to bright lights increases the risk.
• Caffeine overuse: Excessive reliance on coffee and tea may trigger attacks or rebound headaches upon sudden cessation.
• Smoking: Active smoking and secondhand smoke exposure are associated with increased migraine frequency and severity.

Diagnosis of migraine is primarily based on clinical examination and the patient's medical history, as there is no specific laboratory test or imaging that confirms the diagnosis. Doctors use defined international criteria (ICHD-3 criteria) for diagnosis. Additional tests may be ordered if symptoms are atypical or if other more serious conditions are suspected.

• Detailed medical history: The doctor inquires about headache pattern, timing, severity, duration, associated symptoms, and triggering and relieving factors.
• Comprehensive neurological examination: Examination of eyes, cranial nerves, reflexes, balance, and muscle strength to rule out other neurological diseases.
• Magnetic Resonance Imaging (MRI): May be ordered for atypical or complex cases or when suspecting other conditions such as tumors or stroke. Normal value: absence of structural abnormalities.
• Computed Tomography (CT): May be used as an alternative to MRI if unavailable, especially when intracranial bleeding is suspected.
• Blood pressure measurement: To ensure hypertension is not the cause of headache. Normal values: less than 120/80 mmHg.
• Blood tests: Usually not necessary but may be ordered to check for anemia or other disorders that might cause similar symptoms.
• Headache diary: The patient is advised to record headache episodes, symptoms, and triggering factors to aid diagnosis and treatment planning.

Medications

• Acute/Attack-Stopping Medications:
  • Triptans (such as sumatriptan and naratriptan): Considered first-line treatment, they work by narrowing blood vessels and reducing release of pain-causing chemicals. Should be taken at the onset of an attack for best results.
  • Simple pain relievers (paracetamol and ibuprofen): May be effective for mild-to-moderate attacks but should avoid overuse.
  • Acute CGRP inhibitors (such as fremanezumab): New targeted medications given as injections at attack onset.
• Preventive Medications:
  • Beta-blockers (such as propranolol and timolol): Used for recurrent cases, reducing attack frequency by 30-50%.
  • Tricyclic antidepressants (such as amitriptyline): Effective in prevention especially for patients with concurrent depression.
  • Preventive CGRP inhibitors (such as erenumab, fremanezumab, and eptinezumab): Latest options, given as monthly or quarterly injections, highly effective.
  • Topiramate: An anticonvulsant used for prevention that reduces attack frequency.
  • Calcium channel blockers (such as verapamil): Another preventive option.

Procedures

• Botulinum Toxin Injections (Botox): FDA-approved for chronic migraine (more than 15 days per month), injected at multiple points around the head every 12 weeks.
• Neuromodulation (electrical nerve stimulation): Devices such as subcutaneous stimulators or topical devices may provide relief for treatment-resistant cases.
• Hyperbaric oxygen therapy: May be used in certain cases, especially for severe migraine.

Lifestyle Changes

• Identify and avoid triggering factors: Maintain a headache diary to record factors leading to attacks, then avoid them as much as possible.
• Maintain regular sleep schedule: Sleep and wake at consistent times, aiming for 7-9 hours of sleep daily.
• Stress management: Practice yoga, meditation, and deep relaxation; cognitive behavioral therapy may be beneficial.
• Eat regular meals: Do not skip meals and maintain stable blood sugar levels.
• Reduce caffeine: Avoid excessive consumption of coffee, tea, and caffeine-containing beverages.
• Regular exercise: Moderate regular exercise (30 minutes daily, 3-5 days per week) reduces attack frequency.
• Avoid triggering foods: Chocolate, aged cheese, food additives, and preserved foods may trigger attacks.
• Avoid environmental triggers: Minimize exposure to bright or flickering lights and loud sounds.
• Adequate hydration: Drink sufficient water daily; dehydration may trigger attacks.
• Avoid sudden weather changes: Attempt gradual acclimation to temperature and humidity changes.

• Chronic Migraine: Disease progression resulting in daily or near-daily headaches (15 or more days per month), significantly affecting quality of life and productivity.
• Status Migrainosus: A severe and prolonged migraine attack lasting more than 72 hours despite treatment, which may require hospitalization and intravenous therapy.
• Medication Overuse Headache: Overuse of pain relievers (more than 10 days per month) leads to chronic daily headache that is difficult to treat.
• Migraine-Related Stroke: Rare but serious cases, especially in young women with migraine with aura and other risk factors (smoking, hormonal contraceptive use).
• Seizures: Some patients with migraine with aura have higher risk of developing seizures.
• Depression and anxiety: Chronic suffering from recurrent migraine attacks may lead to severe depression and anxiety, affecting mental health.
• Insomnia and sleep disorders: Fear of migraine attacks and chronic pain may cause insomnia and sleep pattern disturbances.
• Loss of employment and productivity: Recurrent and severe attacks may result in work or school absences and loss of income and career opportunities.

• Keep a headache diary: Maintain a detailed record of headache episodes, duration, severity, associated symptoms, and potential triggering factors. This helps identify personal patterns and triggers.
• Avoid known triggering factors: Once identified, try to avoid them as much as possible. These may include certain foods, sleep patterns, stress levels, or weather changes.
• Maintain regular sleep schedule: Sleep and wake at the same time daily, even on weekends. Both insufficient and excessive sleep can trigger attacks.
• Stress and anxiety management: Practice relaxation techniques such as deep breathing exercises, yoga, meditation, or cognitive behavioral therapy.
• Regular physical activity: Engage in moderate exercise regularly (30 minutes daily on most days of the week) such as brisk walking or swimming.
• Maintain healthy diet: Avoid known food triggers, eat regular meals, and avoid skipping meals.
• Reduce caffeine consumption: If consuming large amounts of coffee or tea, reduce gradually to avoid rebound headache.
• Stay hydrated: Drink adequate water daily, as dehydration may trigger attacks.
• Avoid medication overuse: Do not use pain relievers more than 10 days per month to prevent medication overuse headache.
• Seek preventive treatment from your doctor: If headache episodes are frequent (4 or more per month), discuss preventive medication options with your physician.