Brain Pain: Migraines Explained

What is a migraine? 

Throbbing, debilitating, and all-consuming pain. Ask someone to describe a migraine and you can expect to hear these descriptors. Migraines are intense headaches accompanied by symptoms that make it hard to function. But they are more than an annoying occasional discomfort and they have a large impact on society.

Migraines make it hard to work and enjoy free time which creates a strain on quality of life. Too many people leave their migraine disorders undiagnosed or under-treated. Luckily for the estimated 15% of people worldwide who experience migraines, steps can be taken to manage them.1 

Why do migraines happen?

These complex headaches are still somewhat of a mystery. The characteristic pain of migraine is thought to be related to nerve fiber irritation and disruption of blood flow in the vessels of the brain.2 Other professionals believe a disruption in brain chemicals leads to this abnormality. Ultimately, the exact cause is unknown.

Who gets migraines?  

Migraines tend to occur in specific populations. Women are more affected than men, experiencing them up to three times more often.2 There is likely a genetic component as a family history of the disorder is common. Individuals with mental health histories like depression or anxiety are at increased risk. So are those with certain medical conditions such as sleep disorders and high blood pressure. These people will benefit from primary care management.

 What can increase migraine occurrences?

Some triggers increase a person’s chance of having migraines.

• Stress

• Emotional tension

• Low blood sugar

• Lack of sleep

• Excessive light and noise

• Alcohol and tobacco

• Medications

• Hormones

• Head injury

While some of these provoking events are out of a person's control, others are modifiable. Measures should be taken to minimize these triggers.

Symptoms

There are an estimated billion people who endure migraines worldwide. That is too many people struggling with pain. Their episodes have various symptoms.1 The most common symptom is headache, sometimes favoring one side of the head. Migraines can also cause:

• Light or noise sensitivity

• Nausea and vomiting

• Vision changes

• Confusion

• Mood disturbance

• Fatigue or weakness

There are two types of migraines, episodic and chronic.3 Chronic migraines are when someone has 15 or more days in a month with headaches for three months.1 A migraine attack can last anywhere from a few hours up to 72 hours.1 After the acute pain is over there can be fatigue, neck discomfort, and concentration issues for up to two days. These are referred to as postdrome symptoms. In about one-third of people, there is an aura accompanying them.1

 About Migraine Auras

Auras differ in their presentation. They can cause vision loss or appear as zigzag lines. They can also manifest as confusion or as a sensation such as numbness, weakness, or tingling.2 Auras are not experienced by everyone who gets migraines. Auras are temporary and can occur anywhere from 10 to 60 minutes before the onset of discomfort.

 Management

Migraines can put a halt to all activity.3 Imagine trying to sit at a computer and type, care for children, or drive a car with the symptoms listed above. It is beneficial for those prone to migraines to prevent them before they begin. Preventative measures include limiting triggering foods and drinks, eating regularly, drinking plenty of water, and getting enough sleep.2 

Once a migraine has begun the biggest priority is to make it stop. Supportive remedies to alleviate symptoms once they have started may include:

• Resting in a dark quiet place

• Hydrating

• Limiting activity

• Caffeine

• Supplements such as riboflavin and magnesium

• Taking medications for acute attacks

Some seek out professional help if their migraines become consistent or if they persist for days at a time. There are many medications available for acute migraine attack management.

NSAIDs help by reducing inflammation.

Triptans increase serotonin levels in the body and constrict blood vessels.2

Ditans and gepants block the release of CGRP which affects pain signals traveling to the brain.4

Along with medication for acute attacks, there are also drugs for preventative treatment.1 Remember that medication overuse can lead to new problems such as medication-overuse headaches. Take medications as directed by a healthcare provider.

First-line preventative medication includes blood pressure-lowering agents (metoprolol, candesartan) and anticonvulsants (topiramate).

Second-line preventative medication includes calcium channel blockers (flunarizine) and antidepressants (amitriptyline).

Third-line preventative medication includes CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab).

A medical professional will likely refer to a specialist doctor for chronic migraines when common treatments cannot provide relief.

 Non-pharmacological support

Many people oppose medication and would prefer to consider other measures first. Maybe they already take a lot of pills, don’t like medication side effects, or simply do not trust drug companies. For these people there are options.1

Headache calendars or diaries are a useful way to collect data on migraine triggers and make lifestyle adjustments accordingly.

Behavioral treatments such as relaxation training, biofeedback, and cognitive behavioral therapy can provide relief and coping mechanisms.

Magnetic stimulation devices are also an option to assist with activating the nervous system.5

Physical activity is known to be protective against migraine episodes due to the benefits of aerobic movement.

This is not an extensive list of all the modalities available to people with migraines, but it does provide a sample of the many ways to combat them.

 Special Considerations

There are a few specific groups whose standard management may look different.1 Children, breastfeeding or pregnant women, and the elderly have unique needs.

Children

• Bedrest attempted first

• Ibuprofen 

• School nurses involved in management

Pregnant and breastfeeding women

• Avoid preventative medications

• Paracetamol first line for acute attacks

Elderly

• Multiple chronic conditions

• Decreased ability to clear medication

• Suspect secondary cause if migraines are new

There may be other exceptions to the standard treatment regimen. These are just some of the large groups that have specific recommendations to cater to their situation.

 Why is this important?

Of course, no one wants to be in pain themselves or see their loved ones in pain. That goes without saying. But the issue of migraines being so under-treated is deeper than that. 

People with migraines experience a significant health, financial, and social disparity.3 Missed school days for adolescents or workdays for adults can lead to stress and a loss of productivity and income. Having to sit in a quiet room alone means less time with family. You don’t have to be creative to come up with many examples of how migraines impact life. This means that there is a collective interest in controlling the symptoms of those who get migraines.

 Summary

The disabling nature of migraines makes them a burden on society. Migraine symptoms are all-consuming and prevent activities of daily life. Reducing triggers, using preventative strategies, and taking medications can improve quality of life. Long-term management of migraines needs to include collaboration with a primary care provider. Although migraines are difficult to live with providers are there to lessen the impact and minimize disruption of everyday life.

References

1.     Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021; 17(8): 501–514. doi: https://doi.org/10.1038/s41582-021-00509-5

2.     Migraine. National Institute of Neurological Disorders and Stroke. Published July 11, 2023. Accessed November 22, 2023. https://www.ninds.nih.gov/health-information/disorders/migraine#:~:text=Symptoms%20include%20headache%20pain%20that,light%2C%20sound%2C%20or%20noise

3.     Leonardi M, Raggi A. A narrative review on the burden of migraine: when the burden is the impact on people’s life. J Headache Pain. 2019; 20 (1). doi: https://doi.org/10.1186/s10194-019-0993-0

4.     Berger AA, Winnick A, Popovsky D, et al. Lasmiditan for the treatment of migraines with or without aura in adults. Psychopharmacology Bulletin. 2020;50(4):163-188. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901123/ 

5.     Haghdoost F, Togha M. Migraine management: non-pharmacological points for patients and health care professionals. Open Medicine. 2022;17(1):1869-1882. doi: https://doi.org/10.1515/med-2022-0598