Dr. Rahul Chakor Neurologist
Special Interest in Neuroimmunology, Epilepsy

The suffering of a Migraine patient is difficult to understand by those who have never experienced a headache. “It is surprising that man has visited the moon long back and he will conquer other planets and stars as well but there is no cure for migraine headache” exclaimed Osho. The suffering of a Migraine patient is difficult to understand by those who have never experienced a headache. “It is surprising that man has visited the moon long back and he will conquer other planets and stars as well but there is no cure for migraine headache” exclaimed Osho.

The misery, frustration and cry for cure of migraine patient is well represented by George Bernard Shaw. He suffered severe headache once a month till the age of 70. He admonished Nansen the famous arctic explorer, “Have you ever tried to find a cure for headaches?” , Well you have spent your life in trying to discover North Pole, which nobody on earth cares tuppence about, and you have never attempted to discover a cure for headache, which every living person is crying aloud for.”

That is not true anymore, researchers are working on a remedy for migraine. The current understanding has moved on from accusing the patient of defective personality to a disease of the brain. Migraine is a hereditary tendency of the brain which causes impaired modulation of afferent impulses periodically leading to exaggerated perception of headache, vascular pulsation, scalp tenderness, sensitivity to light, sound. The better understanding of pathophysiology has lead to improve treatment and care of migraine patients.

Having treated thousands of patients of migraine and other headaches Dr Chakor has gained significant expertise in all types of Headache treatment. Every day patients are seen in the outpatient clinic or indoor department. Patients are treated by consultation or are admitted for refractory headaches as deemed necessary.

Symptoms

Migraine is 2 to 3 times more frequent in women than in men. The typical headache of migraine starts on one side of the head usually around the eye or forehead. It then gradually builds up in severity and spreads to involve one half of the head, rarely it may involve the entire head. It is usually quite severe and is accompanied by nausea, vomiting sensitivity to sound, light.

The typical migraine headache is:

• Moderate to severe intensity
• Pulsating - hammering, throbbing sensation
• Hemicranial or holocranial
• Gradually builds in severity
• Associated with nausea or vomiting
• Aversion to light and sound

A person suffering from migraines will always like to relax in the dark and quiet place and most of the times relief can be obtained only when vomiting takes place. Many people have a prodrome where they report change in mood, irritability or depression. In patients of migraine with aura a complex of neurologic symptoms may precede or occur with the headache. The aura can be visual, sensory, motor or a combination of these. In atypical visual aura the patient sees a hazy spot or a star in the center of his vision which then increases in size. Its borders are bright and scintillating, shimmering. This is followed by a typical migraine headache.

Many things can trigger a migraine. These include:

• Poor coping strategi
• Anxiety
• Stress - related to exams, deadline, work related, interpersonal, family etc.
• Travel
• Lack of food
• Lack of sleep or sleeping more than usual
• Exposure to bright sunlight
• Hormonal changes (in women)- perimenstrual migraine
• Certain food like cheese, banana, curds, coffee

Some triggers typical to Indian patients are:

• Summer hot and  humid weather
• Having a bath with cold water
• Applying Mehndi to the hair
• Toothache
• Sinusitis
• Pungent smell - of perfume, spices, while cooking e or smell of petrol

All headaches are not migraine. Essentially migraine is a diagnosis of exclusion, which means other secondary causes of headache are ruled out by appropriate tests. A headache may not be migraine if it does not fulfill the criteria for migraine. New onset headache, headache occurring for the first time, headache with convulsion, confusion, fever, and abnormal behavior is not migraine headache. Headache in patients who have low immunity or those on treatment for cancer likely have a cause of headache other than migraine.

Other serious causes of headache
- Brain tumor
- Thrombosis of cerebral veins
- Temporal arteritis
- Rise in intracranial pressure
- Low intracranial pressure
- Aneurysms of cerebral artery
- Meningitis, encephalitis
- Dissection of vessels
- Brain Hemorrhage
- Stroke

Diagnosis of Migraine
It is essentially diagnosed on history of the symptoms. History of recurrent one sided headache accompanied with nausea vomiting in a woman with family history of similar headaches in virtually diagnostic of migraine. The neurological examination is normal in patients with migraine. Secondary causes which can cause headaches have to be ruled out by appropriate tests like CT scan or MRI where indicated.

Treatment
Migraine presents in different severity in different patients and even in the same patient at different times. The treatment has to be tailored as per the severity and disability caused by the headache.

Many factors may contribute to the occurrence of migraine attacks. They are known as trigger factors and may include diet, sleep, activity, psychological issues as well as many other factors. Avoidance of identifiable trigger factors reduces the number of headaches a patient may experience. Non-pharmacological techniques for control of migraine are helpful to some patients. These include biofeedback, relaxation technique, physical medicine, yoga, pranaayaam and counseling.

Good Sleep - is of prime importance to all migraine patients. Remember the sleep requirement of each individual is different.

Migraine headache may prevent one from falling asleep or wake you may wake up at night with a migraine headache. Commonly migraines are often triggered by a poor night's sleep. The following tips for good sleep may be useful - These are similar to sleep hygiene measures advised for insomnia.

• Establish regular sleep hours. Wake up and go to bed at the same time every day — even on weekends keep the sleep time fixed. If you nap during the day, keep it short for 20 minutes.
• Relax at the end of the day. Listen to soothing music. Take a warm bath or read your favorite book. Avoid intense exercise, heavy meals, caffeine, nicotine and alcohol as these can interfere with sleep.
• Minimize distractions. Save your bedroom for sleep and intimacy. Don't watch television or take work related stress to bed. Close your bedroom door. Use a fan to muffle distracting noises.
• Don't try to sleep. The harder you try to sleep, the more awake you'll feel. If you can't fall asleep, read or do another quiet activity until you become drowsy.
• Check your medications. Medications that contain caffeine or other stimulants — including some medications to treat migraines — may interfere with sleep.

Regularly Exercise
The benefits of regular exercise go beyond control of migraine, have a habit of regular exercise.

• During physical activity, your body releases certain chemicals (neurotransmitters- endorphins, enkephalins) that block pain signals to your brain. These chemicals also help alleviate anxiety and depression — conditions that can make migraines worse. If your doctor agrees, choose any exercise you enjoy. Walking, swimming and cycling are often good choices. But it's important to start slowly. Exercising too vigorously can trigger migraines
• It is not possible to get angry while walking briskly. Take a brisk walk daily.

Stress, do not try to manage it-
Stress and migraines often go hand in hand. You can't avoid daily stress, but you can avoid stressful situations or people, it will help you prevent migraines.

• Be detached - Try to be a witness to your life. Try being a third party - observing your own self.
• Simplify your life. Rather than looking for ways to squeeze more activities and multitasking into the day, find a way to delete few things.
• Adjust your attitude or better Live without an attitude. Stay positive. Remember the tough get going when the going gets tough.
• Manage your time wisely. Keep checklists Update your to-do list every day — both at work and at home. Delegate what you can, and break large projects into manageable chunks.
• Take a break. If you feel overwhelmed, a few slow stretches or a quick walk may renew your energy for the task at hand.
• Let go and laugh at it. Don't worry about things you can't control. Things just happen on their own accord.
• Relax. Deep breathing from your diaphragm can help you relax. Focus on inhaling and exhaling slowly and deeply for at least 10 minutes every day. It may also help to consciously relax your muscles, one group at a time. When you're done, sit quietly for a minute or two

Good eating habits
Your eating habits are important for migraines-

• Be consistent. Eat at about the same time every day
• Don't skip meals. Breakfast is especially important.
• Avoid foods that trigger migraines. If you suspect that a certain food — such as aged cheese, chocolate, caffeine or alcohol — is triggering your migraines, eliminate it from your diet to see what happens.

Biofeedback

As an alternative to drug therapy, this training uses special equipment that monitors physical tension to teach the patient how to control the physical processes that are related to stress. Once familiar with this technique, people can use it, without the monitoring equipment, to stop an attack or reduce its effects.

Self-hypnosis exercises are also taught to control both muscle contraction and the swelling of blood vessels. This patient-directed therapy, with the clinician serving as a guide or teacher, should be practiced daily. Children have an excellent response to biofeedback training, since they are open to new methods, learn quickly and have not become firmly entrenched in a chronic pain pattern.

Medical Treatment

Drugs used in treatment of acute attacks
For mild headache nonsteroidal anti- inflammatory drugs (NSAIDS) drugs like Paracetamol, Aspirin, ibuprofen, naproxen, diclofenac are effective.

For more severe attacks specific medicines like ergotamine, dihydroergotamine or triptans like sumatriptan, naratriptan, zolmitriptan are effective.

For headache nonresponsive to oral medications and lasting for more than 72 hrs patients may be admitted to hospital and treated with injectable medicines.

Drugs for preventing migraine attacks

Generally speaking preventive therapy is started if the patient has headache twice a month and do not respond to acute therapy. If the headache is less frequent but is very severe in intensity prevention may be necessary.

If infrequent migraine headaches can be prevented by use of sumatriptan, ergotamine, NSAIDs there is no need for the patient to take prophylactic medication. If these agents are not completely effective preventive therapy is necessary. The various drugs available for prevention are:

• Topiramate
• Divalproex
• Amitriptyline
• Flunarizine
• Propranolol and other beta blockers
• Pizotifen
• Cyproheptadine
• Methysergide
• Gabapentin
• Botox
• Occipital nerve block
• Monoclonal antibodies – Erenumab (Suviray), Galcanezumab, Fremanezumab, Eptinezumab
• Gepants- Rimegepant, ubrogepant, atogepant
• Ditans - Lasmiditan