MIGRAINE

DEFINITION
* Migraine is a famalial disorder characterised by recurrent attacks of headache widely variable in intensity, frequency & duration. Attacks are commonly unilateral & are usually associated with anorexia, nausea, vomiting

INTRODUCTION
 Migraine is a neurological syndrome characterised by severe headache & nausea  The word Migraine is borrowed from old french MIGRAIGNE ( originally as megrim )  Typical Migraine headache is unilateral & pulsating lasting from 4 to 72 hours

HISTORY
 In 400 BC Hippocrates describe the visual aura

that can precede the migraine headache & the relief which occur through vomiting.  Galenus of pagamon used the term HEMICRANIA from which migraine was derived  In the middle ages migraine was recognised as a descrete medical disorder.

CLASSIFICATION
 According to international classification of headache disorders,2nd addition classified as,

 1.Migraine without aura: Involves

Migraine headaches that are not accompained by an aura (unusual, visual, olfactory other sensary disturbances)

Migraine with aura:

* Involves Migraine headache accompained with an aura. * It includes: a. Famalial hemiplegic migraine b. Sporadic hemiplegic c. Migraine with typical aura. d. Basilar Migraine. e. Migraine aura without headache f. Migraine with acute onset aura.

3.Childhood periodic syndromes:

 These are commonly precurssors of migraine include cyclicalvomiting,Abdominal migraine,Benign paroxysmal vertigo of childhood.

4.Retinal Migraine:
 Involves migraine headaches accompained by visual disturbances or even blindness in one eye

5.Complications of migraine:


These are usually long or unusually frequent or associated with a seizure or brain lesion. 6. Migranous disorder not fulfilling above criteria

NORMAL HEADACHE
Tensionheadache involves muscles & fascia of the scalp & muscle tightening & causing pain.

MIGRAINE HEADACHE
It involves a large chemical change that effects the entire body

DIFFERENTIATING COMMON PRIMARY HEADACHES

DIAGNOSIS
Diagnosis of migraine without aura
 5 or more attacks  4 hours to 3 days in duration  2 or more of unilateral location, pulsating quality,

moderate to severe pain ,aggravation by or avoidance of routine physical activity  One or more accompaining symptoms like nasuea, vomiting,photophobia,phonophobia  Diagnosis of migraine with aura  Only two attacks are required to justify

SIGNS & SYMPTOMS

 Signs&Symptoms of migraine vary among patients.In this 4 phases we can recognise;    

1.Prodrome phase 2.Aura phase 3.Pain phase 4.Postdrome phase

Prodrome phase
 Prodrome symptoms occur 40-60 % of migraine suffers  Altered mood, irritibality, depression,or euphoria,fatigue,yawing,excessive sleepiness,crawing for certain food(Eg;Chocolate)

Aura phase
 20-30% of individuals who suffer migraine with aura.  This aura comprises focal neurological phenomena that precede or accompany the attack  Symptoms of migraine aura can be visual sensory or motor in nature.

Visual symptoms of migraine aura

Enhancements reminiscent of a zigzag fort structure

Negative scotoma, loss of awareness of local structures

Positive scotoma, local perception of additional structures

Mostly one-sided loss of perception

Pain phase
 Pain peaks subsides & usually lasts 4-72 hours in adults and 1-48 hours in children  Head pain varies greatly in intensity  Nausea occurs in 90% and vomiting occurs in about 1/3rd of patients  Hyperexcitebility manifestated by photophobia,phonophobia,osmophobia and seek a dark and quiet room

Postdrome phase
*The patient may feel tired or hung over & have head pain, congentive difficulties, mood changes & weakness. *Some people feel unusually refreshed or euphoric after an attack, where as others note depression & melease.

Causes for migraine  1.Menstruation

 2.Stress  3.Skipping meals  4.Foodslikenitrates,tyramine,icecream,chocol

ate,fatty/fried foods,cheese,caffiene etc..,  5.Alcohol  6.Changes in harmone levels  7.Smoking,weather changes,travel

PATHOPHISIOLOGY
 There are different theories for this approach;

1. Depolorization theory 2.Vascular theory 3.Serotonin theory 4.Neural theory 5.Unifying theory

Depolorization theory  Cortical spreading depression can cause

migraine.  Here neurological activity is depressed over an area of the cortex of the brain.  Then there is the release of inflammatory mediators leading to the irritation of cranial nerve roots.

Vascular theory
 Migraines can begin when blood vessels in the

brain contract & expand inappropriately  Because of contraction the reduced flow of blood from the occipital lobe triggers the aura  When the contraction stops & the blood vessels dilate, then these blood vessels become permeable & some fluid leaks out.  This leakage is recognised by pain receptors &cause pain.

Serotonin theory
 Serotonin is a type of neurotransmitter.  Low serotonin levels in brain lead to a

process of constriction & dilation of blood vessels which triggers migraine.

Neural Theory
 When certain nerves or an area in the brain stem become irritated a migraine begins.  In response to the irritation the body release chemicals which cause inflammation of blood vessels.  These chemicals cause further irritation of the nerves and blood vessels and results in pain.

Unifying theory
 It says that both vascular and neural influences causes migraine.  1.Stress triggers changes in the brain.  2.These changes cause serotonin to be release.  3.Blood vessels constrict and dilate  4.Chemicals including substance p irritate nerves,blood vessels and causing pain

PREVENTION
 To avoid medication over use headache.  Avoid the foods which cause migraine  Be aware from the conditions which triggers migraine

MANAGEMENT
 Non-pharmacological treatment  1.Identification of triggers  2.Meditation  3.Relaxation training  4.Psychotherapy

Pharmacotherapy
NSAIDs  Paracetamol benifited over half of the patients  Naproxen is also in use.  Simple analgesics combined with caffeine ex:Excedrin(asprin with caffiene)

Serotonin Agonists Sumatriptan and related serotonin receptor agonists are used Steroids. Dexamethasone Antidepressants Nefazodone Show antagonistic effects on 5HT2A & 5HT2C receptors

Ergot alkaloids  Cafergot, Ercaf -ergotamine caffeine tablets  Dihydro ergotamine-used as injection or inhalation Other agents  Fioricet /Fiorinal-combination of Butalbital(barbiturate) and paracetamol  Amidrine ,duradin and midrin-combination of acetaminophen ,dichloralphenazone, isometheptene

AYURVEDIC TREATMENT
 Suvarna sutushekhara  Godanti bhasma  Shadbindhu taila  Anutaila

EPIDIMEOLOGY
 The prevalance of migraine ranges from 615% men 14-35% women  Migraine without aura is more common than migraine with aura,with a ratio between 1.5:1 & 2:1  There is strong relationship between age, gender & type of migraine

NEW DRUGS FOR MIGRAINE

 Telcagepant(300mg) & Zolmitriptan (5mg)

these are placebo for pain relief, pain freedom & the absence of phonophobia, photophobia,nausea

CONCLUSION
Migraine is a syndrome with severe headache & nausea with aura or without aura & it can be treated by analgesics to relieve from pain & antidepressants, antiemetics can also be given.It can also effect heart if it is severe,so we can prevent it by reducing the common triggers

REFERENCES
 The international classification of headache disorders 2nd edition  Mathew, Minan.T,Evans Randolphw. Hand book of headache  Hagerstown,MD:Lippincott williams & wilkins