Why Do People Age?
Ageing is a result of the gradual failure of the body’s cell and organs to replace and repair themselves. This is because there is a limit to the number of times that each cell can divide. As the body’s cells begin this limit, the rate at which they divide slow down. Sometimes the new cells that produced have defects or do not carry out their usual task effectively. Organs can begin to fail, tissues change in structure, and the chemical reactions that power the body become less efficient. Sometimes the blood supply to the brain is not effective. The brain cells become starved of nutrients, leading to forgetfulness. For most old people memories bring great pleasure. Strangely, even though recent events may be forgotten, old people often clearly remember events that took place in their childhood.The Immune System plays a big role in this aging process with its operation located in the thymus gland. When this gland fail, the immune system of the body fails and organs are at the mercy of virus, bacteria, etc.Nutrients that help keep the thymus healthy are Vitamin A, C and E along with the minerals zinc and selenium.Causes of Aging : Smoking and polluted air produce molecular crossing in cells and this are responsible for skin and tissue hardening which causes brittle and wrinkled skin.This effect of molecular crossing is also produced by free radicals which tend to destroy and disintegrate cell, proteins and tissues, as well as the heart of cell, the DNA, by oxidation.Free radicals are produced by ultra violet rays from the sun, by the normal metabolism of certain fats and polluted air.Free radicals affect cerebral cells causing old age such as the loss of memory, depression, insommia, sexual impotency, arteriosclerosis, etc.Suggestion for Healthier Body and Mind :1. Consume Grains - Grains are rich in protiens, minerals(calcium, iron, potassium, sodium, magnesium) and starches.Types of Grains:Cereal : rice, corn, wheat and oatsLegumes : (Rich in proteins) all types of beans - kidney, lentil, lima, garbanzos, soybeans and peas.2. Consume Vegetables - Leafy green vegetables, seed pod, flower, stalk and root.Leafy : All types of tomatoes, squash, hot peppers, eggplant, green beans, cucumber.Flower : Cauliflower, broccoli, squash blossom, artichokes, palm flowers.Stalks : Celery, asparagus, mushrooms, corn smut.Roots : Beets, all types of onions, garlic, carrots, radishes, turnips.The intake of these vegetables should varied in order to acquire the wide variety of vitamins and minerals that the body needs.3. Consume Fruits - Fruits contain monosaccharide sugars which are easily assimilated by the body.Fruits are classified into three categories :Juice : Orange, grapefruit, lime, grape, mandarin, lemon.Pulp : Banana, mango, papaya, strawberry, pineapple, watermelon, cantaloupe, tamarind.Endosperm : Apple, pear, peach, apricot, plum, quince, prickly pear, fig, grape, guava, kiwi, date, coconut, pomegranate, jicama.Avocado has the most calories than any other fruits. Papaya has the most protein.4. Consume Tubers - Potatoes and yams are the most common. These products are rich in polysaccharide carbohydrates(starches). The sugars in fruits and tubers provide the most important source of energy for the body.5. Fiber - Soluble fiber is found in oats, fruits, vegetables. It helps to lower cholesterol and concentrated sugars in the blood. Insoluble fiber that is found in cereals and legumes is good for the digestive system and protects gainst cancer of the colon. It is suggested to consume from 20 to 30 grams per day.6. Fat - In a good diet, fat should be removed, as long as it is not more than 30% of the daily calorie intake.Daily supplements for adult (150lbs) use :Supplement Suggested Daily Use Comments1. A Beta Carotene with 2 capsules daily Powerful antioxidantVit. E and Selenium 1 capsule before each Helps resist infections;meal repair tissues2. Chinese lycium 2 to 3 capsules per day Powerful anti+ Vit. C 1 capsule before each oxidant. Preventsmeal oxidation of cells in the body Strengthens the immune system3. Ginseng and/or 3 tablets daily. Use for energy, impotence,Royal Jelly 1 tablet, 20 minutes enchancing immune systembefore each meal 4. Multi- minerals 6 tablets daily Zinc and Selenium are impt.(Zinc, Selenium) 2 tablets each meal for the immune system5. Aloe Vera Juice 3 ounces daily Aloe Vera is helpful inor nectar 1 ounce before each infections, skin cancer,meal arthritis, allergies6. Bee Pollen 3 tablets daily of 5gr Energy, vitamins, minerals1 tablet each meal amino acids, nutrients7. Omega-3 3 to 6 caps daily Fish oil contains EPA1 to 2 caps before high in polyunsaturatedeach meal fatty acids.
Blood :White cells:
There are five main types of white blood cell and each has a specific function. They are divided into two groups by the presence or absence of cytoplasmic granules, and by the structure of the nucleus.GranulocytesNeutrophils are the most numerous of the white cells. They are characterized by their multilobed nucleus and by the presence of cytoplasmic granules that stain with neither basic nor acidophilic dyes. The cytoplasm of these cells suggests that there is little synthesis by the mature cell, implying that once the cell is activated it has a short lifespan. The granules contain molecules active in killing bacteria, such as myeloperoxidase. One unique feature of neutrophils is their ability to function in areas of low oxygen tension. They are therefore well suited to operate in areas of infection and tissue damage. Neutrophils are increased in bacterial infection and inflammation.Eosiniphils are much less numerous than neutrophils, and can be recognized by their eosinophilic cytoplasmic granules. The secretions of eosinophils tend to inhibit mast cell degranulation and limit the destructive effects of mast cells. Their major acivity is with respect to parasitic diseases and allergic disorders.Basophils are even less common than eosinophils. They have basophilic cytoplasmic granules and a bilobed nucleus. The cytoplasmic granules contain heparin, histamine and chondroitin sulphate. The surface of basophils is coated with IgE produced by plasma cells. Antigen binding results in rapid degranulation.Agranular white cellsLymphocytes are found circulating in the blood as small cells with a round dense nucleus and very little cytoplasm. Small lymphocytes increase in size upon stimulation by antigen. Large lymphocytes represent activated B cells. They travel to the tissues where they are transformed into plasma cells.Monocytes are the largest of the white cells being about 20um in diameter. The have a large kidney-shaped nucleus and pale cytoplasm. Monocyte travel from the blood into the tissues where they transform into macrophages.Connective TissueConnective tissue is found in the body as a covering around organs, as layers of fascia , as the substrate for sheets of epithelium lining the surfaces of the body, and as major components involved in force transmission in the musculoskeletal system Connective tissue is derived from mesoderm.OrganizationAll of the forms of connective tissue show variations on a basic plan. The connective tissues are composed of a matrix in which are embedded cells. The proportions of matrix/cells vary as do the composition of the matrix and the types and numbers of cells present. According to composition the connective tissues are divided into general and special supporting tissues. The general forms appear either as loose (areolar) or dense. The dense forms may be regular or irregular.General Connective TissueThe CellsThe cells may be grouped into three types according to their function. They are either involved in synthesis and maintenance of the matrix, store fat, or are involved in defence and immune functions.FibroblastsFibroblasts are elongated cells found embedded in a matrix which they have produced. Since the fibroblast is responsible for synthesis and release of the components of the matrix the cytoplasm of the cell is filled with extensive RER and Golgi. Fibroblasts synthesize collagen, reticular and elastic fibres and the glycosaminoglycans of the ground substance. Quiescent cells are termed fibrocytes. Active fibroblasts are found in wound healing where they synthesize the matrix. At sites of scar formation myofibroblasts may also be found. Myofibroblasts contain contractile filaments and are able to cause shrinkage of scar tissue.MacrophagesMonocytes circulating in the blood migrate into the tissues where they transform into macrophages. Macrophages can divide in the tissues. As monocytes transform to macrophages the cell enlarges and organelles multiply. There is an increase in Golgi complex, RER, lysosomes, microtubules and microfilaments. The cell outline becomes irregular with many pseudopodia. The major functions of macrophages are the injestion and digestion of particles, and the secretion of molecules active in defence mechanisms.Mast CellsMast cells are found in loose and irregular connective tissue. Their prevalence below the skin, GI epithelium, below the peritoneum and around blood vessels reflects their importance in defence. Mast cells are round or oval cells up to 30um in diameter. The cytoplasm is packed with basophilic granules. Mast cells release heparin, chondroitin sulphate, histamine and leukotrienes. The surface of mast cells contains receptors for IgE. IgE is produced by plasma cells in response to antigenic stimulation. The antibody then binds strongly to the surface of mast cells. Anaphylactic shock may result from massive stimulation of mast cells through binding of a specific antigen with the IgE on the mast cell surface. Histamine causes contraction of smooth muscle in the bronchioles, dilates cpillaries and increases permeability.Plasma cellsPlasma cells are formed from large lymphocytes in the tissues. Plasma cells are not normally found circulating in the blood. Plasma cell cytoplasm is packed with RER, reflecting their role in antibody production. Plasma cells are short-lived in the tissuesThe MatrixThe matrix is formed of a ground substance in which fibres are embedded. Both the substrate and the fibres show a wide range of variability, producing connective tissue able to meet a wide range of requirements.The ground substance is formed of a hydrated gel of glycosaminoglycans. There are four main groups of molecules in the glycosaminoglycans family: hyaluronic acid; chondroitin sulphate and dermatan sulphate; heparan sulphate and heparin; keratan sulphate. Glycosaminoglycan molecules are large and complex with a strong negative charge. Because they are unable to be sharply bent, and they are strongly hydrophilic, glycosaminoglycan complexes tend to take the form of coils filled with water molecules. Each of the molecules of the glycosaminoglycans family has specific characteristics which allow the construction of gels with a range of pore sizes important at filtration sites such as the renal glomerulus, and a range of tensile strength resistance to compression as in cartilage. The type of gel present in each form of connective tissue varies but in each case its normal structure and function is essential to the integrity of the connective tissue.The fibres of the matrix are of four types: collagen, elastin, fibrillin, and fibronectin. Collagen fibres are the most common in all forms of connective tissue, and there are many types of collagen Collagen fibres resist tensile stresses and so are ideal in tissues such as tendons and ligaments. However collagen is also found as sheets of basement membrane separating the primary tissues of the body. Elastin fibres are formed by an arrangement between elastin and fibrillin. These fibres allow connective tissue to stretch and recoil, important features of blood vessels and the lung. Fibronectin is found in a range of forms, with an ability to bind to collagen, heparin and cell adhesion molecules, the integrins. Fibronectin is thus of great importance in the adhesion of cells to the substrate. Other non fibrillar proteins, such as laminin, entactin and Tenascin, also participate in cell adhes.
Thursday, August 7, 2008
CONFERENCE CALL
Conference Call Recording Made Easy
I have created my fair share of podcasts and found that recording phone conversations for interviews was a must. I also found that recording conference calls was a brutal exercise in futility and frustrating to say the least.
Yes, there are plenty of conference call companies out there who provide recording now but it seems bizarre how many of them are still delivering actual CDs and Tapes!? Most of them do not even make the recordings available online after the call, you have to ask for it and it costs extra.
There are free conference call providers out there that allow you to use their service free of charge who do provide recordings, but you have to pay for the long distance toll charges.
With some services it's as simple as a checkbox when you create your conference call online or if you are using the system in an ad-hoc reservationless fashion you can just enter "6#" on your phone to start or stop recording. Within a few minutes your call recording(s) will be waiting for you.
You can listen to the conference recording using the embedded flash player or download the recording MP3 to your computer. Some services also offers an RSS feed for the recordings that is quite unique. You can add recordings to your RSS feed creating a podcast that listeners can use to download recordings directly to their MP3 player or iPod. It's as easy as click on the plus button next to your recording. You can reverse the process as well by clicking the minus button to remove it from your podcast feed.
Now that we have our RSS feed link we can post it to our blog. When a reader subscribes to that RSS feed their reader will reflect the changes that you make to your feed. If you add a conference call to your feed they will see that and be able to listen to it. If you remove a conference call they will lose that call from their feed.The Benefits of Having a Reservationless Conference Call
Organizations of all types today utilize new communications technology to facilitate collaboration among members. One of the most-used and most useful applications is the teleconference, which enables multiple people and groups of people in separate locations to connect and talk on the same phone call. The teleconference has become a staple of business life, and it is used by all types of organizations, including multinational corporations, government agencies, universities and academic collaborators, and small businesses. New communications technologies facilitate the spread of information and ideas, and conference calls are no exception.
However, conference calls today still are not very user-friendly. Often there is a long dial-in number that needs to be distributed beforehand either through email or another phone call. Then after dialing that number, the teleconference participant must enter a code or password in order to join the conference. This process can be tedious and annoying in everyday situations; in the event of an emergency, this type of delay could actually be dangerous.
The reservationless conference call is the answer to quickly setting up and participating in a teleconference with either a handful or dozens of other people. Not all mass notification companies offer the option of setting up an instant conference call, so it is important to make sure that the company you select offers this service. The notification company will contain the contact information of the organization's members in its database, and when an administrator or other user sends out a message, they can select the option to connect that person to an on-demand conference call.
Imagine this situation: your company receives word that a natural disaster has occurred at or near one of its facilities. Management needs to be notified immediately to determine the details of the situation and to decide what course of action to take. How do you connect all of these people in the fastest way possible? You could contact all of them by phone individually, but this wastes valuable time in a critical situation. You can email them, but there is no guarantee they will see the email or realize the severity immediately.
The solution is an emergency notification service that has the ability to set up a reservationless conference call. Simply send out a message to your users, telling them that a critical situation has occurred. This message will be send over multiple modalities, including email, SMS text message to cell phones, and voice messages to cell phones, home phones, work phones, and BlackBerry PINs. The message will give the user the option to connect instantly to an on-demand conference call. In a matter of seconds, your whole team can be connected to a reservationless conference call, without all the hassle and waste of first setting up the conference, then notifying all of the participants of the dial-in number and the password, and then waiting for all the the participants to dial in and enter their passwords.
Conference Call Providers
Conference call providers are the ones who enable the basic service for conference calls, either on web conferencing software or on a comparative low cost audio conferencing solution for online conference call meetings. They provide advanced teleconferencing platforms for customers to place international phone calls to anywhere in the world. With these features and calling flexibility, the telecom costs can be easily reduced by 90% over the traditional phone companies. This helps businesses to save money on international phone bills.
An organization can have up to 50 people connected on a single call through a conference caller, and be billed the same rate as a regular phone call. They don’t have to pay those high per-minute rates from other telecom companies. Conference call providers use the latest digital routing and switching equipment. Nowadays, conference call providers use full fiber-optic cabling throughout the network, providing callers with the finest quality service available, with a good bandwidth and less noise and transmission errors. There are multiple options to connect to a conference call provider. You can dial into a local toll-free access number, enter your conference code and get connected.
For conference call providers, with Conference Caller Web Dial Out, the calls are initiated via the Internet, are able to be received at any time of the day, 7 days a week. The fully automated system acts as a 24-hour operator, connecting organizations to their international partners and clients.
A lot of these providers are full-service conference call companies offering quality service and low-cost options. These companies provide personalized service for all of your conferencing needs. Affordable conference call provider rates, obviously, are preferred by most businesses. Reasonable pricing is the growing trend in the conferencing industry. Conference call providers are battling for their share of the marketplace. One must be sure to discuss and negotiate the best deals from their providers.
One should note that many providers offer a limited selection of conferencing services. Most of the companies specialize in one or two services, like audio, video, web, or data. Web collaboration software, video equipment, and conferencing phones are also offered by some companies.
I have created my fair share of podcasts and found that recording phone conversations for interviews was a must. I also found that recording conference calls was a brutal exercise in futility and frustrating to say the least.
Yes, there are plenty of conference call companies out there who provide recording now but it seems bizarre how many of them are still delivering actual CDs and Tapes!? Most of them do not even make the recordings available online after the call, you have to ask for it and it costs extra.
There are free conference call providers out there that allow you to use their service free of charge who do provide recordings, but you have to pay for the long distance toll charges.
With some services it's as simple as a checkbox when you create your conference call online or if you are using the system in an ad-hoc reservationless fashion you can just enter "6#" on your phone to start or stop recording. Within a few minutes your call recording(s) will be waiting for you.
You can listen to the conference recording using the embedded flash player or download the recording MP3 to your computer. Some services also offers an RSS feed for the recordings that is quite unique. You can add recordings to your RSS feed creating a podcast that listeners can use to download recordings directly to their MP3 player or iPod. It's as easy as click on the plus button next to your recording. You can reverse the process as well by clicking the minus button to remove it from your podcast feed.
Now that we have our RSS feed link we can post it to our blog. When a reader subscribes to that RSS feed their reader will reflect the changes that you make to your feed. If you add a conference call to your feed they will see that and be able to listen to it. If you remove a conference call they will lose that call from their feed.The Benefits of Having a Reservationless Conference Call
Organizations of all types today utilize new communications technology to facilitate collaboration among members. One of the most-used and most useful applications is the teleconference, which enables multiple people and groups of people in separate locations to connect and talk on the same phone call. The teleconference has become a staple of business life, and it is used by all types of organizations, including multinational corporations, government agencies, universities and academic collaborators, and small businesses. New communications technologies facilitate the spread of information and ideas, and conference calls are no exception.
However, conference calls today still are not very user-friendly. Often there is a long dial-in number that needs to be distributed beforehand either through email or another phone call. Then after dialing that number, the teleconference participant must enter a code or password in order to join the conference. This process can be tedious and annoying in everyday situations; in the event of an emergency, this type of delay could actually be dangerous.
The reservationless conference call is the answer to quickly setting up and participating in a teleconference with either a handful or dozens of other people. Not all mass notification companies offer the option of setting up an instant conference call, so it is important to make sure that the company you select offers this service. The notification company will contain the contact information of the organization's members in its database, and when an administrator or other user sends out a message, they can select the option to connect that person to an on-demand conference call.
Imagine this situation: your company receives word that a natural disaster has occurred at or near one of its facilities. Management needs to be notified immediately to determine the details of the situation and to decide what course of action to take. How do you connect all of these people in the fastest way possible? You could contact all of them by phone individually, but this wastes valuable time in a critical situation. You can email them, but there is no guarantee they will see the email or realize the severity immediately.
The solution is an emergency notification service that has the ability to set up a reservationless conference call. Simply send out a message to your users, telling them that a critical situation has occurred. This message will be send over multiple modalities, including email, SMS text message to cell phones, and voice messages to cell phones, home phones, work phones, and BlackBerry PINs. The message will give the user the option to connect instantly to an on-demand conference call. In a matter of seconds, your whole team can be connected to a reservationless conference call, without all the hassle and waste of first setting up the conference, then notifying all of the participants of the dial-in number and the password, and then waiting for all the the participants to dial in and enter their passwords.
Conference Call Providers
Conference call providers are the ones who enable the basic service for conference calls, either on web conferencing software or on a comparative low cost audio conferencing solution for online conference call meetings. They provide advanced teleconferencing platforms for customers to place international phone calls to anywhere in the world. With these features and calling flexibility, the telecom costs can be easily reduced by 90% over the traditional phone companies. This helps businesses to save money on international phone bills.
An organization can have up to 50 people connected on a single call through a conference caller, and be billed the same rate as a regular phone call. They don’t have to pay those high per-minute rates from other telecom companies. Conference call providers use the latest digital routing and switching equipment. Nowadays, conference call providers use full fiber-optic cabling throughout the network, providing callers with the finest quality service available, with a good bandwidth and less noise and transmission errors. There are multiple options to connect to a conference call provider. You can dial into a local toll-free access number, enter your conference code and get connected.
For conference call providers, with Conference Caller Web Dial Out, the calls are initiated via the Internet, are able to be received at any time of the day, 7 days a week. The fully automated system acts as a 24-hour operator, connecting organizations to their international partners and clients.
A lot of these providers are full-service conference call companies offering quality service and low-cost options. These companies provide personalized service for all of your conferencing needs. Affordable conference call provider rates, obviously, are preferred by most businesses. Reasonable pricing is the growing trend in the conferencing industry. Conference call providers are battling for their share of the marketplace. One must be sure to discuss and negotiate the best deals from their providers.
One should note that many providers offer a limited selection of conferencing services. Most of the companies specialize in one or two services, like audio, video, web, or data. Web collaboration software, video equipment, and conferencing phones are also offered by some companies.
Sunday, July 27, 2008
MIGRAINE
Migraine
From Wikipedia, the free encyclopedia
Jump to: navigation, search
This article is about the disorder. For other uses, see Migraine
(disambiguation).
MigraineClassification and external resources
ICD-10
G43.
ICD-9
346
OMIM
157300
DiseasesDB
8207
MedlinePlus
000709
eMedicine
neuro/218 neuro/517 emerg/230 neuro/529
MeSH
D008881
Migraine is a neurological syndrome characterized by altered bodily experiences, painful headaches, and nausea. It is a common condition which affects women more frequently than it does men.
The typical migraine headache is one-sided and pulsating, lasting 4 to 72 hours[1]. Accompanying complaints are nausea and vomiting, and a heightened sensitivity to bright lights (photophobia) and noise (hyperacusis).[2][3][4] Approximately one third of people who experience migraine get a preceding aura, in which a patient may sense a strange light or unpleasant smell.[5] Patients often describe triggers they feel precipitate an episode of migraine, such as certain foods and beverages (like chocolate or alcohol), stress or menstruation. In some migraine types there are typical features but the headache remains absent, and in children abdominal pain may be a prominent feature.
Although the exact cause of migraine remains unknown, the most widespread theory is that it is a disorder of the serotonergic control system. Genetic factors may also contribute.[6] Studies on twins show that genes have a 60 to 65% influence on the development of migraine .[7][8] Fluctuating hormone levels show a relation to migraine in several ways: three quarters of adult migraine patients are female while migraine affects approximately equal numbers of boys and girls before puberty,[citation needed] and migraine is known to disappear during pregnancy in a substantial number of sufferers.
The treatment of migraine begins with simple painkillers for headache and anti-emetics for nausea, and avoidance of triggers if present. Specific anti-migraine drugs can be used to treat migraine. If the condition is severe and frequent enough, preventative drugs might be considered.
The word migraine is French in origin and comes from the Greek hemicrania, as does the Old English term megrim. Literally, hemicrania means "half (the) head".
Contents[hide]
1 Classification
1.1 Defining severity of pain
1.2 Migraine without aura
1.3 Migraine with aura
1.4 Basilar type migraine
1.5 Familial hemiplegic migraine
1.6 Abdominal migraine
1.7 Acephalgic migraine
1.8 Menstrual migraine
2 Signs and symptoms
2.1 Prodrome phase
2.2 Aura phase
2.3 Pain phase
2.4 Postdrome phase
3 Diagnosis
4 Pathophysiology
4.1 Depolarization theory
4.2 Vascular theory
4.3 Serotonin theory
4.4 Neural theory
4.5 Unifying theory
5 Epidemiology
6 Triggers
6.1 Food
6.2 Weather
6.3 Head position
7 Treatment
7.1 Abortive treatment
7.1.1 Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)
7.1.2 Analgesics combined with antiemetics
7.1.3 Serotonin agonists
7.1.4 Ergot alkaloids
7.1.5 Steroids
7.1.6 Other agents
7.1.6.1 Status migrainosus
7.1.6.2 Herbal treatment
7.1.7 Comparative studies
7.2 Preventive treatment
7.2.1 Prescription drugs
7.2.2 Trigger avoidance
7.2.3 Herbal and nutritional supplements
7.2.3.1 Butterbur
7.2.3.2 Cannabis
7.2.3.3 Coenzyme Q10
7.2.3.4 Feverfew
7.2.3.5 Magnesium Citrate
7.2.3.6 Riboflavin
7.2.3.7 Vitamin B12
7.2.4 Surgical treatments
7.2.5 Noninvasive medical treatments
7.2.6 Behavioral treatments
7.2.7 Alternative medicine
8 History
9 Economic impact
10 Migraine and cardiovascular risks
11 References
11.1 Migraine triggers
11.2 Treatment
11.2.1 Triptans
11.3 General
11.4 Economic impact
11.5 Clinical picture
12 Footnotes
13 External links
13.1 General information
13.2 Organizations
//
[edit] Classification
Migraines have been classified by the International Headache Society which periodically revises their classification.[9]
[edit] Defining severity of pain
In addition to classifying the type of headache, the International Headache Society defines intensity of pain on a verbal 4 point scale:[10]
Number
Name
Annotations
0
no pain
1
mild pain
does not interfere with usual activities
2
moderate pain
inhibits, but does not wholly prevent usual activities
3
severe pain
prevents all activities
[edit] Migraine without aura
This is the most commonly seen form of migraine; patients who primarily suffer from migraine without aura may also have attacks of migraine with aura. According to the International Classification of Headache Disorders[9] it is a recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and hyperacusis. In order to diagnose migraine without aura, there must have been at least five attacks not attributable to another cause that fulfill the following criteria:
Headache attacks lasting 4–72 hours when untreated
At least two of the following characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity
During the headache there must be at least one of the following associated symptom clusters:
Nausea and/or vomiting
Photophobia and hyperacusis
Where these criteria are not fully met, the problem may be classified as "probable migraine without aura" but other diagnoses such as "episodic tension type headache" must also be considered.
[edit] Migraine with aura
This is the second most commonly seen form of migraine: patients who primarily suffer from migraine with aura may also have attacks of migraine without aura. According to the International Classification of Headache Disorders[9] it is a recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes. Headache with the features of "migraine without aura" usually follows the aura symptoms. Less commonly, the aura may occur without a subsequent headache or the headache may be non-migrainous in type.
In order to diagnose migraine with aura, there must have been at least two attacks not attributable to another cause that fulfill the following criteria:
Aura consisting of at least one of the following, but no muscle weakness or paralysis:
Fully reversible visual symptoms (e.g. flickering lights, spots, lines, loss of vision)
Fully reversible sensory symptoms (e.g. pins and needles, numbness)
Fully reversible dysphasia (speech disturbance)
Aura has at least two of the following characteristics:
Visual symptoms affecting just one side of the field of vision and/or sensory symptoms affecting just one side of the body
At least one aura symptom develops gradually over more than 5 minutes and/or different aura symptoms occur one after the other over more than 5 minutes
Each symptom lasts from 5–60 minutes
Where these criteria are not fully met, a diagnosis of "probable migraine with aura" may be considered, although other neurological causes must also be considered. If the picture complies with the criteria but includes one-sided muscular weakness or paralysis, a diagnosis of "sporadic hemiplegic migraine" or "familial hemiplegic migraine" should be considered.
[edit] Basilar type migraine
Basilar type migraine (BTM), formerly known as basilar artery migraine (BAM) or basilar migraine (BM), is an uncommon type of complicated migraine with symptoms that result from brainstem dysfunction. Serious episodes of BTM can lead to stroke, coma, or even death. The use of triptans and other vasoconstrictors as abortive treatments in BTM is contraindicated. Abortive treatments for BTM often focus on vasodilation and restoration of normal blood flow to the vertebrobasilar territory and subsequent return of normal brainstem function.
[edit] Familial hemiplegic migraine
Main article: Familial hemiplegic migraine
Familial hemiplegic migraine 'FHM' is a type of migraine with a possible polygenetic component. These migraine attacks may last 4–72 hours[9] and are apparently caused by ion channel mutations, three types of which have been identified to date. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties. A non-familial form exists as well, "sporadic hemiplegic migraine" (SHM). It is often difficult to make the diagnosis between basilar-type migraine and hemiplegic migraine. When making the differential diagnosis is difficult, the deciding symptom is often the motor weakness or unilateral paralysis which can occur in FHM or SHM. While basilar-type migraine can present with tingling or numbness, true motor weakness and/or paralysis occur only in hemiplegic migraine.
[edit] Abdominal migraine
According to the International Classification of Headache Disorders[9] abdominal migraine is a recurrent disorder of unknown origin which occurs mainly in children. It is characterised by episodes of moderate to severe central abdominal pain lasting 1–72 hours. There is usually associated nausea and vomiting but the child is entirely well between attacks.
In order to diagnose abdominal migraine, there must be at least five attacks, not attributable to another cause, fulfilling the following criteria:
Attacks lasting 1–72 hours when untreated
Pain must have ALL of the following characteristics:
Location in the midline, around the umbilicus or poorly localised
Dull or 'just sore' quality
Moderate or severe intensity
During an attack there must be at least two of the following:
Loss of appetite
Nausea
Vomiting
Pallor
Most children with abdominal migraine will develop migraine headache later in life and the two may co-exist during adolescence.
[edit] Acephalgic migraine
Acephalgic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience aura symptoms such as scintillating scotoma, nausea, photophobia, hemiparesis and other migraine symptoms but does not experience headache. Acephalgic migraine is also referred to as amigrainous migraine, ocular migraine, or optical migraine.
Sufferers of acephalgic migraine are more likely than the general population to develop classical migraine with headache.
The prevention and treatment of acephalgic migraine is broadly the same as for classical migraine. However, because of the absence of "headache", diagnosis of acephalgic migraine is apt to be significantly delayed and the risk of misdiagnosis significantly increased.
Visual snow might be a form of acephalgic migraine.
If symptoms are primarily visual, it may be necessary to consult an ophthalmologist to rule out potential eye disease before considering this diagnosis.
[edit] Menstrual migraine
Menstrual migraine is distinct from other migraines. Approximately 21 million women in the US suffer from migraines,[11] and about 60% of them suffer from menstrual migraines.[12]
There are two types of menstrual migraine – Menstrually Related Migraine (MRM) and Pure Menstrual Migraine (PMM)
MRM is a headache of moderate-to-severe pain intensity that happens around the time of a woman’s period and at other times of the month as well.
PMM is similar in every respect but only occurs around the time of a woman’s period.[13]
The exact causes of menstrual migraine are uncertain but evidence suggest there may be a link between menstruation and migraine due to the drop in estrogen levels that normally occurs right before the period starts.[14]
Menstrual migraine has been reported to be more likely to occur during a five-day window, from two days before to two days after menstruation.[15]
When compared with migraines that occur at other times of the month, menstrual migraines have been reported to
Last longer—up to 72 hours[16]
Be more severe[15][17]
Occur more often with nausea and vomiting[12]
Be more difficult to treat—occur more frequently[18]
[edit] Signs and symptoms
The signs and symptoms of migraine vary among patients. Therefore, what a patient experiences before, during and after an attack cannot be defined exactly. The four phases of a migraine attack listed below are common but not necessarily experienced by all migraine sufferers. Additionally, the phases experienced and the symptoms experienced during them can vary from one migraine attack to another in the same migraineur:
The prodrome, which occurs hours or days before the headache.
The aura, which immediately precedes the headache.
The pain phase, also known as headache phase.
The postdrome.
[edit] Prodrome phase
Prodromal symptoms occur in 40 to 60% of migraineurs (migraine sufferers). This phase may consist of altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff muscles (especially in the neck), constipation or diarrhea, increased urination, and other visceral symptoms. These symptoms usually precede the headache phase of the migraine attack by several hours or days, and experience teaches the patient or observant family how to detect that a migraine attack is near.
[edit] Aura phase
For the 20–30%[19][20] of individuals who suffer migraine with aura, this aura comprises focal neurological phenomena that precede or accompany the attack. They appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes. The headache phase of the migraine attack usually begins within 60 minutes of the end of the aura phase, but it is sometimes delayed up to several hours, and it can be missing entirely. Symptoms of migraine aura can be visual, sensory, or motor in nature.[21]
Visual aura is the most common of the neurological events. There is a disturbance of vision consisting usually of unformed flashes of white and/or black or rarely of multicolored lights (photopsia) or formations of dazzling zigzag lines (scintillating scotoma; often arranged like the battlements of a castle, hence the alternative terms "fortification spectra" or "teichopsia"). Some patients complain of blurred or shimmering or cloudy vision, as though they were looking through thick or smoked glass, or, in some cases, tunnel vision and hemianopsia. The somatosensory aura of migraine consists of digitolingual or cheiro-oral paresthesias, a feeling of pins-and-needles experienced in the hand and arm as well as in the nose-mouth area on the same side. Paresthesia migrate up the arm and then extend to involve the face, lips and tongue.
Other symptoms of the aura phase can include auditory or olfactory hallucinations, temporary dysphasia, vertigo, tingling or numbness of the face and extremities, and hypersensitivity to touch.
[edit] Pain phase
The typical migraine headache is unilateral, throbbing, moderate to severe and can be aggravated by physical activity. Not all of these features are necessary. The pain may be bilateral at the onset or start on one side and become generalized, and usually alternates sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides, and usually lasts between 4 and 72 hours in adults and 1 and 48 hours in children. The frequency of attacks is extremely variable, from a few in a lifetime to several times a week, and the average migraineur experiences from one to three headaches a month. The head pain varies greatly in intensity.
The pain of migraine is invariably accompanied by other features. Nausea occurs in almost 90 percent of patients, while vomiting occurs in about one third of patients. Many patients experience sensory hyperexcitability manifested by photophobia, phonophobia, osmophobia and seek a dark and quiet room. Blurred vision, nasal stuffiness, diarrhea, polyuria, pallor or sweating may be noted during the headache phase. There may be localized edema of the scalp or face, scalp tenderness, prominence of a vein or artery in the temple, or stiffness and tenderness of the neck. Impairment of concentration and mood are common. Lightheadedness, rather than true vertigo and a feeling of faintness may occur. The extremities tend to be cold and moist.
[edit] Postdrome phase
The patient may feel tired, "washed out", irritable, or listless and may have impaired concentration, scalp tenderness or mood changes. Some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise. Often, some of the minor headache phase symptoms may continue, such as loss of appetite, photophobia, and lightheadedness. On some patients, a 5 to 6 hour nap may reduce the pain, but slight headaches may still occur when standing or sitting quickly. Normally these symptoms go away after a good night's rest.
[edit] Diagnosis
Migraines are underdiagnosed[22] and misdiagnosed.[23] The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":
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
1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia
For migraine with aura, only two attacks are required to justify the diagnosis.
The mnemonic POUNDing (Pulsating, duration of 4–72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.[24]
The presence of either disability, nausea or sensitivity, can diagnose migraine with:[25]
sensitivity of 81%
specificity of 75%
[edit] Pathophysiology
Migraines were once thought to be initiated exclusively by problems with blood vessels. The vascular theory of migraines is now considered secondary to brain dysfunction[26] and claimed to have been discredited by others.[27]
The effects of migraine may persist for some days after the main headache has ended. Many sufferers report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed.
Migraine headaches can be a symptom of hypothyroidism.[citation needed]
[edit] Depolarization theory
A phenomenon known as cortical spreading depression can cause migraines.[28] In cortical spreading depression, neurological activity is depressed over an area of the cortex of the brain. This situation results in the release of inflammatory mediators leading to irritation of cranial nerve roots, most particularly the trigeminal nerve, which conveys the sensory information for the face and much of the head.
This view is supported by neuroimaging techniques, which appear to show that migraine is primarily a disorder of the brain (neurological), not of the blood vessels (vascular). A spreading depolarization (electrical change) may begin 24 hours before the attack, with onset of the headache occurring around the time when the largest area of the brain is depolarized. A French study in 2007, using the Positron Emission Tomography (PET) technique identified the hypothalamus as being critically involved in the early stages.[29]
[edit] Vascular theory
Migraines can begin when blood vessels in the brain contract and expand inappropriately. This may start in the occipital lobe, in the back of the brain, as arteries spasm. The reduced flow of blood from the occipital lobe triggers the aura that some individuals who have migraines experience because the visual cortex is in the occipital area.[26]
When the constriction stops and the blood vessels dilate, they become too wide. The once solid walls of the blood vessels become permeable and some fluid leaks out. This leakage is recognized by pain receptors in the blood vessels of surrounding tissue. In response, the body supplies the area with chemicals which cause inflammation. With each heart beat, blood passes through this sensitive area causing a throb of pain.[26]
The vascular theory of migraines is now seen as secondary to brain dysfunction.[26]
[edit] Serotonin theory
Serotonin is a type of neurotransmitter, or "communication chemical" which passes messages between nerve cells. It helps to control mood, pain sensation, sexual behaviour, sleep, as well as dilation and constriction of the blood vessels among other things. Serotonin levels in the brain may lead to a process of constriction and dilation of the blood vessels which trigger a migraine.[26] Triptans activate serotonin receptors to stop a migraine attack.[26]
[edit] Neural theory
When certain nerves or an area in the brain stem become irritated, a migraine begins. In response to the irritation, the body releases chemicals which cause inflammation of the blood vessels. These chemicals cause further irritation of the nerves and blood vessels and results in pain. Substance P is one of the substances released with first irritation. Pain then increases because substance P aids in sending pain signals to the brain.[26]
[edit] Unifying theory
Both vascular and neural influences cause migraines.
stress triggers changes in the brain
these changes cause serotonin to be released
blood vessels constrict
chemicals including substance P irritate nerves and blood vessels causing pain[26]
[edit] Epidemiology
Age-Gender Incidence
Migraine is an extremely common condition which will affect 12–28% of people at some point in their lives.[30] However this figure — the lifetime prevalence — does not provide a very clear picture of how many patients there are with active migraine at any one time. Typically, therefore, the burden of migraine in a population is assessed by looking at the one-year prevalence — a figure that defines the number of patients who have had one or more attacks in the previous year. The third figure, which helps to clarify the picture, is the incidence — this relates to the number of first attacks occurring at any given age and helps understanding of how the disease grows and shrinks over time.
Based on the results of a number of studies, one year prevalence of migraine ranges from 6–15% in adult men and from 14–35% in adult women.[30] These figures vary substantially with age: approximately 4–5% of children aged under 12 suffer from migraine, with little apparent difference between boys and girls.[31] There is then a rapid growth in incidence amongst girls occurring after puberty,[32][33][34] which continues throughout early adult life.[35] By early middle age, around 25% of women experience a migraine at least once a year, compared with fewer than 10% of men.[30][36] After menopause, attacks in women tend to decline dramatically, so that in the over 70s there are approximately equal numbers of male and female sufferers, with prevalence returning to around 5%.[30][36]
At all ages, migraine without aura is more common than migraine with aura, with a ratio of between 1.5:1 and 2:1.[37][38] Incidence figures show that the excess of migraine seen in women of reproductive age is mainly due to migraine without aura.[37] Thus in pre-pubertal and post-menopausal populations, migraine with aura is somewhat more common than amongst 15–50 year olds.[35][39]
There is a strong relationship between age, gender and type of migraine.[40]
Geographical differences in migraine prevalence are not marked. Studies in Asia and South America suggest that the rates there are relatively low,[41][42] but they do not fall outside the range of values seen in European and North American studies.[30][36]
The incidence of migraine is related to the incidence of epilepsy in families, with migraine twice as prevalent in family members of epilepsy sufferers, and more common in epilepsy sufferers themselves.[43]
[edit] Triggers
A migraine trigger is any factor that, on exposure or withdrawal, leads to the development of an acute migraine headache. Triggers may be categorized as behavioral, environmental, infectious, dietary, chemical, or hormonal. In the medical literature, these factors are known as 'precipitants.'
The MedlinePlus Medical Encyclopedia, for example, offers the following list of migraine triggers:
Migraine attacks may be triggered by:
Allergic reactions
Bright lights, loud noises, and certain odors or perfumes
Physical or emotional stress
Changes in sleep patterns
Smoking or exposure to smoke
Skipping meals
Alcohol
Menstrual cycle fluctuations, birth control pills, hormone fluctuations during the menopause transition
Tension headaches
Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG) or nitrates (like bacon, hot dogs, and salami)
Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products, and fermented or pickled foods.
—MedlinePlus medical encyclopedia[44]
Sometimes the migraine occurs with no apparent "cause". The trigger theory supposes that exposure to various environmental factors precipitates, or triggers, individual migraine episodes. Migraine patients have long been advised to try to identify personal headache triggers by looking for associations between their headaches and various suspected trigger factors and keeping a "headache diary" recording migraine incidents and diet to look for correlations in order to avoid trigger foods. It must be mentioned, that some trigger factors are quantitative in nature, i.e., a small block of dark chocolate may not cause a migraine, but half a slab of dark chocolate almost definitely will, in a susceptible person. In addition, being exposed to more than one trigger factor simultaneously will more likely cause a migraine, than a single trigger factor in isolation, e.g., drinking and eating various known dietary trigger factors on a hot, humid day, when feeling stressed and having had little sleep will probably result in a migraine in a susceptible person, but consuming a single trigger factor on a cool day, after a good night's rest with minimal environmental stress may mean that the sufferer will not develop a migraine after all. Migraines can be complex to avoid, but keeping an accurate migraine diary and making suitable lifestyle changes can have a very positive effect on the sufferer's quality of life. Some trigger factors are virtually impossible to avoid, e.g. the weather or emotions, but by limiting the avoidable trigger factors, the unavoidable ones may have less of an impact on the sufferer. [45]
[edit] Food
A 2005 literature review found that the available information about dietary trigger factors relies mostly on the subjective assessments of patients.[46] Some suspected dietary trigger factors appear to genuinely promote or precipitate migraine episodes, but many other suspected dietary triggers have never been demonstrated to trigger migraines. The review authors found that alcohol, caffeine withdrawal, and missing meals are the most important dietary migraine precipitants, that dehydration deserved more attention, and that some patients report sensitivity to red wine. Little or no evidence associated notorious suspected triggers like chocolate, cheese, histamine, tyramine, nitrates, or nitrites with migraines. The artificial sweetener aspartame has not been shown to trigger headache, but in a large and definitive study monosodium glutamate (MSG) in large doses (2.5 grams) was associated with adverse symptoms including headache more often than was placebo. The review authors also note that while general dietary restriction has not been demonstrated to be an effective migraine therapy, it is beneficial for the individual to avoid what has been a definite cause of the migraine.
The National Headache Foundation has a specific list of triggers based on the tyramine theory, detailing allowed, with caution and avoid triggers.[47]
[edit] Weather
Several studies have found some migraines are triggered by changes in weather. One study noted 62% of the subjects thought weather was a factor but only 51% were sensitive to weather changes.[48] Among those whose migraines did occur during a change in weather, the subjects often picked a weather change other than the actual weather data recorded. Most likely to trigger a migraine were, in order:
Temperature mixed with humidity. High humidity plus high or low temperature was the biggest cause.
Significant changes in weather
Changes in barometric pressure
Another study examined the effects of warm chinook winds on migraines, with many patients reporting increased incidence of migraines immediately before and/or during the chinook winds. The number of people reporting migrainous episodes during the chinook winds was higher on high-wind chinook days. The probable cause was thought to be an increase in positive ions in the air.[49]
[edit] Head position
One study suggests that migraines can be triggered by the head being held downwards for an extended period, as when washing hair in a basin.[50]
[edit] Treatment
Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs. Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all.
Children and adolescents, are often first given drug treatment, but the value of diet modification should not be overlooked. The simple task of starting a diet journal to help modify the intake of trigger foods like hot dogs, chocolate, cheese and ice cream could help alleviate symptoms[51]
[edit] Abortive treatment
Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. Hot or cold water applied to the head, resting in a dark and silent room or ingesting caffeine at an appropriate time may be as helpful as medication for some patients.[citation needed]
For patients who have been diagnosed with recurring migraines, migraine abortive medications can be used to treat the attack, and may be more effective if taken early, losing effectiveness once the attack has begun. Treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks.[citation needed]
[edit] Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)
The first line of treatment is over-the-counter abortive medication.
Regarding non-steroidal anti-inflammatory drugs, a randomized controlled trial found that naproxen can abort about one third of migraine attacks, which was 5% less than the benefit of sumatriptan.[52]
Paracetamol, at a dose of 1000 mg, benefited over half of patients with mild or moderate migraines in a randomized controlled trial.[53]
Simple analgesics combined with caffeine may help.[54] During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect, and probably accounts for its benefit.[citation needed] Excedrin is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. FDA as an Over The Counter Drug (OTC) treatment for migraine[citation needed].
Patients themselves often start off with paracetamol (known as acetaminophen in the USA), aspirin, ibuprofen, or other simple analgesics that are useful for tension headaches. OTC drugs may provide some relief, although they are typically not effective for most sufferers. It is one of doctors' practical diagnoses of migraine head pain when patients say typical OTC drugs "won't touch it".[citation needed]
[edit] Analgesics combined with antiemetics
Anti-emetics by mouth may help relieve symtoms of nausea and help prevent vomiting, which can diminish the effectiveness of orally taken analgesia. In addition some antiemetics such as metoclopramide are prokinetics and help gastric emptying which is often impaired during episodes of migraine. In the UK there are three combination antiemetic and analgesic preparations available: MigraMax (aspirin with metoclopramide), Migraleve (paracetamol/codeine for analgesia, with buclizine as the antiemetic) and paracetamol/metoclopramide (Paramax in UK).[55] The earlier these drugs are taken in the attack, the better their effect.
Some patients find relief from taking other sedative antihistamines which have anti-nausea properties, such as Benadryl which in the US contains diphenhydramine (but a different non-sedative product in the UK).
[edit] Serotonin agonists
Main article: triptans
Sumatriptan and related selective serotonin receptor agonists are excellent for severe migraines or those that do not respond to NSAIDs[52] or other over-the-counter drugs.[53] Triptans are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.
[edit] Ergot alkaloids
Until the introduction of sumatriptan in 1991, ergot derivatives (see ergoline) were the primary oral drugs available to abort a migraine once it is established.
Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine. However, ergotamine tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike triptans), have fallen out of favour due to the problem of ergotism. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. Anti-nausea administration is available by ergotamine suppository (or Ergostat sublingual tablets made until circa 1992). Ergot drugs themselves can be so nauseating it is advisable for the sufferer to have something at hand to counteract this effect when first using this drug. Ergotamine-caffeine 1/100 mg fixed ratio tablets (like Cafergot, Ercaf, etc.) are much less expensive per headache than triptans, and are commonly available in Asia. They are difficult to obtain in the USA. Ergotamine-caffeine can't be regularly used to abort evening or night onset migraines due to debilitating caffeine interference with sleep. Pure ergotamine tartrate is highly effective for evening-night migraines, but is rarely or never available in the USA. Dihydroergotamine (DHE), which must be injected or inhaled, can be as effective as ergotamine tartrate, but is much more expensive than $2 USD Cafergot tablets.
[edit] Steroids
Based on a recent meta analysis a single dose of iv dexamethasone, when added to standard treatment, is associated with a 26% decrease in headache recurrence.[56]
[edit] Other agents
If over-the-counter medications do not work, or if triptans are unaffordable, the next step for many doctors is to prescribe Fioricet or Fiorinal, which is a combination of butalbital (a barbiturate), Paracetamol (in Fioricet) or acetylsalicylic acid (more commonly known as aspirin and present in Fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches. Barbiturate-containing medications are not available in many European countries.
Amidrine (a cocktail of a pain reliever, a sedative, and a vasoconstrictor) is sometimes prescribed for migraine headaches.
Anti-emetics may need to be given by suppository or injection where vomiting dominates the symptoms.
[edit] Status migrainosus
Status migrainosus is characterized by migraine lasting more than 72 hours, with not more than four hours of relief during that period. It is generally understood that status migrainosus has been refractory to usual outpatient management upon presentation.
Treatment of status migrainosus consists of managing comorbidities (i. e. correcting fluid and electrolyte abnormalities resulting from anorexia and nausea/vomiting often accompanying status migr.), and usually administering parenteral medication to "break" (abort) the headache.
Although the literature is full of many case reports concerning treatment of status migrainosus, first line therapy consists of intravenous fluids, metoclopramide, and triptans or DHE.[57]
[edit] Herbal treatment
The herbal supplement feverfew (more commonly used for migraine prevention, see below) is marketed by the GelStat Corporation as an OTC migraine abortive, administered sublingually (under the tongue) in a mixture with ginger.[58] An open-label study (funded by GelStat) found some tentative evidence of the treatment's effectiveness,[59] but no scientifically sound study has been done. Cannabis in addition to prevention, is also known to relieve pain during the onset of a migraine.[citation needed]
[edit] Comparative studies
Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial[60] reveals that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and ibuprofen 400 mg are equally effective at providing relief from pain, although sumatriptan was superior in terms of the more demanding outcome of rendering patients entirely free of pain and all other migraine-related symptoms.
Another randomized controlled trial, funded by the manufacturer of the study drug, found that a combination of sumatriptan 85 mg and naproxen sodium 200 mg was better than either drug alone.[52]
[edit] Preventive treatment
Preventive (also called prophylactic) treatment of migraines can be an important component of migraine management. Such treatments can take many forms, including everything from taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers. One such book that outlines these preventative measures quite well is "7 Steps To A Healthy Brain" by Dr. Winner.
The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy.[61] Another reason to pursue these goals is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which is a common problem among migraneurs. This is believed to occur in part due to overuse of pain medications, and can result in chronic daily headache.[62]
[edit] Prescription drugs
A 2006 review article by S. Modi and D. Lowder offers some general guidelines on when a physician should consider prescribing drugs for migraine prevention:
Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered.
...Therapy should be initiated with medications that have the highest levels of effectiveness and the lowest potential for adverse reactions; these should be started at low dosages and titrated slowly. A full therapeutic trial may take two to six months. After successful therapy (e.g., reduction of migraine frequency by approximately 50 percent or more) has been maintained for six to 12 months, discontinuation of preventive therapy can be considered.
—[61]
Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
The most effective prescription medications include several drug classes:
beta blockers such as propranolol and atenolol. A meta-analysis by the Cochrane Collaboration of nine randomized controlled trials or crossover studies, which together included 668 patients, found that propranolol had an "overall relative risk of response to treatment (here called the 'responder ratio')" was 1.94.[63]
anticonvulsants such as valproic acid and topiramate. A meta-analysis by the Cochrane Collaboration of ten randomized controlled trials or crossover studies, which together included 1341 patients, found anticonvulsants had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a number needed to treat of 3.8.[64] However, concerns have been raised about the marketing of gabapentin.[65]
antidepressants include tricyclic antidepressants (TCAs) such as amitriptyline and the newer selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine. A meta-analysis by the Cochrane Collaboration found selective serotonin reuptake inhibitors are no more effective than placebo.[66] Another meta-analysis found benefit from SSRIs among patients with migraine or tension headache; however, the effect of SSRIs on only migraines was not separately reported.[67] A randomized controlled trial found that amitriptyline was better than placebo and similar to propranolol.[68]
Other drugs:
Sansert was withdrawn from the US market by Novartis, but is available in Canadian pharmacies. Although highly effective, it has rare but serious side effects, including retroperitoneal fibrosis.
Namenda, memantine HCI tablets, which is used in the treatment of Alzheimer's Disease, is beginning to be used off label for the treatment of migraines. It has not yet been approved by the FDA for the treatment of migraines.
ASA or Aspirin can be taken daily in low doses such as 80 to 81 mg, the blood thinners in ASA have been shown to help some migrainures, especially those who have an aura.
[edit] Trigger avoidance
Patients can attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. General dietary restriction has not been demonstrated to be an effective approach to treating migraine, and migraine is remarkably resistant to the placebo effect [3]
Nonetheless, some people fervently claim that they have successfully identified foods that are likely to result in migraines, and by avoiding them, can decrease the likelihood of an episode.
[edit] Herbal and nutritional supplements
[edit] Butterbur
50 mg or 75 mg/day of butterbur (Petasites hybridus) rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex, does not.[4]
[edit] Cannabis
Cannabis was a standard treatment for migraines from the mid-19th century until it was outlawed in the early 20th century in the USA. It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura. There is some indication that semi-regular use may reduce the frequency of attacks. Further studies are being conducted. Some migraine sufferers report that cannabis decreases throbbing and pain, especially if smoked. A pharmaceutical company is currently conducting trials of a whole cannabis extract spray for migraine[5]
[edit] Coenzyme Q10
Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines. In an open-label trial,[69] Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.[70]
[edit] Feverfew
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. A number of clinical trials have been carried out to test this claim, but a 2004 review article concluded that the results have been contradictory and inconclusive.[71] However, since then, more studies have been carried out.[72] As well as its prophylactic properties, feverfew is also touted as a migraine abortative.
[edit] Magnesium Citrate
Magnesium citrate has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9–12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.[73]
[edit] Riboflavin
The supplement Riboflavin (also called Vitamin B2) has been shown (in a placebo-controlled trial)[74] to reduce the number of migraines, when taken at the high dose of 400 mg daily for three months.[75][76]
[edit] Vitamin B12
There is tentative evidence that Vitamin B12 may be effective in preventing migraines.[75] In particular, in an open-label pilot study, 1 mg of intranasal hydroxocobalamin (a form of Vitamin B12), taken daily for three months, was shown to reduce migraine frequency by 50% or more in 10 of 19 participants.[77] Although the study was not placebo-controlled, this response is larger than the typical placebo effect in migraine prophylaxis.[78]
[edit] Surgical treatments
Surgery may be used to treat migraines by severing the corrugator supercilii muscle and zygomaticotemporal nerve.[79] The treatment may reduce or eliminate headaches in some individuals.[80]
In 2005, research[81] was published indicating that in some people with a patent foramen ovale (PFO), a hole between the upper chambers of the heart, suffer from migraines which may have been caused by the PFO. The migraines reduce in frequency if the hole is patched. Several clinical trials are currently under way in an effort to determine if a causal link between PFO and migraine can be found. Early speculation as to this relationship has centered on the idea that the lungs detoxify blood as it passes through. The PFO allows uncleaned blood to go directly from the right side of the heart to the left without passing through the lungs.
Botulin toxin has been used to treat individuals with frequent or chronic migraines.[82] Its usefulness is uncertain with evidence suggesting it is not superior to placebo treatment[83] and does not appear to be useful in the treatment of episodic migraine.[84]
Spinal cord stimulators are an implanted medical device sometimes used for those who suffer severe migraines several days each month.[85]
[edit] Noninvasive medical treatments
Transcranial Magnetic Stimulation (TMS): At the 49th Annual meeting of the American Headache Society in June 2006, scientists from Ohio State University Medical Center presented medical research on 47 candidates that demonstrated that TMS — a medically non-invasive technology for treating depression, obsessive compulsive disorder and tinnitus, among other ailments — helped to prevent and even reduce the severity of migraines among its patients. This treatment essentially disrupts the aura phase of migraines before patients develop full-blown migraines.[6] In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light.[7] Their research suggests that there is a strong neurological component to migraines. A larger study will be conducted soon to better assess TMS's complete effectiveness.[86] In June 2008, a hand-held apparatus designed to apply TMS as a preemptive therapy to avert a migraine attack at the onset of the aura phase was introduced in California.[8]
Biofeedback has been used successfully by some to control migraine symptoms through training and practice.[87]
Hyperbaric oxygen therapy has been used successfully in treating migraines.[88] This suggests that sufferers might be treated during an attack with a hyperbaric chamber of some sort, such as a Gamow bag (as is done in the treatment of "The Bends" and altitude sickness).
Bruxism, clenching or grinding of teeth, especially at night, is a trigger for many migraineurs. A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching. It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth. It has a success rate similar to butterbur and co-enzyme Q10, although it has not been subjected to the same rigorous testing as the supplements. Massage therapy of the jaw area can also reduce such pain.
There is a speculative connection between vision correction (particular with prism eyeglasses) and migraines. Two British studies, one from 1934[89] and another from 1956[90] claimed that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions, which included prescribed prism. However, both studies are subject to criticism because of sample bias, sample size, and the lack of a control group. A more recent study [9] found that precision tinted lenses may be an effective migraine treatment. (Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches.)
[edit] Behavioral treatments
Many physicians believe that exercise for 15–20 minutes per day is helpful for reducing the frequency of migraines.[91]
Sleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.
Diet, visualization, and self-hypnosis are also alternative treatments and prevention approaches.
Sexual activity has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases.[10]
In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache.
[edit] Alternative medicine
A number of forms of alternative medicine, particularly bodywork, are used in preventing migraines.
Massage therapy and physical therapy are often very effective forms of treatment to reduce the frequency and intensity of migraines.[citation needed] However, it is important to be treated by a well-trained therapist who understands the pathophysiology of migraines. Deep massage can 'trigger' a migraine attack in a person who is not used to such treatments. It is advisable to start sessions as short in duration and then work up to longer treatments. Likewise, some migraine sufferers find relief through chiropractic care.[citation needed]
Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that Myofascial Release can relieve this tension and in doing so reduce or eliminate the stress headache element.[citation needed]
Some migraine sufferers find relief through acupuncture, which is usually used to help prevent headaches from developing.[92] Sometimes acupuncture is used to relieve the pain of an active migraine headache.[93] In one controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.[citation needed]
Additionally acupressure is used by some for relief. For instance pressure between the thumbs and index finger to help subside headaches if the headache or migraine isn't too severe.[citation needed]
Incense and scents are shown to help. The smell and incense of peppermint and lavender have been proven to help with migraines and headaches more so than most other scents.[94] However, some scents can be a trigger factor.
[edit] History
9000 year old skulls exist with evidence of trepanation. It is hypothesized that this drastic step was taken in response to headaches, though there is no clear evidence proving this.[citation needed]. Headache with neuralgia was recorded in the medical documents of the ancient Egyptians as early as 1200 BC. In 400 BC Hippocrates described the visual aura that can precede the migraine headache and the relief which can occur through vomiting. Aretaeus of Cappadocia is credited as the "discoverer" of migraines because of his second century description of the symptoms of a unilateral headache associated with vomiting, with headache-free intervals in between attacks. Galenus of Pergamon used the term "hemicrania" (half-head), from which the word "migraine" was derived. He thought there was a connection between the stomach and the brain because of the nausea and vomiting that often accompany an attack. For relief of migraine, Andalusian-born physician Abulcasis, also known as Abu El Quasim, suggested application of a hot iron to the head or insertion of garlic into an incision made in the temple. In the Medieval Ages migraine was recognized as a discrete medical disorder with treatment ranging from hot irons to blood letting and even witchcraft[citation needed]. Followers of Galenus explained migraine as caused by aggressive yellow bile. Ebn Sina (Avicenna) described migraine in his textbook "El Qanoon fel teb" as "... small movements, drinking and eating, and sounds provoke the pain... the patient cannot tolerate the sound of speaking and light. He would like to rest in darkness alone." Abu Bakr Mohamed Ibn Zakariya Râzi noted the association of headache with different events in the lives of women, "...And such a headache may be observed after delivery and abortion or during menopause and dysmenorrhea."
In Bibliotheca Anatomica, Medic, Chirurgica, published in London in 1712, five major types of headaches are described, including the "Megrim", recognizable as classic migraine. Graham and Wolff (1938) published their paper advocating ergotamine tart for relieving migraine. Later in the 20th century, Harold Wolff (1950) developed the experimental approach to the study of headache and elaborated the vascular theory of migraine, which has come under attack as the pendulum again swings to the neurogenic theory.
[edit] Economic impact
In addition to being a major cause of pain and suffering, chronic migraine attacks are a significant source of both medical costs and lost productivity. Medical costs per migraine sufferer (mostly physician and emergency room visits) averaged $107 USD over six months in one 1988 study,[citation needed] with total costs including lost productivity averaging $313. Annual employer cost of lost productivity due to migraines was estimated at $3,309 per sufferer. Total medical costs associated with migraines in the United States amounted to one billion dollars in 1994, in addition to lost productivity estimated at thirteen to seventeen billion dollars per year. Employers may benefit from educating themselves on the effects of migraines in order to facilitate a better understanding in the workplace. The workplace model of 9–5, 5 days a week may not be viable for a migraine sufferer. With education and understanding an employer could compromise with an employee to create a workable solution for both.
[edit] Migraine and cardiovascular risks
The risk of stroke may be increased two- to threefold in migraine sufferers. Young adult sufferers and women using hormonal contraception appear to be at particular risk.[95] The mechanism of any association is unclear, but chronic abnormalities of cerebral blood vessel tone may be involved. Women who experience auras have been found to have twice the risk of strokes and heart attacks over non-aura migraine sufferers and women who do not have migraines.[96][95] Migraine sufferers seem to be at risk for both thrombotic and hemorrhagic stroke as well as transient ischemic attacks.[97] Death from cardiovascular causes was higher in people with migraine with aura in a Women's Health Initiative study, but more research is needed to confirm this.[98][99]
[edit] References
[edit] Migraine triggers
Federation of American Societies for Experimental Biology [FASEB] [1995]. Analysis of adverse reactions to monosodium glutamate (MSG). Bethesda, MD: Life Sciences Research Office, FASEB.
Ravishankar, K (2006). 'Hair wash' or 'Head bath' triggering migraine - observations in 94 Indian patients". Cephalagia 26 (11): 1330–1334. ISSN 0333-1024.
[edit] Treatment
Pearce, J.M.S. (1994). Headache. Neurological Management series. Journal of Neurology Neurosurgery and Psychiatry. 57, 134–144.
Mayo Clinic Staff. (2005). Migraine Headache. Retrieved August 14, 2005
Cathy Wong, ND. (2005). Migraine Elimination Diet Retrieved August 14, 2005
Treatment Articles (2005). Butterbur, Co-enzyme Q-10, Melatonin, Folic Acid
Buchholz, D. (2002) Heal your headache: The 1-2-3 Program, New York: Workman Publishing, ISBN 0-7611-2566-3
Livingstone, I. and Novak, D. (2003) Breaking the Headache Cycle, New York: Henry Holt and Co. ISBN 0-8050-7221-7
Izecksohn L, and Izecksohn C. . Fluids' Hypertension Syndromes, ISBN 978-85-906664-0-0.
[edit] Triptans
Cohen JA, Beall D, Beck A, et al. Sumatriptan treatment for migraine in a health maintenenace organization: economic, humanistic, and clinical outcomes. Clin Ther 1999;21:190–205.
Adelman JU, Sharfman M, Johnson R, et al. Impact of oral sumatriptan on workplace productivity, health-related quality of life, healthcare use, and patient satisfaction with medication in nurses with migraine. Am J Manag Care 1996;2:1407–1416.
Cohen JA, Beall DG, Miller DW, Beck A, Pait G, Clements BD. Subcutaneous sumatriptan for the treatment of migraine: humanistic, economic, and clinical consequences. Fam Med 1996;28:171–177.
Jhingran P, Cady RK, Rubino J, Miller D, Grice RB, Gutterman DL. Improvements in health-related quality of life with sumatriptan treatment for migraine. J Med Econ 1996;42:36–42.
Solomon GD, Nielsen K, Miller D. The effects of sumatriptan on migraine: health-related quality of life. Med Interface 1995;June:134–141.
Solomon GD, Skobieranda FG, Genzen JR. Quality of life assessment among migraine patients treated with sumatriptan. Headache 1995;35:449–454.
Santanello NC, Polis AB, Hartmaier SL, Kramer MS, Block GA, Silberstein SD. Improvement in migrainespecific quality of life in a clinical trial of rizatriptan. Cephalalgia 1997;17:867–872.
Caro JJ, Getsios D. Pharmacoeconomic evidence and considerations for triptan treatment of migraine. Expert Opin Pharmacother 2002;3:237–248.
Lofland JH, Johnson NE, Batenhorst AS, Nash DB. Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective. Arch Intern Med 1999;159: 857–863.
Cady RC, Ryan R, Jhingran P, O’Quinn S, Pait DG. Sumatriptan injection reduces productivity loss during a migraine attack. Arch Intern Med 1998;158: 1013–1018.
Litaker DG, Solomon GD, Genzen JR. Impact of sumatriptan on clinic utilization and costs of care in migraineurs. Headache 1996;36:538–541.
Greiner DL, Addy SN. Sumatriptan use in a large group-model health maintenance organization. Am J Health Syst Pharm 1996;53:633–638.
Lofland JH, Kim SS, Batenhorst AS, et al. Cost-effectiveness and cost-benefit of sumatriptan in patients with migraine. Mayo Clin Proc 2001;76:1093–1101.
Biddle AK, Shih YC, Kwong WJ. Cost-benefit analysis of sumatriptan tablets versus usual therapy for treatment of migraine. Pharmacotherapy 2000;20: 1356–1364.
Caro JJ, Getsios D, Raggio G, Caro G, Black L. Treatment of migraine in Canada with naratriptan: a costeffectiveness analysis. Headache 2001;41:456–464.
[edit] General
Sacks, Oliver (1999) Migraine, Vintage ISBN 0-520-08223-0
Relouzat, Raoul & Thiollet, Jean-Pierre, Vaincre la migraine, Anagramme, 2006 ISBN 2-35035046
[edit] Economic impact
Edmeads J, Mackell JA. The economic impact of migraine: an analysis of direct and indirect costs. Headache 2002;42:501–509.
Gerth WC, Carides GW, Dasbach EJ, Visser WH, Santanello NC. The multinational impact of migraine symptoms on healthcare utilisation and work loss. Pharmacoeconomics 2001;19:197–206.
Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med 1999;159:813–818.
Osterhaus JT, Gutterman DL, Plachetka JR. Healthcare resource and low labour costs of migraine headaches in the US. Pharmacoeconomics 1992;2:2–11.
[edit] Clinical picture
Blau JN. Classical migraine: symptoms between visual aura and headache onset. Lancet 1992;340:355-6.
Silberstein SD: Migraine symptoms: Results of a survey of self-reported migraineurs. Headache 1995;35:387-96.
Silberstein SD, Saper JR, Freitag F. Migraine: Diagnosis and treatment. In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Wolff's headache and other head pain. 7th ed. New York: Oxford University Press, 2001:121–237.
From Wikipedia, the free encyclopedia
Jump to: navigation, search
This article is about the disorder. For other uses, see Migraine
(disambiguation).MigraineClassification and external resources
ICD-10
G43.
ICD-9
346
OMIM
157300
DiseasesDB
8207
MedlinePlus
000709
eMedicine
neuro/218 neuro/517 emerg/230 neuro/529
MeSH
D008881
Migraine is a neurological syndrome characterized by altered bodily experiences, painful headaches, and nausea. It is a common condition which affects women more frequently than it does men.
The typical migraine headache is one-sided and pulsating, lasting 4 to 72 hours[1]. Accompanying complaints are nausea and vomiting, and a heightened sensitivity to bright lights (photophobia) and noise (hyperacusis).[2][3][4] Approximately one third of people who experience migraine get a preceding aura, in which a patient may sense a strange light or unpleasant smell.[5] Patients often describe triggers they feel precipitate an episode of migraine, such as certain foods and beverages (like chocolate or alcohol), stress or menstruation. In some migraine types there are typical features but the headache remains absent, and in children abdominal pain may be a prominent feature.
Although the exact cause of migraine remains unknown, the most widespread theory is that it is a disorder of the serotonergic control system. Genetic factors may also contribute.[6] Studies on twins show that genes have a 60 to 65% influence on the development of migraine .[7][8] Fluctuating hormone levels show a relation to migraine in several ways: three quarters of adult migraine patients are female while migraine affects approximately equal numbers of boys and girls before puberty,[citation needed] and migraine is known to disappear during pregnancy in a substantial number of sufferers.
The treatment of migraine begins with simple painkillers for headache and anti-emetics for nausea, and avoidance of triggers if present. Specific anti-migraine drugs can be used to treat migraine. If the condition is severe and frequent enough, preventative drugs might be considered.
The word migraine is French in origin and comes from the Greek hemicrania, as does the Old English term megrim. Literally, hemicrania means "half (the) head".
Contents[hide]
1 Classification
1.1 Defining severity of pain
1.2 Migraine without aura
1.3 Migraine with aura
1.4 Basilar type migraine
1.5 Familial hemiplegic migraine
1.6 Abdominal migraine
1.7 Acephalgic migraine
1.8 Menstrual migraine
2 Signs and symptoms
2.1 Prodrome phase
2.2 Aura phase
2.3 Pain phase
2.4 Postdrome phase
3 Diagnosis
4 Pathophysiology
4.1 Depolarization theory
4.2 Vascular theory
4.3 Serotonin theory
4.4 Neural theory
4.5 Unifying theory
5 Epidemiology
6 Triggers
6.1 Food
6.2 Weather
6.3 Head position
7 Treatment
7.1 Abortive treatment
7.1.1 Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)
7.1.2 Analgesics combined with antiemetics
7.1.3 Serotonin agonists
7.1.4 Ergot alkaloids
7.1.5 Steroids
7.1.6 Other agents
7.1.6.1 Status migrainosus
7.1.6.2 Herbal treatment
7.1.7 Comparative studies
7.2 Preventive treatment
7.2.1 Prescription drugs
7.2.2 Trigger avoidance
7.2.3 Herbal and nutritional supplements
7.2.3.1 Butterbur
7.2.3.2 Cannabis
7.2.3.3 Coenzyme Q10
7.2.3.4 Feverfew
7.2.3.5 Magnesium Citrate
7.2.3.6 Riboflavin
7.2.3.7 Vitamin B12
7.2.4 Surgical treatments
7.2.5 Noninvasive medical treatments
7.2.6 Behavioral treatments
7.2.7 Alternative medicine
8 History
9 Economic impact
10 Migraine and cardiovascular risks
11 References
11.1 Migraine triggers
11.2 Treatment
11.2.1 Triptans
11.3 General
11.4 Economic impact
11.5 Clinical picture
12 Footnotes
13 External links
13.1 General information
13.2 Organizations
//
[edit] Classification
Migraines have been classified by the International Headache Society which periodically revises their classification.[9]
[edit] Defining severity of pain
In addition to classifying the type of headache, the International Headache Society defines intensity of pain on a verbal 4 point scale:[10]
Number
Name
Annotations
0
no pain
1
mild pain
does not interfere with usual activities
2
moderate pain
inhibits, but does not wholly prevent usual activities
3
severe pain
prevents all activities
[edit] Migraine without aura
This is the most commonly seen form of migraine; patients who primarily suffer from migraine without aura may also have attacks of migraine with aura. According to the International Classification of Headache Disorders[9] it is a recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and hyperacusis. In order to diagnose migraine without aura, there must have been at least five attacks not attributable to another cause that fulfill the following criteria:
Headache attacks lasting 4–72 hours when untreated
At least two of the following characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity
During the headache there must be at least one of the following associated symptom clusters:
Nausea and/or vomiting
Photophobia and hyperacusis
Where these criteria are not fully met, the problem may be classified as "probable migraine without aura" but other diagnoses such as "episodic tension type headache" must also be considered.
[edit] Migraine with aura
This is the second most commonly seen form of migraine: patients who primarily suffer from migraine with aura may also have attacks of migraine without aura. According to the International Classification of Headache Disorders[9] it is a recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes. Headache with the features of "migraine without aura" usually follows the aura symptoms. Less commonly, the aura may occur without a subsequent headache or the headache may be non-migrainous in type.
In order to diagnose migraine with aura, there must have been at least two attacks not attributable to another cause that fulfill the following criteria:
Aura consisting of at least one of the following, but no muscle weakness or paralysis:
Fully reversible visual symptoms (e.g. flickering lights, spots, lines, loss of vision)
Fully reversible sensory symptoms (e.g. pins and needles, numbness)
Fully reversible dysphasia (speech disturbance)
Aura has at least two of the following characteristics:
Visual symptoms affecting just one side of the field of vision and/or sensory symptoms affecting just one side of the body
At least one aura symptom develops gradually over more than 5 minutes and/or different aura symptoms occur one after the other over more than 5 minutes
Each symptom lasts from 5–60 minutes
Where these criteria are not fully met, a diagnosis of "probable migraine with aura" may be considered, although other neurological causes must also be considered. If the picture complies with the criteria but includes one-sided muscular weakness or paralysis, a diagnosis of "sporadic hemiplegic migraine" or "familial hemiplegic migraine" should be considered.
[edit] Basilar type migraine
Basilar type migraine (BTM), formerly known as basilar artery migraine (BAM) or basilar migraine (BM), is an uncommon type of complicated migraine with symptoms that result from brainstem dysfunction. Serious episodes of BTM can lead to stroke, coma, or even death. The use of triptans and other vasoconstrictors as abortive treatments in BTM is contraindicated. Abortive treatments for BTM often focus on vasodilation and restoration of normal blood flow to the vertebrobasilar territory and subsequent return of normal brainstem function.
[edit] Familial hemiplegic migraine
Main article: Familial hemiplegic migraine
Familial hemiplegic migraine 'FHM' is a type of migraine with a possible polygenetic component. These migraine attacks may last 4–72 hours[9] and are apparently caused by ion channel mutations, three types of which have been identified to date. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties. A non-familial form exists as well, "sporadic hemiplegic migraine" (SHM). It is often difficult to make the diagnosis between basilar-type migraine and hemiplegic migraine. When making the differential diagnosis is difficult, the deciding symptom is often the motor weakness or unilateral paralysis which can occur in FHM or SHM. While basilar-type migraine can present with tingling or numbness, true motor weakness and/or paralysis occur only in hemiplegic migraine.
[edit] Abdominal migraine
According to the International Classification of Headache Disorders[9] abdominal migraine is a recurrent disorder of unknown origin which occurs mainly in children. It is characterised by episodes of moderate to severe central abdominal pain lasting 1–72 hours. There is usually associated nausea and vomiting but the child is entirely well between attacks.
In order to diagnose abdominal migraine, there must be at least five attacks, not attributable to another cause, fulfilling the following criteria:
Attacks lasting 1–72 hours when untreated
Pain must have ALL of the following characteristics:
Location in the midline, around the umbilicus or poorly localised
Dull or 'just sore' quality
Moderate or severe intensity
During an attack there must be at least two of the following:
Loss of appetite
Nausea
Vomiting
Pallor
Most children with abdominal migraine will develop migraine headache later in life and the two may co-exist during adolescence.
[edit] Acephalgic migraine
Acephalgic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience aura symptoms such as scintillating scotoma, nausea, photophobia, hemiparesis and other migraine symptoms but does not experience headache. Acephalgic migraine is also referred to as amigrainous migraine, ocular migraine, or optical migraine.
Sufferers of acephalgic migraine are more likely than the general population to develop classical migraine with headache.
The prevention and treatment of acephalgic migraine is broadly the same as for classical migraine. However, because of the absence of "headache", diagnosis of acephalgic migraine is apt to be significantly delayed and the risk of misdiagnosis significantly increased.
Visual snow might be a form of acephalgic migraine.
If symptoms are primarily visual, it may be necessary to consult an ophthalmologist to rule out potential eye disease before considering this diagnosis.
[edit] Menstrual migraine
Menstrual migraine is distinct from other migraines. Approximately 21 million women in the US suffer from migraines,[11] and about 60% of them suffer from menstrual migraines.[12]
There are two types of menstrual migraine – Menstrually Related Migraine (MRM) and Pure Menstrual Migraine (PMM)
MRM is a headache of moderate-to-severe pain intensity that happens around the time of a woman’s period and at other times of the month as well.
PMM is similar in every respect but only occurs around the time of a woman’s period.[13]
The exact causes of menstrual migraine are uncertain but evidence suggest there may be a link between menstruation and migraine due to the drop in estrogen levels that normally occurs right before the period starts.[14]
Menstrual migraine has been reported to be more likely to occur during a five-day window, from two days before to two days after menstruation.[15]
When compared with migraines that occur at other times of the month, menstrual migraines have been reported to
Last longer—up to 72 hours[16]
Be more severe[15][17]
Occur more often with nausea and vomiting[12]
Be more difficult to treat—occur more frequently[18]
[edit] Signs and symptoms
The signs and symptoms of migraine vary among patients. Therefore, what a patient experiences before, during and after an attack cannot be defined exactly. The four phases of a migraine attack listed below are common but not necessarily experienced by all migraine sufferers. Additionally, the phases experienced and the symptoms experienced during them can vary from one migraine attack to another in the same migraineur:
The prodrome, which occurs hours or days before the headache.
The aura, which immediately precedes the headache.
The pain phase, also known as headache phase.
The postdrome.
[edit] Prodrome phase
Prodromal symptoms occur in 40 to 60% of migraineurs (migraine sufferers). This phase may consist of altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff muscles (especially in the neck), constipation or diarrhea, increased urination, and other visceral symptoms. These symptoms usually precede the headache phase of the migraine attack by several hours or days, and experience teaches the patient or observant family how to detect that a migraine attack is near.
[edit] Aura phase
For the 20–30%[19][20] of individuals who suffer migraine with aura, this aura comprises focal neurological phenomena that precede or accompany the attack. They appear gradually over 5 to 20 minutes and generally last fewer than 60 minutes. The headache phase of the migraine attack usually begins within 60 minutes of the end of the aura phase, but it is sometimes delayed up to several hours, and it can be missing entirely. Symptoms of migraine aura can be visual, sensory, or motor in nature.[21]
Visual aura is the most common of the neurological events. There is a disturbance of vision consisting usually of unformed flashes of white and/or black or rarely of multicolored lights (photopsia) or formations of dazzling zigzag lines (scintillating scotoma; often arranged like the battlements of a castle, hence the alternative terms "fortification spectra" or "teichopsia"). Some patients complain of blurred or shimmering or cloudy vision, as though they were looking through thick or smoked glass, or, in some cases, tunnel vision and hemianopsia. The somatosensory aura of migraine consists of digitolingual or cheiro-oral paresthesias, a feeling of pins-and-needles experienced in the hand and arm as well as in the nose-mouth area on the same side. Paresthesia migrate up the arm and then extend to involve the face, lips and tongue.
Other symptoms of the aura phase can include auditory or olfactory hallucinations, temporary dysphasia, vertigo, tingling or numbness of the face and extremities, and hypersensitivity to touch.
[edit] Pain phase
The typical migraine headache is unilateral, throbbing, moderate to severe and can be aggravated by physical activity. Not all of these features are necessary. The pain may be bilateral at the onset or start on one side and become generalized, and usually alternates sides from one attack to the next. The onset is usually gradual. The pain peaks and then subsides, and usually lasts between 4 and 72 hours in adults and 1 and 48 hours in children. The frequency of attacks is extremely variable, from a few in a lifetime to several times a week, and the average migraineur experiences from one to three headaches a month. The head pain varies greatly in intensity.
The pain of migraine is invariably accompanied by other features. Nausea occurs in almost 90 percent of patients, while vomiting occurs in about one third of patients. Many patients experience sensory hyperexcitability manifested by photophobia, phonophobia, osmophobia and seek a dark and quiet room. Blurred vision, nasal stuffiness, diarrhea, polyuria, pallor or sweating may be noted during the headache phase. There may be localized edema of the scalp or face, scalp tenderness, prominence of a vein or artery in the temple, or stiffness and tenderness of the neck. Impairment of concentration and mood are common. Lightheadedness, rather than true vertigo and a feeling of faintness may occur. The extremities tend to be cold and moist.
[edit] Postdrome phase
The patient may feel tired, "washed out", irritable, or listless and may have impaired concentration, scalp tenderness or mood changes. Some people feel unusually refreshed or euphoric after an attack, whereas others note depression and malaise. Often, some of the minor headache phase symptoms may continue, such as loss of appetite, photophobia, and lightheadedness. On some patients, a 5 to 6 hour nap may reduce the pain, but slight headaches may still occur when standing or sitting quickly. Normally these symptoms go away after a good night's rest.
[edit] Diagnosis
Migraines are underdiagnosed[22] and misdiagnosed.[23] The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":
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
1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia
For migraine with aura, only two attacks are required to justify the diagnosis.
The mnemonic POUNDing (Pulsating, duration of 4–72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.[24]
The presence of either disability, nausea or sensitivity, can diagnose migraine with:[25]
sensitivity of 81%
specificity of 75%
[edit] Pathophysiology
Migraines were once thought to be initiated exclusively by problems with blood vessels. The vascular theory of migraines is now considered secondary to brain dysfunction[26] and claimed to have been discredited by others.[27]
The effects of migraine may persist for some days after the main headache has ended. Many sufferers report a sore feeling in the area where the migraine was, and some report impaired thinking for a few days after the headache has passed.
Migraine headaches can be a symptom of hypothyroidism.[citation needed]
[edit] Depolarization theory
A phenomenon known as cortical spreading depression can cause migraines.[28] In cortical spreading depression, neurological activity is depressed over an area of the cortex of the brain. This situation results in the release of inflammatory mediators leading to irritation of cranial nerve roots, most particularly the trigeminal nerve, which conveys the sensory information for the face and much of the head.
This view is supported by neuroimaging techniques, which appear to show that migraine is primarily a disorder of the brain (neurological), not of the blood vessels (vascular). A spreading depolarization (electrical change) may begin 24 hours before the attack, with onset of the headache occurring around the time when the largest area of the brain is depolarized. A French study in 2007, using the Positron Emission Tomography (PET) technique identified the hypothalamus as being critically involved in the early stages.[29]
[edit] Vascular theory
Migraines can begin when blood vessels in the brain contract and expand inappropriately. This may start in the occipital lobe, in the back of the brain, as arteries spasm. The reduced flow of blood from the occipital lobe triggers the aura that some individuals who have migraines experience because the visual cortex is in the occipital area.[26]
When the constriction stops and the blood vessels dilate, they become too wide. The once solid walls of the blood vessels become permeable and some fluid leaks out. This leakage is recognized by pain receptors in the blood vessels of surrounding tissue. In response, the body supplies the area with chemicals which cause inflammation. With each heart beat, blood passes through this sensitive area causing a throb of pain.[26]
The vascular theory of migraines is now seen as secondary to brain dysfunction.[26]
[edit] Serotonin theory
Serotonin is a type of neurotransmitter, or "communication chemical" which passes messages between nerve cells. It helps to control mood, pain sensation, sexual behaviour, sleep, as well as dilation and constriction of the blood vessels among other things. Serotonin levels in the brain may lead to a process of constriction and dilation of the blood vessels which trigger a migraine.[26] Triptans activate serotonin receptors to stop a migraine attack.[26]
[edit] Neural theory
When certain nerves or an area in the brain stem become irritated, a migraine begins. In response to the irritation, the body releases chemicals which cause inflammation of the blood vessels. These chemicals cause further irritation of the nerves and blood vessels and results in pain. Substance P is one of the substances released with first irritation. Pain then increases because substance P aids in sending pain signals to the brain.[26]
[edit] Unifying theory
Both vascular and neural influences cause migraines.
stress triggers changes in the brain
these changes cause serotonin to be released
blood vessels constrict
chemicals including substance P irritate nerves and blood vessels causing pain[26]
[edit] Epidemiology
Age-Gender Incidence
Migraine is an extremely common condition which will affect 12–28% of people at some point in their lives.[30] However this figure — the lifetime prevalence — does not provide a very clear picture of how many patients there are with active migraine at any one time. Typically, therefore, the burden of migraine in a population is assessed by looking at the one-year prevalence — a figure that defines the number of patients who have had one or more attacks in the previous year. The third figure, which helps to clarify the picture, is the incidence — this relates to the number of first attacks occurring at any given age and helps understanding of how the disease grows and shrinks over time.
Based on the results of a number of studies, one year prevalence of migraine ranges from 6–15% in adult men and from 14–35% in adult women.[30] These figures vary substantially with age: approximately 4–5% of children aged under 12 suffer from migraine, with little apparent difference between boys and girls.[31] There is then a rapid growth in incidence amongst girls occurring after puberty,[32][33][34] which continues throughout early adult life.[35] By early middle age, around 25% of women experience a migraine at least once a year, compared with fewer than 10% of men.[30][36] After menopause, attacks in women tend to decline dramatically, so that in the over 70s there are approximately equal numbers of male and female sufferers, with prevalence returning to around 5%.[30][36]
At all ages, migraine without aura is more common than migraine with aura, with a ratio of between 1.5:1 and 2:1.[37][38] Incidence figures show that the excess of migraine seen in women of reproductive age is mainly due to migraine without aura.[37] Thus in pre-pubertal and post-menopausal populations, migraine with aura is somewhat more common than amongst 15–50 year olds.[35][39]
There is a strong relationship between age, gender and type of migraine.[40]
Geographical differences in migraine prevalence are not marked. Studies in Asia and South America suggest that the rates there are relatively low,[41][42] but they do not fall outside the range of values seen in European and North American studies.[30][36]
The incidence of migraine is related to the incidence of epilepsy in families, with migraine twice as prevalent in family members of epilepsy sufferers, and more common in epilepsy sufferers themselves.[43]
[edit] Triggers
A migraine trigger is any factor that, on exposure or withdrawal, leads to the development of an acute migraine headache. Triggers may be categorized as behavioral, environmental, infectious, dietary, chemical, or hormonal. In the medical literature, these factors are known as 'precipitants.'
The MedlinePlus Medical Encyclopedia, for example, offers the following list of migraine triggers:
Migraine attacks may be triggered by:
Allergic reactions
Bright lights, loud noises, and certain odors or perfumes
Physical or emotional stress
Changes in sleep patterns
Smoking or exposure to smoke
Skipping meals
Alcohol
Menstrual cycle fluctuations, birth control pills, hormone fluctuations during the menopause transition
Tension headaches
Foods containing tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), monosodium glutamate (MSG) or nitrates (like bacon, hot dogs, and salami)
Other foods such as chocolate, nuts, peanut butter, avocado, banana, citrus, onions, dairy products, and fermented or pickled foods.
—MedlinePlus medical encyclopedia[44]
Sometimes the migraine occurs with no apparent "cause". The trigger theory supposes that exposure to various environmental factors precipitates, or triggers, individual migraine episodes. Migraine patients have long been advised to try to identify personal headache triggers by looking for associations between their headaches and various suspected trigger factors and keeping a "headache diary" recording migraine incidents and diet to look for correlations in order to avoid trigger foods. It must be mentioned, that some trigger factors are quantitative in nature, i.e., a small block of dark chocolate may not cause a migraine, but half a slab of dark chocolate almost definitely will, in a susceptible person. In addition, being exposed to more than one trigger factor simultaneously will more likely cause a migraine, than a single trigger factor in isolation, e.g., drinking and eating various known dietary trigger factors on a hot, humid day, when feeling stressed and having had little sleep will probably result in a migraine in a susceptible person, but consuming a single trigger factor on a cool day, after a good night's rest with minimal environmental stress may mean that the sufferer will not develop a migraine after all. Migraines can be complex to avoid, but keeping an accurate migraine diary and making suitable lifestyle changes can have a very positive effect on the sufferer's quality of life. Some trigger factors are virtually impossible to avoid, e.g. the weather or emotions, but by limiting the avoidable trigger factors, the unavoidable ones may have less of an impact on the sufferer. [45]
[edit] Food
A 2005 literature review found that the available information about dietary trigger factors relies mostly on the subjective assessments of patients.[46] Some suspected dietary trigger factors appear to genuinely promote or precipitate migraine episodes, but many other suspected dietary triggers have never been demonstrated to trigger migraines. The review authors found that alcohol, caffeine withdrawal, and missing meals are the most important dietary migraine precipitants, that dehydration deserved more attention, and that some patients report sensitivity to red wine. Little or no evidence associated notorious suspected triggers like chocolate, cheese, histamine, tyramine, nitrates, or nitrites with migraines. The artificial sweetener aspartame has not been shown to trigger headache, but in a large and definitive study monosodium glutamate (MSG) in large doses (2.5 grams) was associated with adverse symptoms including headache more often than was placebo. The review authors also note that while general dietary restriction has not been demonstrated to be an effective migraine therapy, it is beneficial for the individual to avoid what has been a definite cause of the migraine.
The National Headache Foundation has a specific list of triggers based on the tyramine theory, detailing allowed, with caution and avoid triggers.[47]
[edit] Weather
Several studies have found some migraines are triggered by changes in weather. One study noted 62% of the subjects thought weather was a factor but only 51% were sensitive to weather changes.[48] Among those whose migraines did occur during a change in weather, the subjects often picked a weather change other than the actual weather data recorded. Most likely to trigger a migraine were, in order:
Temperature mixed with humidity. High humidity plus high or low temperature was the biggest cause.
Significant changes in weather
Changes in barometric pressure
Another study examined the effects of warm chinook winds on migraines, with many patients reporting increased incidence of migraines immediately before and/or during the chinook winds. The number of people reporting migrainous episodes during the chinook winds was higher on high-wind chinook days. The probable cause was thought to be an increase in positive ions in the air.[49]
[edit] Head position
One study suggests that migraines can be triggered by the head being held downwards for an extended period, as when washing hair in a basin.[50]
[edit] Treatment
Conventional treatment focuses on three areas: trigger avoidance, symptomatic control, and preventive drugs. Patients who experience migraines often find that the recommended treatments are not 100% effective at preventing migraines, and sometimes may not be effective at all.
Children and adolescents, are often first given drug treatment, but the value of diet modification should not be overlooked. The simple task of starting a diet journal to help modify the intake of trigger foods like hot dogs, chocolate, cheese and ice cream could help alleviate symptoms[51]
[edit] Abortive treatment
Migraine sufferers usually develop their own coping mechanisms for the pain of a migraine attack. Hot or cold water applied to the head, resting in a dark and silent room or ingesting caffeine at an appropriate time may be as helpful as medication for some patients.[citation needed]
For patients who have been diagnosed with recurring migraines, migraine abortive medications can be used to treat the attack, and may be more effective if taken early, losing effectiveness once the attack has begun. Treating the attack at the onset can often abort it before it becomes serious, and can reduce the near-term frequency of subsequent attacks.[citation needed]
[edit] Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)
The first line of treatment is over-the-counter abortive medication.
Regarding non-steroidal anti-inflammatory drugs, a randomized controlled trial found that naproxen can abort about one third of migraine attacks, which was 5% less than the benefit of sumatriptan.[52]
Paracetamol, at a dose of 1000 mg, benefited over half of patients with mild or moderate migraines in a randomized controlled trial.[53]
Simple analgesics combined with caffeine may help.[54] During a migraine attack, emptying of the stomach is slowed, resulting in nausea and a delay in absorbing medication. Caffeine has been shown to partially reverse this effect, and probably accounts for its benefit.[citation needed] Excedrin is an example of an aspirin with caffeine product. Caffeine is recognized by the U.S. FDA as an Over The Counter Drug (OTC) treatment for migraine[citation needed].
Patients themselves often start off with paracetamol (known as acetaminophen in the USA), aspirin, ibuprofen, or other simple analgesics that are useful for tension headaches. OTC drugs may provide some relief, although they are typically not effective for most sufferers. It is one of doctors' practical diagnoses of migraine head pain when patients say typical OTC drugs "won't touch it".[citation needed]
[edit] Analgesics combined with antiemetics
Anti-emetics by mouth may help relieve symtoms of nausea and help prevent vomiting, which can diminish the effectiveness of orally taken analgesia. In addition some antiemetics such as metoclopramide are prokinetics and help gastric emptying which is often impaired during episodes of migraine. In the UK there are three combination antiemetic and analgesic preparations available: MigraMax (aspirin with metoclopramide), Migraleve (paracetamol/codeine for analgesia, with buclizine as the antiemetic) and paracetamol/metoclopramide (Paramax in UK).[55] The earlier these drugs are taken in the attack, the better their effect.
Some patients find relief from taking other sedative antihistamines which have anti-nausea properties, such as Benadryl which in the US contains diphenhydramine (but a different non-sedative product in the UK).
[edit] Serotonin agonists
Main article: triptans
Sumatriptan and related selective serotonin receptor agonists are excellent for severe migraines or those that do not respond to NSAIDs[52] or other over-the-counter drugs.[53] Triptans are a mid-line treatment suitable for many migraineurs with typical migraines. They may not work for atypical or unusually severe migraines, transformed migraines, or status (continuous) migraines.
[edit] Ergot alkaloids
Until the introduction of sumatriptan in 1991, ergot derivatives (see ergoline) were the primary oral drugs available to abort a migraine once it is established.
Ergot drugs can be used either as a preventive or abortive therapy, though their relative expense and cumulative side effects suggest reserving them as an abortive rescue medicine. However, ergotamine tartrate tablets (usually with caffeine), though highly effective, and long lasting (unlike triptans), have fallen out of favour due to the problem of ergotism. Oral ergotamine tablet absorption is reliable unless the patient is nauseated. Anti-nausea administration is available by ergotamine suppository (or Ergostat sublingual tablets made until circa 1992). Ergot drugs themselves can be so nauseating it is advisable for the sufferer to have something at hand to counteract this effect when first using this drug. Ergotamine-caffeine 1/100 mg fixed ratio tablets (like Cafergot, Ercaf, etc.) are much less expensive per headache than triptans, and are commonly available in Asia. They are difficult to obtain in the USA. Ergotamine-caffeine can't be regularly used to abort evening or night onset migraines due to debilitating caffeine interference with sleep. Pure ergotamine tartrate is highly effective for evening-night migraines, but is rarely or never available in the USA. Dihydroergotamine (DHE), which must be injected or inhaled, can be as effective as ergotamine tartrate, but is much more expensive than $2 USD Cafergot tablets.
[edit] Steroids
Based on a recent meta analysis a single dose of iv dexamethasone, when added to standard treatment, is associated with a 26% decrease in headache recurrence.[56]
[edit] Other agents
If over-the-counter medications do not work, or if triptans are unaffordable, the next step for many doctors is to prescribe Fioricet or Fiorinal, which is a combination of butalbital (a barbiturate), Paracetamol (in Fioricet) or acetylsalicylic acid (more commonly known as aspirin and present in Fiorinal), and caffeine. While the risk of addiction is low, butalbital can be habit-forming if used daily, and it can also lead to rebound headaches. Barbiturate-containing medications are not available in many European countries.
Amidrine (a cocktail of a pain reliever, a sedative, and a vasoconstrictor) is sometimes prescribed for migraine headaches.
Anti-emetics may need to be given by suppository or injection where vomiting dominates the symptoms.
[edit] Status migrainosus
Status migrainosus is characterized by migraine lasting more than 72 hours, with not more than four hours of relief during that period. It is generally understood that status migrainosus has been refractory to usual outpatient management upon presentation.
Treatment of status migrainosus consists of managing comorbidities (i. e. correcting fluid and electrolyte abnormalities resulting from anorexia and nausea/vomiting often accompanying status migr.), and usually administering parenteral medication to "break" (abort) the headache.
Although the literature is full of many case reports concerning treatment of status migrainosus, first line therapy consists of intravenous fluids, metoclopramide, and triptans or DHE.[57]
[edit] Herbal treatment
The herbal supplement feverfew (more commonly used for migraine prevention, see below) is marketed by the GelStat Corporation as an OTC migraine abortive, administered sublingually (under the tongue) in a mixture with ginger.[58] An open-label study (funded by GelStat) found some tentative evidence of the treatment's effectiveness,[59] but no scientifically sound study has been done. Cannabis in addition to prevention, is also known to relieve pain during the onset of a migraine.[citation needed]
[edit] Comparative studies
Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial[60] reveals that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and ibuprofen 400 mg are equally effective at providing relief from pain, although sumatriptan was superior in terms of the more demanding outcome of rendering patients entirely free of pain and all other migraine-related symptoms.
Another randomized controlled trial, funded by the manufacturer of the study drug, found that a combination of sumatriptan 85 mg and naproxen sodium 200 mg was better than either drug alone.[52]
[edit] Preventive treatment
Preventive (also called prophylactic) treatment of migraines can be an important component of migraine management. Such treatments can take many forms, including everything from taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers. One such book that outlines these preventative measures quite well is "7 Steps To A Healthy Brain" by Dr. Winner.
The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy.[61] Another reason to pursue these goals is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which is a common problem among migraneurs. This is believed to occur in part due to overuse of pain medications, and can result in chronic daily headache.[62]
[edit] Prescription drugs
A 2006 review article by S. Modi and D. Lowder offers some general guidelines on when a physician should consider prescribing drugs for migraine prevention:
Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered.
...Therapy should be initiated with medications that have the highest levels of effectiveness and the lowest potential for adverse reactions; these should be started at low dosages and titrated slowly. A full therapeutic trial may take two to six months. After successful therapy (e.g., reduction of migraine frequency by approximately 50 percent or more) has been maintained for six to 12 months, discontinuation of preventive therapy can be considered.
—[61]
Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
The most effective prescription medications include several drug classes:
beta blockers such as propranolol and atenolol. A meta-analysis by the Cochrane Collaboration of nine randomized controlled trials or crossover studies, which together included 668 patients, found that propranolol had an "overall relative risk of response to treatment (here called the 'responder ratio')" was 1.94.[63]
anticonvulsants such as valproic acid and topiramate. A meta-analysis by the Cochrane Collaboration of ten randomized controlled trials or crossover studies, which together included 1341 patients, found anticonvulsants had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a number needed to treat of 3.8.[64] However, concerns have been raised about the marketing of gabapentin.[65]
antidepressants include tricyclic antidepressants (TCAs) such as amitriptyline and the newer selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine. A meta-analysis by the Cochrane Collaboration found selective serotonin reuptake inhibitors are no more effective than placebo.[66] Another meta-analysis found benefit from SSRIs among patients with migraine or tension headache; however, the effect of SSRIs on only migraines was not separately reported.[67] A randomized controlled trial found that amitriptyline was better than placebo and similar to propranolol.[68]
Other drugs:
Sansert was withdrawn from the US market by Novartis, but is available in Canadian pharmacies. Although highly effective, it has rare but serious side effects, including retroperitoneal fibrosis.
Namenda, memantine HCI tablets, which is used in the treatment of Alzheimer's Disease, is beginning to be used off label for the treatment of migraines. It has not yet been approved by the FDA for the treatment of migraines.
ASA or Aspirin can be taken daily in low doses such as 80 to 81 mg, the blood thinners in ASA have been shown to help some migrainures, especially those who have an aura.
[edit] Trigger avoidance
Patients can attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. General dietary restriction has not been demonstrated to be an effective approach to treating migraine, and migraine is remarkably resistant to the placebo effect [3]
Nonetheless, some people fervently claim that they have successfully identified foods that are likely to result in migraines, and by avoiding them, can decrease the likelihood of an episode.
[edit] Herbal and nutritional supplements
[edit] Butterbur
50 mg or 75 mg/day of butterbur (Petasites hybridus) rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex, does not.[4]
[edit] Cannabis
Cannabis was a standard treatment for migraines from the mid-19th century until it was outlawed in the early 20th century in the USA. It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura. There is some indication that semi-regular use may reduce the frequency of attacks. Further studies are being conducted. Some migraine sufferers report that cannabis decreases throbbing and pain, especially if smoked. A pharmaceutical company is currently conducting trials of a whole cannabis extract spray for migraine[5]
[edit] Coenzyme Q10
Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines. In an open-label trial,[69] Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.[70]
[edit] Feverfew
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. A number of clinical trials have been carried out to test this claim, but a 2004 review article concluded that the results have been contradictory and inconclusive.[71] However, since then, more studies have been carried out.[72] As well as its prophylactic properties, feverfew is also touted as a migraine abortative.
[edit] Magnesium Citrate
Magnesium citrate has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9–12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.[73]
[edit] Riboflavin
The supplement Riboflavin (also called Vitamin B2) has been shown (in a placebo-controlled trial)[74] to reduce the number of migraines, when taken at the high dose of 400 mg daily for three months.[75][76]
[edit] Vitamin B12
There is tentative evidence that Vitamin B12 may be effective in preventing migraines.[75] In particular, in an open-label pilot study, 1 mg of intranasal hydroxocobalamin (a form of Vitamin B12), taken daily for three months, was shown to reduce migraine frequency by 50% or more in 10 of 19 participants.[77] Although the study was not placebo-controlled, this response is larger than the typical placebo effect in migraine prophylaxis.[78]
[edit] Surgical treatments
Surgery may be used to treat migraines by severing the corrugator supercilii muscle and zygomaticotemporal nerve.[79] The treatment may reduce or eliminate headaches in some individuals.[80]
In 2005, research[81] was published indicating that in some people with a patent foramen ovale (PFO), a hole between the upper chambers of the heart, suffer from migraines which may have been caused by the PFO. The migraines reduce in frequency if the hole is patched. Several clinical trials are currently under way in an effort to determine if a causal link between PFO and migraine can be found. Early speculation as to this relationship has centered on the idea that the lungs detoxify blood as it passes through. The PFO allows uncleaned blood to go directly from the right side of the heart to the left without passing through the lungs.
Botulin toxin has been used to treat individuals with frequent or chronic migraines.[82] Its usefulness is uncertain with evidence suggesting it is not superior to placebo treatment[83] and does not appear to be useful in the treatment of episodic migraine.[84]
Spinal cord stimulators are an implanted medical device sometimes used for those who suffer severe migraines several days each month.[85]
[edit] Noninvasive medical treatments
Transcranial Magnetic Stimulation (TMS): At the 49th Annual meeting of the American Headache Society in June 2006, scientists from Ohio State University Medical Center presented medical research on 47 candidates that demonstrated that TMS — a medically non-invasive technology for treating depression, obsessive compulsive disorder and tinnitus, among other ailments — helped to prevent and even reduce the severity of migraines among its patients. This treatment essentially disrupts the aura phase of migraines before patients develop full-blown migraines.[6] In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light.[7] Their research suggests that there is a strong neurological component to migraines. A larger study will be conducted soon to better assess TMS's complete effectiveness.[86] In June 2008, a hand-held apparatus designed to apply TMS as a preemptive therapy to avert a migraine attack at the onset of the aura phase was introduced in California.[8]
Biofeedback has been used successfully by some to control migraine symptoms through training and practice.[87]
Hyperbaric oxygen therapy has been used successfully in treating migraines.[88] This suggests that sufferers might be treated during an attack with a hyperbaric chamber of some sort, such as a Gamow bag (as is done in the treatment of "The Bends" and altitude sickness).
Bruxism, clenching or grinding of teeth, especially at night, is a trigger for many migraineurs. A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching. It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth. It has a success rate similar to butterbur and co-enzyme Q10, although it has not been subjected to the same rigorous testing as the supplements. Massage therapy of the jaw area can also reduce such pain.
There is a speculative connection between vision correction (particular with prism eyeglasses) and migraines. Two British studies, one from 1934[89] and another from 1956[90] claimed that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions, which included prescribed prism. However, both studies are subject to criticism because of sample bias, sample size, and the lack of a control group. A more recent study [9] found that precision tinted lenses may be an effective migraine treatment. (Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches.)
[edit] Behavioral treatments
Many physicians believe that exercise for 15–20 minutes per day is helpful for reducing the frequency of migraines.[91]
Sleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.
Diet, visualization, and self-hypnosis are also alternative treatments and prevention approaches.
Sexual activity has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases.[10]
In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache.
[edit] Alternative medicine
A number of forms of alternative medicine, particularly bodywork, are used in preventing migraines.
Massage therapy and physical therapy are often very effective forms of treatment to reduce the frequency and intensity of migraines.[citation needed] However, it is important to be treated by a well-trained therapist who understands the pathophysiology of migraines. Deep massage can 'trigger' a migraine attack in a person who is not used to such treatments. It is advisable to start sessions as short in duration and then work up to longer treatments. Likewise, some migraine sufferers find relief through chiropractic care.[citation needed]
Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that Myofascial Release can relieve this tension and in doing so reduce or eliminate the stress headache element.[citation needed]
Some migraine sufferers find relief through acupuncture, which is usually used to help prevent headaches from developing.[92] Sometimes acupuncture is used to relieve the pain of an active migraine headache.[93] In one controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.[citation needed]
Additionally acupressure is used by some for relief. For instance pressure between the thumbs and index finger to help subside headaches if the headache or migraine isn't too severe.[citation needed]
Incense and scents are shown to help. The smell and incense of peppermint and lavender have been proven to help with migraines and headaches more so than most other scents.[94] However, some scents can be a trigger factor.
[edit] History
9000 year old skulls exist with evidence of trepanation. It is hypothesized that this drastic step was taken in response to headaches, though there is no clear evidence proving this.[citation needed]. Headache with neuralgia was recorded in the medical documents of the ancient Egyptians as early as 1200 BC. In 400 BC Hippocrates described the visual aura that can precede the migraine headache and the relief which can occur through vomiting. Aretaeus of Cappadocia is credited as the "discoverer" of migraines because of his second century description of the symptoms of a unilateral headache associated with vomiting, with headache-free intervals in between attacks. Galenus of Pergamon used the term "hemicrania" (half-head), from which the word "migraine" was derived. He thought there was a connection between the stomach and the brain because of the nausea and vomiting that often accompany an attack. For relief of migraine, Andalusian-born physician Abulcasis, also known as Abu El Quasim, suggested application of a hot iron to the head or insertion of garlic into an incision made in the temple. In the Medieval Ages migraine was recognized as a discrete medical disorder with treatment ranging from hot irons to blood letting and even witchcraft[citation needed]. Followers of Galenus explained migraine as caused by aggressive yellow bile. Ebn Sina (Avicenna) described migraine in his textbook "El Qanoon fel teb" as "... small movements, drinking and eating, and sounds provoke the pain... the patient cannot tolerate the sound of speaking and light. He would like to rest in darkness alone." Abu Bakr Mohamed Ibn Zakariya Râzi noted the association of headache with different events in the lives of women, "...And such a headache may be observed after delivery and abortion or during menopause and dysmenorrhea."
In Bibliotheca Anatomica, Medic, Chirurgica, published in London in 1712, five major types of headaches are described, including the "Megrim", recognizable as classic migraine. Graham and Wolff (1938) published their paper advocating ergotamine tart for relieving migraine. Later in the 20th century, Harold Wolff (1950) developed the experimental approach to the study of headache and elaborated the vascular theory of migraine, which has come under attack as the pendulum again swings to the neurogenic theory.
[edit] Economic impact
In addition to being a major cause of pain and suffering, chronic migraine attacks are a significant source of both medical costs and lost productivity. Medical costs per migraine sufferer (mostly physician and emergency room visits) averaged $107 USD over six months in one 1988 study,[citation needed] with total costs including lost productivity averaging $313. Annual employer cost of lost productivity due to migraines was estimated at $3,309 per sufferer. Total medical costs associated with migraines in the United States amounted to one billion dollars in 1994, in addition to lost productivity estimated at thirteen to seventeen billion dollars per year. Employers may benefit from educating themselves on the effects of migraines in order to facilitate a better understanding in the workplace. The workplace model of 9–5, 5 days a week may not be viable for a migraine sufferer. With education and understanding an employer could compromise with an employee to create a workable solution for both.
[edit] Migraine and cardiovascular risks
The risk of stroke may be increased two- to threefold in migraine sufferers. Young adult sufferers and women using hormonal contraception appear to be at particular risk.[95] The mechanism of any association is unclear, but chronic abnormalities of cerebral blood vessel tone may be involved. Women who experience auras have been found to have twice the risk of strokes and heart attacks over non-aura migraine sufferers and women who do not have migraines.[96][95] Migraine sufferers seem to be at risk for both thrombotic and hemorrhagic stroke as well as transient ischemic attacks.[97] Death from cardiovascular causes was higher in people with migraine with aura in a Women's Health Initiative study, but more research is needed to confirm this.[98][99]
[edit] References
[edit] Migraine triggers
Federation of American Societies for Experimental Biology [FASEB] [1995]. Analysis of adverse reactions to monosodium glutamate (MSG). Bethesda, MD: Life Sciences Research Office, FASEB.
Ravishankar, K (2006). 'Hair wash' or 'Head bath' triggering migraine - observations in 94 Indian patients". Cephalagia 26 (11): 1330–1334. ISSN 0333-1024.
[edit] Treatment
Pearce, J.M.S. (1994). Headache. Neurological Management series. Journal of Neurology Neurosurgery and Psychiatry. 57, 134–144.
Mayo Clinic Staff. (2005). Migraine Headache. Retrieved August 14, 2005
Cathy Wong, ND. (2005). Migraine Elimination Diet Retrieved August 14, 2005
Treatment Articles (2005). Butterbur, Co-enzyme Q-10, Melatonin, Folic Acid
Buchholz, D. (2002) Heal your headache: The 1-2-3 Program, New York: Workman Publishing, ISBN 0-7611-2566-3
Livingstone, I. and Novak, D. (2003) Breaking the Headache Cycle, New York: Henry Holt and Co. ISBN 0-8050-7221-7
Izecksohn L, and Izecksohn C. . Fluids' Hypertension Syndromes, ISBN 978-85-906664-0-0.
[edit] Triptans
Cohen JA, Beall D, Beck A, et al. Sumatriptan treatment for migraine in a health maintenenace organization: economic, humanistic, and clinical outcomes. Clin Ther 1999;21:190–205.
Adelman JU, Sharfman M, Johnson R, et al. Impact of oral sumatriptan on workplace productivity, health-related quality of life, healthcare use, and patient satisfaction with medication in nurses with migraine. Am J Manag Care 1996;2:1407–1416.
Cohen JA, Beall DG, Miller DW, Beck A, Pait G, Clements BD. Subcutaneous sumatriptan for the treatment of migraine: humanistic, economic, and clinical consequences. Fam Med 1996;28:171–177.
Jhingran P, Cady RK, Rubino J, Miller D, Grice RB, Gutterman DL. Improvements in health-related quality of life with sumatriptan treatment for migraine. J Med Econ 1996;42:36–42.
Solomon GD, Nielsen K, Miller D. The effects of sumatriptan on migraine: health-related quality of life. Med Interface 1995;June:134–141.
Solomon GD, Skobieranda FG, Genzen JR. Quality of life assessment among migraine patients treated with sumatriptan. Headache 1995;35:449–454.
Santanello NC, Polis AB, Hartmaier SL, Kramer MS, Block GA, Silberstein SD. Improvement in migrainespecific quality of life in a clinical trial of rizatriptan. Cephalalgia 1997;17:867–872.
Caro JJ, Getsios D. Pharmacoeconomic evidence and considerations for triptan treatment of migraine. Expert Opin Pharmacother 2002;3:237–248.
Lofland JH, Johnson NE, Batenhorst AS, Nash DB. Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective. Arch Intern Med 1999;159: 857–863.
Cady RC, Ryan R, Jhingran P, O’Quinn S, Pait DG. Sumatriptan injection reduces productivity loss during a migraine attack. Arch Intern Med 1998;158: 1013–1018.
Litaker DG, Solomon GD, Genzen JR. Impact of sumatriptan on clinic utilization and costs of care in migraineurs. Headache 1996;36:538–541.
Greiner DL, Addy SN. Sumatriptan use in a large group-model health maintenance organization. Am J Health Syst Pharm 1996;53:633–638.
Lofland JH, Kim SS, Batenhorst AS, et al. Cost-effectiveness and cost-benefit of sumatriptan in patients with migraine. Mayo Clin Proc 2001;76:1093–1101.
Biddle AK, Shih YC, Kwong WJ. Cost-benefit analysis of sumatriptan tablets versus usual therapy for treatment of migraine. Pharmacotherapy 2000;20: 1356–1364.
Caro JJ, Getsios D, Raggio G, Caro G, Black L. Treatment of migraine in Canada with naratriptan: a costeffectiveness analysis. Headache 2001;41:456–464.
[edit] General
Sacks, Oliver (1999) Migraine, Vintage ISBN 0-520-08223-0
Relouzat, Raoul & Thiollet, Jean-Pierre, Vaincre la migraine, Anagramme, 2006 ISBN 2-35035046
[edit] Economic impact
Edmeads J, Mackell JA. The economic impact of migraine: an analysis of direct and indirect costs. Headache 2002;42:501–509.
Gerth WC, Carides GW, Dasbach EJ, Visser WH, Santanello NC. The multinational impact of migraine symptoms on healthcare utilisation and work loss. Pharmacoeconomics 2001;19:197–206.
Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med 1999;159:813–818.
Osterhaus JT, Gutterman DL, Plachetka JR. Healthcare resource and low labour costs of migraine headaches in the US. Pharmacoeconomics 1992;2:2–11.
[edit] Clinical picture
Blau JN. Classical migraine: symptoms between visual aura and headache onset. Lancet 1992;340:355-6.
Silberstein SD: Migraine symptoms: Results of a survey of self-reported migraineurs. Headache 1995;35:387-96.
Silberstein SD, Saper JR, Freitag F. Migraine: Diagnosis and treatment. In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Wolff's headache and other head pain. 7th ed. New York: Oxford University Press, 2001:121–237.
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