Migraine is the primary episodic form of headache, manifested by intense, paroxysmal headaches (more often unilateral) with a combination of neurological, vegetative and gastrointestinal manifestations. It usually appears for the first time at the age of 12 to 22 years. It ranks second in frequency after tension headache. Often a migraine attack occurs after some aura and ends with a feeling of general weakness and weakness. During the diagnosis, it is necessary to exclude organic pathology of the brain and to understand the possible causes of this disease. Treatment consists of means to stop the attack that has arisen and prevent the appearance of a new episode of migraine.
ICD 10
G43 Migraine
Etiology and pathogenesis
Previously, disease was considered as a vascular pathology, since during a migraine attack there is an expansion of the vessels of the dura mater, in the innervation of which trigeminovascular fibers participate. However, pain during a migraine attack is secondary, they arise as a result of the release of pain neuropeptides-vasodilators from the endings of trigeminovascular fibers, the most important of which are neurokinin A and peptide.
Thus, a migraine attack occurs due to activation of the trigeminovascular system. Such activation occurs in patients with hypersensitization of trigeminovascular fibers and increased excitability of the cerebral cortex. The “provocateurs” of a migraine attack are most often emotional stress (a migraine attack occurs immediately after a stressful situation), menstruation, physical stress, hunger, as well as some products containing phenylethylamine and tyramine (citrus fruits, chocolate, champagne, red wine).
Migraine symptoms
Migraines are characterized by pressing, throbbing headaches that capture half of the head with localization in the forehead / temple / eye area. In some cases, migraine pain occurs in the occipital region, followed by a transition to one half of the head. From time to time, the localization of headache can change from one half of the head to the other. Moreover, permanent (or periodic) unilateral headaches are not characteristic of this disease, but are considered an absolute indication for examination in order to exclude organic brain damage.
In some cases, there is a prodrome, manifested by weakness, decreased concentration, and postdrome in the form of general weakness, pallor and yawning. A migraine attack is usually accompanied by nausea, photo- and phonophobia, and a deterioration in appetite. The headache gets worse when climbing stairs and walking. In childhood, a migraine attack is accompanied by drowsiness, and after sleep, the pain usually goes away. Migraine is closely related to the female genitals, therefore, in 35% of cases, disease is provoked by menstruation, and the so-called menstrual migraine — in 8-10%. Taking hormonal contraceptives and hormone replacement therapy aggravates the course in 70-80% of cases of the disease.
There are several clinical varieties:
- vegetative or panic — the attack is accompanied by vegetative symptoms (chills, increased heartbeat, lacrimation, feeling of suffocation, facial swelling);
- migraine with aura – transient, visual, speech, sensory, motor disorders appear before the attack; its type is basilar migraine;
- associative – headache paroxysm is accompanied by a transient neurological deficit; its varieties are aphatic, cerebellar, hemiplegic and ophthalmoplegic migraine.
- sleep — an attack occurs during sleep or in the morning, during awakening;
- menstrual migraine is a type of form associated with the menstrual cycle. It has been proven that the attack of such migraine is caused by a decrease in the level of estrogens in the late luteal phase of the normal menstrual cycle;
- chronic — attacks occur more often than 15 days / month for three months or longer. The number of seizures increases every year until the appearance of daily headaches. The intensity of headache in chronic form increases with each attack.
Diagnostics
As with other primary cephalgias, the basis for the diagnosis is the patient’s complaints and anamnesis data. In most cases, there is no need for additional research methods (EEG, rheoencephalography, MRI of the brain). The manifestation of neurological symptoms was noted only in 2-3% of patients. At the same time, in most cases, there is tension and soreness of one or more pericranial muscles, which becomes a constant source of discomfort and even pain in the neck and occipital region.
Migraine needs to be differentiated from episodic tension pain, for which, unlike migraines, bilateral, independent of physical exertion, less intense headaches of a pressing (compressive) nature are typical.
Migraine treatment
Migraine therapy can be divided into two stages: relief of the developed attack and further preventive treatment in order to prevent new migraine attacks.
Relief of the attack. The appointment by a neurologist of certain drugs for the relief of a migraine attack depends on its intensity. Attacks of mild or moderate intensity lasting less than two days are stopped with the help of simple or combined analgesics: ibuprofen (0.2—0.4 g), paracetamol (0.5 g), acetylsalicylic acid (0.5—1 g); as well as codeine-containing drugs (a combination of codeine, paracetamol, sodium metamizole and phenobarbital). It is possible to perform therapeutic blockades.
In severe migraine (high intensity of headache, duration of attacks for more than two days), drugs of specific therapy are used — triptans (serotonin receptor agonists of type 5NT); for example, zolmitriptan, sumatriptan, eletriptan, as well as other forms of triptans (candles, solution for subcutaneous injections, nasal spray).
Prognosis and prevention
The prognosis is generally favorable, except in those rare cases when dangerous complications may develop (migraine status, migraine stroke). To prevent the chronization of the disease and improve the quality of life, preventive treatment is carried out, the purpose of which is: to reduce the duration, frequency and severity of seizures; to reduce the impact on the patient’s daily life.
The components of preventive treatment are selected individually for each patient, taking into account the pathogenetic mechanisms of the disease, provoking factors and emotional and personal disorders. Beta-blockers (metoprolol, propranolol), antidepressants (amitriptyline, citalopram), calcium channel blockers (nimodipine), as well as NSAIDs (naproxen, acetylsalicylic acid) have become the most widespread. In modern medicine, non-drug methods (progressive muscle relaxation, psychotherapy, acupuncture) are increasingly used to prevent migraines.