It is estimated that 22 million Americans suffer from migraines and this can be a debilitating condition for up to 85% of them. Migraines are believed to be due to a mixture of environmental and genetic factors. About two-thirds of cases run in families. New research regarding the brain’s processing of pain has led to a discovery of new medications that can help restore a pain free state.
Migraines come in multiple forms. Migraines were traditionally believed to be a result of a blood vessel spasms, but more recently evidence points to an increased excitability of the cerebral cortex and abnormal control of pain neurons in the trigeminal nucleus of the brainstem. Not all migraines result in a severe headache and some may only have visual complications. Migraines are classified as to their type of presentation. The common migraine is a headache without visual symptoms. The classic migraine is one in which there is visual aura followed by the headache. Other migraines can simply give the visual symptoms without the headache and these are called acephalgic migraines. Migraines can occur in clusters as well and affect the eye alone. We will discuss each of the types of migraines and then their treatment in the subsequent paragraphs.
The common migraine is a migraine that does not have visual symptoms. This is the type of migraine most people think of when someone describes a migraine. Although, these headaches are not immediately preceded by the visual symptoms, they are often preceded by some poorly defined symptoms such as yawning, depression and irritability for hours prior to the occurrence of the headache. The headaches often occur on awakening or during hours of relaxation after a stressful period. The headaches are initially throbbing on one side of the head. They often feel that they are behind the eye. As the pain intensifies over several hours, it becomes more constant and spreads over the entire head. Some specific circumstances may precipitate a migraine. These include sleep deprivation, hunger, nauseous odors, bright fluorescent lighting, medications such as oral contraceptives, red wine, chocolate, Monosodium glutamate (MSG), processed meats, artificial sweeteners and aged cheeses. Sometimes, patients can identify the causative agent and avoid this substance or situation in the future. Associated symptoms may include nausea, vomiting, photophobia (increased sensitivity to light), phonophobia (increased sensitivity to sound) and the pain is generally aggravated by physical activity.
The classic migraine is a migraine that is preceded by visual symptoms. These visual symptoms often involve a scintillating blind spot in the visual field. It typically begins as a small C shaped, luminous zigzag near the center of the vision and then slowly expands and drifts toward the side vision involving one-half of the visual field. The entire phenomenon can last 20 to 40 minutes and it results in a headache that is most often on the opposite side of the head when compared to the visual field defect. These classic migraines are somewhat less common than the common migraine described above. Many patients feel they have a visual problem and often attribute it to the eye on the same side as the visual field defect. However, these visual field defects are usually in both eyes which can be determined by covering one eye, then the other.
An acephalgic migraine is one in which the individual gets the visual symptom described above, but it is not followed by the headache. Most of these patients feel they have an eye problem and often end up in the eye doctor’s office because of the scintillating blind spot. Ophthalmic migraines are a very rare condition. They occur most often in children with transient paralysis of the muscles that move the eye. This diagnosis is often difficult and one of exclusion of other serious central nervous system problems.
A retinal migraine is a temporary loss of vision in one eye that is accompanied by a headache in an otherwise young and healthy patient. Examination of the eye during the attack would demonstrate constriction of the arteries and veins within the eye. This temporary reduction of blood flow causes the decrease in vision.
Cluster migraines are episodes of pain around the eye on one side of the head that are accompanied by redness, droopy eyelid, and a constriction of the pupil. Sometimes, these can occur more than once a day and they are usually clustered with multiple episodes over a six to twelve week period. After this period, the patient often receives resolution for quite some time, however, they may return later. The pain tends to be very severe in this form of migraine.
Migraines are most often treated with pain medications; however, patient with significant debilitating migraines can now have quicker relief with some of the newer drugs that block receptors that lead to the pain. One such drug is called Sumatriptan. This drug is administered by a subcutaneous injection with a response rate up to 77% at 60 minutes. There are oral forms and intranasal forms as well. However, these routes of administration take somewhat longer to alleviate the pain. There are some newer drugs developed along the same lines to treat the immediate migraine pain.
More long standing treatments would include drugs such as Midrin with two capsules. These drugs provide significant relief for many patients without having to perform an injection. For patients with frequent disabling migraines, there are medications that can be used to prevent migraines. Beta blockers that are also used to treat heart disease, such as Propranolol can prevent frequent migraines. Patients with significant migraines should consult their medical physician for the best form of preventative therapy available for them. The form of therapy chosen may depend on their medical history.
In summary, migraine is not a curable disease, but current treatment modalities to relieve and abort the symptoms are very helpful. Although our current treatments are not perfect, there are certainly more options today than ever before in both the treatment of acute symptoms of the migraine and long term prevention of migraine occurrence.