Classical migraine

Alternative names:

Migraine (classical); migraine headache, migraine with aura

Treatment:

It is valuable to maintain a headache diary - a calendar record of headaches and associated symptoms. Diet, sleep patterns, menstrual cycles, and other relevant environmental factors should also be noted on the calendar. With this diary, a relationship between migraines and a particular environmental factor may became apparent and provide a mechanism of reducing the frequency of attacks. For example, the diary may reveal that headaches tend to occur more often on days when the patient awakens earlier than usual. A subsequent change in sleep schedule may then result in fewer migraine attacks. Even in the absence of a clear factor that provokes migraine attacks, changes in life style are frequently useful. Many patients may benefit from a regular sleep schedule and exercise. Avoidance of smoking, caffeine, and alcohol is also beneficial. Some patients have found biofeedback and self-hypnosis to be effective at reducing the frequency of migraine attacks. Joining a support group where members share common experiences and problems can often help the stress of illness. Some oral contraceptive pills and other medications may increase headache frequency. Your healthcare provider should address questions regarding their use.

Although there is no cure for migraine headaches, numerous treatment options are available. Methods of migraine treatment include:

• Prevention of migraine or reducing the frequency of their occurrence
• Aborting the migraine, once early symptoms develop
• Treating the symptoms of migraine (e.g. pain, nausea)

All medications have potential side effects and may be incompatible with other medications used to treat coexisting medical problems or may worsen an underlying medical problem. Also, many of these medications are associated with birth defects and are therefore not safe to use during pregnancy. A physician will individualize treatment based on these factors. Often, several classes of medications are tried before one (or a combination) is found to be effective.

Many medications can reduce the frequency of migraines. Generally, these preventative medications need to be taken daily in order to be effective. Because they must be taken even in-between headaches, they are less useful and tolerable to patients with infrequent headaches. Medications in this category include:

• Beta-blockers (e.g. propanolol)
• Anti-depressants (e.g. amitriptyline)
• Anti-convulsants (e.g. valproic acid)
• Calcium-channel blockers (e.g. verapamil)
• Serotonin re-uptake inhibitors

Other medications are taken when there is the first sign of an impending migraine attack. In the case of classic migraine, this is typically when visual disturbances are first noted. These medications can effectively stop the migraine in its tracks, preventing the progression to other migraine symptoms or reducing the severity of the attack. Many of these medications cause constriction of blood vessels and cannot be given to patients at risk of heart attack or other conditions. These medications include:

• Ergots (e.g. DHE-45)
• Serotonin agonists / triptans (e.g. sumatriptan)
• isometheptene

Many of these medications come in various preparations to enable administration via different routes. For example, patients who experience vomiting and cannot keep pills down may benefit from a nasal spray or injectable dose. Call for an appointment with your health care provider if taking an ergotamine-containing medication and you are likely to become pregnant (these medications can have serious side effects to a developing fetus).

Other medications are primarily given to treat the symptoms of migraine. Used alone or in combinations, these drugs can minimize pain, nausea, or emotional distress caused by the migraine. Some of these medications may also have some effect on the underlying process in addition to providing symptomatic relief. Medications in this category include:

• Anti-emetics (e.g. prochlorperazine)
• Sedatives (e.g. butalbital)
• Anti-inflammatories (e.g. ibuprofen)
• Acetaminophen
• Narcotic analgesics (e.g. meperidine)

Expectations (prognosis):

Migraine headaches usually represent no significant threat to overall health. However, there are rare circumstances when patients with migraine are at risk of other serious medical illnesses such as stroke. Experienced physicians can identify certain patients who may be at increased risk from these complications and who can implement treatment to reduce such risk. The large number of people affected by migraine has initiated extensive research into the finding the cause for and effective treatment of the disorder. Numerous medications have recently been released and many others are in the development stages.

Frequently Asked Questions:

Q. Do migraine headaches mean that I may have a brain tumor?

A. True migraine headaches are not a result of underlying brain tumors or other serious medical problems. However, only an experienced physician can determine whether headache symptoms represent migraine or some underlying medical condition that requires further tests. This assessment can only be made after a review of a patient's history and a thorough neurological examination.

Q. I have been diagnosed with migraines. Do I have to stop eating all of the foods mentioned above?

A. Generally, most patients with migraine can identify select foods that are closely associated with a migraine headache. A method of finding out which food(s) are responsible is to initially avoid all of the above foods and then gradually work each food back into the diet. In this manner, many patients can identify specific foods that need to be avoided. An accurate headache diary helps determine which foods may be responsible.

Calling your health care provider:

Call for an appointment with your health care provider if symptoms of migraine are severe, persistent, recurrent, or accompanied by other symptoms.

Also call if previously effective treatments are no longer helpful, or if symptoms indicating side effects of medications occur, including irregular heartbeat, changes in skin color (pale or blue), extreme sleepiness or sedation, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain or cramps, dry mouth, extreme thirst, or others (see specific medication).

Call for an appointment with your health care provider if taking an ergotamine-containing medication and you are likely to become pregnant (these medications should not be taken when pregnant).

Sources:

"Headache: a guide to prevention and treatment" National headache foundation. Available at: http://www.headaches.org/products/guide.htm

Raskin NH. Headache. Churchill Livingston, NY 1988.

Bartleson, JD. Treatment of migraine headaches. Mayo Clin Proc 1999;74:702-708.

Update Date: 05/08/00
Joseph Campellone, M.D., Assistant Professor of Neurology (Department of Medicine) Robert Wood Johnson Medical School, New Jersey. Director, Neurophysiology Laboratory, Cooper Hospital.VeriMed Healthcare Network