Migraine
21035
225951205
2008-07-16T04:28:36Z
218.214.79.173
/* Alternative medicine */
{{this|the disorder}}
{{Infobox_Disease |
Name = Migraine |
Image = |
Caption = |
DiseasesDB = 8207 |
ICD9 = {{ICD9|346}} |
ICD10 = {{ICD10|G|43||g|40}}|
ICDO = |
OMIM = 157300 |
MedlinePlus = 000709 |
eMedicineSubj = neuro |
eMedicineTopic = 218 |
eMedicine_mult = {{eMedicine2|neuro|517}} {{eMedicine2|emerg|230}} {{eMedicine2|neuro|529}} |
MeshID = D008881 |
}}
'''Migraine''' is a [[neurology|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<ref>http://216.25.100.131/upload/CT_Clas/diagnost.pdf The International Classification of Headache Disorders, 2nd Edition</ref>. Accompanying complaints are [[nausea]] and [[vomiting]], and a heightened sensitivity to bright lights ([[photophobia]]) and noise ([[hyperacusis]]).<ref>{{cite web | title = NINDS Migraine Information Page | work= National Institute of Neurological Disorders and Stroke, National Institutes of Health | url = http://www.ninds.nih.gov/disorders/migraine/migraine.htm | accessdate=2007-06-25}}</ref><ref>{{cite web | title = Advances in Migraine Prophylaxis: Current State of the Art and Future Prospects| work= National Headache Foundation (CME monograph) | url = http://www.headaches.org/professional/educationresources/PDF/botoxcme.pdf | accessdate=2007-06-25}}</ref><ref name="pmid11859906">{{cite journal |author=Gallagher RM, Cutrer FM |title=Migraine: diagnosis, management, and new treatment options |journal=Am J Manag Care |volume=8 |issue=3 Suppl |pages=S58–73 |year=2002 |pmid=11859906 |doi=}}</ref> Approximately one third of people who experience migraine get a preceding [[Aura (symptom)|aura]], in which a patient may sense a strange light or unpleasant smell.<ref>{{cite web | title = Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache, Jan 2007,British Association for the Study of Headache| | url = http://216.25.100.131/upload/NS_BASH/BASH_guidelines_2007.pdf | accessdate=2007-06-25}}</ref> Patients often describe [[#Triggers|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 [[idiopathic|unknown]], the most widespread theory is that it is a disorder of the [[serotonergic]] control system. Genetic factors may also contribute.<ref name="pmid9601620">{{cite journal |author=Ogilvie AD, Russell MB, Dhall P, ''et al'' |title=Altered allelic distributions of the serotonin transporter gene in migraine without aura and migraine with aura |journal=Cephalalgia |volume=18 |issue=1 |pages=23–6 |year=1998 |pmid=9601620| doi = 10.1046/j.1468-2982.1998.1801023.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> Studies on twins show that genes have a 60 to 65% influence on the development of migraine .<ref name="pmid10496258">{{cite journal |author=Gervil M, Ulrich V, Kaprio J, Olesen J, Russell MB |title=The relative role of genetic and environmental factors in migraine without aura |journal=Neurology |volume=53 |issue=5 |pages=995–9 |year=1999 |month=September |pmid=10496258 |doi= |url=http://www.neurology.org/cgi/pmidlookup?view=long&pmid=10496258}}</ref><ref name="pmid10204850">{{cite journal |author=Ulrich V, Gervil M, Kyvik KO, Olesen J, Russell MB |title=The inheritance of migraine with aura estimated by means of structural equation modelling |journal=J. Med. Genet. |volume=36 |issue=3 |pages=225–7 |year=1999 |month=March |pmid=10204850 |pmc=1734315 |doi= |url=http://jmg.bmj.com/cgi/pmidlookup?view=long&pmid=10204850}}</ref> 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]],{{Fact|date=November 2007}} 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 language|Greek]] ''hemicrania'', as does the Old English term ''megrim''. Literally, ''hemicrania'' means "half (the) head".
==Classification==
Migraines have been classified by the [[International Headache Society]] which periodically revises their classification.<ref name="pmid14979299">{{cite journal |author=Headache Classification Subcommittee of the International Headache Society |title=The International Classification of Headache Disorders: 2nd edition |journal=Cephalalgia : an international journal of headache |volume=24 Suppl 1 |issue= |pages=9–160 |year=2004 |pmid=14979299 |doi=10.1111/j.1468-2982.2004.00653.x}} [http://www.i-h-s.org/upload/ct_clas/ihc_II_main_no_print.pdf Complete supplement online]</ref>
===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:<ref name="pmid14979299p150">{{cite journal |author=Headache Classification Subcommittee of the International Headache Society |title=The International Classification of Headache Disorders: 2nd edition |journal=Cephalalgia : an international journal of headache |volume=24 Suppl 1 |issue= |pages=150 |year=2004 |pmid=14979299 |doi=10.1111/j.1468-2982.2004.00653.x}} [http://www.i-h-s.org/upload/ct_clas/ihc_II_main_no_print.pdf Complete supplement online] (see page 150)</ref>
{| class="wikitable"
|-Scale
!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
|}
===Migraine without aura===
This is the most commonly seen form of migraine; patients who primarily suffer from migraine without [[aura (symptom)|aura]] may also have attacks of migraine with aura. According to the International Classification of Headache Disorders<ref name="pmid14979299"/> 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.
===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<ref name="pmid14979299"/> 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.
===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 [[triptan]]s and other [[vasoconstrictor]]s as abortive treatments in BTM is [[Contraindication|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.
===Familial hemiplegic migraine===
{{main|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<ref name="pmid14979299"/><!-- reverting previous change and adding reference. These migraines rarely last more than 72 hours, and if they do, they are then status migrainousus, an emergency situation --> 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.
=== Abdominal migraine ===
According to the International Classification of Headache Disorders<ref name="pmid14979299"/> 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.
=== Acephalgic migraine ===
Acephalgic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience [[aura (symptom)|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.
===Menstrual migraine===
Menstrual migraine is distinct from other migraines. Approximately 21 million women in the US suffer from migraines,<ref name="pmid11554952">{{cite journal |author=Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M |title=Prevalence and burden of migraine in the United States: data from the American Migraine Study II |journal=Headache |volume=41 |issue=7 |pages=646–57 |year=2001 |pmid=11554952| doi = 10.1046/j.1526-4610.2001.041007646.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> and about 60% of them suffer from menstrual migraines.<ref name="pmid8376100">{{cite journal |author=Granella F, Sances G, Zanferrari C, Costa A, Martignoni E, Manzoni GC |title=Migraine without aura and reproductive life events: a clinical epidemiological study in 1300 women |journal=Headache |volume=33 |issue=7 |pages=385–9 |year=1993 |pmid=8376100| doi = 10.1111/j.1526-4610.1993.hed3307385.x <!--Retrieved from CrossRef by DOI bot-->}}</ref>
*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.<ref>(2004) "The International Classification of Headache Disorders: 2nd edition". Cephalalgia 24 Suppl 1: 9–160.</ref>
*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.<ref name="pmid16622144">{{cite journal |author=Brandes JL |title=The influence of estrogen on migraine: a systematic review |journal=JAMA |volume=295 |issue=15 |pages=1824–30 |year=2006 |pmid=16622144 |doi=10.1001/jama.295.15.1824}}</ref>
*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.<ref name="pmid15277635">{{cite journal |author=MacGregor EA, Hackshaw A |title=Prevalence of migraine on each day of the natural menstrual cycle |journal=Neurology |volume=63 |issue=2 |pages=351–3 |year=2004 |pmid=15277635 |doi=}}</ref>
When compared with migraines that occur at other times of the month, menstrual migraines have been reported to
*Last longer—up to 72 hours<ref name="pmid15315526">{{cite journal |author=Granella F, Sances G, Allais G, ''et al'' |title=Characteristics of menstrual and nonmenstrual attacks in women with menstrually related migraine referred to headache centres |journal=Cephalalgia |volume=24 |issue=9 |pages=707–16 |year=2004 |pmid=15315526 |doi=10.1111/j.1468-2982.2004.00741.x}}</ref>
*Be more severe<ref name="pmid15277635"/><ref name="pmid12716349">{{cite journal |author=Couturier EG, Bomhof MA, Neven AK, van Duijn NP |title=Menstrual migraine in a representative Dutch population sample: prevalence, disability and treatment |journal=Cephalalgia |volume=23 |issue=4 |pages=302–8 |year=2003 |pmid=12716349| doi = 10.1046/j.1468-2982.2003.00516.x <!--Retrieved from CrossRef by DOI bot-->}}</ref>
*Occur more often with nausea and vomiting<ref name="pmid8376100"/>
*Be more difficult to treat—occur more frequently<ref name="pmid16178949">{{cite journal |author=Martin VT, Wernke S, Mandell K, ''et al'' |title=Defining the relationship between ovarian hormones and migraine headache |journal=Headache |volume=45 |issue=9 |pages=1190–201 |year=2005 |pmid=16178949 |doi=10.1111/j.1526-4610.2005.00242.x}}</ref>
== 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 (symptom)|aura]], which immediately precedes the headache.
# The [[pain]] phase, also known as headache phase.
# The postdrome.
===Prodrome phase===
Prodromal symptoms occur in 40 to 60% of migraineurs (migraine sufferers). This phase may consist of altered mood, irritability, [[clinical depression|depression]] or [[Euphoria (emotion)|euphoria]], [[fatigue (physical)|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.
===Aura phase===
For the 20–30%<ref name="isbn1842142739">{{cite book |author=Silberstein, Stephen D. |title=Atlas Of Migraine And Other Headaches |publisher=Taylor & Francis Group |location=London |year=2005 |pages= |isbn=1842142739 |oclc= |doi=}}</ref><ref name="isbn078175223X">{{cite book |author=Mathew, Ninan T.; Evans, Randolph W. |title=Handbook of headache |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2005 |pages= |isbn=078175223X |oclc= |doi=}}</ref> 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.<ref name="isbn1-901865-88-6">{{cite book |author=Silberstein, Stephen D. |title=Headache in Clinical Practice, 2nd Edition |publisher=Taylor & Francis Group |location=London |year=2002 |pages= |isbn=1-901865-88-6 |oclc= |doi=}}</ref>
Visual [[aura (symptom)|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 [[paresthesia]]s, 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 (medical)|vertigo]], tingling or numbness of the face and extremities, and hypersensitivity to touch.
===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 (medical)|vertigo]] and a feeling of faintness may occur. The extremities tend to be cold and moist.
===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.
==Diagnosis==
Migraines are underdiagnosed<ref name="pmid1599358">{{cite journal |author=Lipton RB, Stewart WF, Celentano DD, Reed ML |title=Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis |journal=Arch. Intern. Med. |volume=152 |issue=6 |pages=1273–8 |year=1992 |pmid=1599358| doi = 10.1001/archinte.152.6.1273 <!--Retrieved from CrossRef by DOI bot-->}}</ref> and misdiagnosed.<ref name="pmid15364670">{{cite journal |author=Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C |title=Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache |journal=Arch. Intern. Med. |volume=164 |issue=16 |pages=1769–72 |year=2004 |pmid=15364670 |doi=10.1001/archinte.164.16.1769}}</ref> 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 ('''P'''ulsating, duration of 4–72 h'''O'''urs, '''U'''nilateral, [[Nausea]], '''D'''isabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive [[likelihood-ratio test| likelihood ratio]] for diagnosing migraine is 24.<ref name="pmid16968852">{{cite journal |author=Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM |title=Does this patient with headache have a migraine or need neuroimaging? |journal=JAMA |volume=296 |issue=10 |pages=1274–83 |year=2006 |pmid=16968852 |doi=10.1001/jama.296.10.1274}}</ref>
The presence of either disability, nausea or sensitivity, can diagnose migraine with:<ref name="pmid12913201">{{cite journal |author=Lipton RB, Dodick D, Sadovsky R, ''et al'' |title=A self-administered screener for migraine in primary care: The ID Migraine validation study |journal=Neurology |volume=61 |issue=3 |pages=375–82 |year=2003 |pmid=12913201 |doi=}}</ref>
* [[sensitivity (tests)|sensitivity]] of 81%
* [[specificity (tests)|specificity]] of 75%
== 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<ref name="isbn0-446-67826-0">{{cite book |author=Alexander Mauskop; Fox, Barry |title=What Your Doctor May Not Tell You About(TM): Migraines : The Breakthrough Program That Can Help End Your Pain (What Your Doctor May Not Tell You About...(Paperback)) |publisher=Warner Books |location=New York |year=2001 |pages= |isbn=0-446-67826-0 |oclc= |doi=}}</ref> and claimed to have been discredited by others.<ref name="CohenNeuroimaging">{{cite journal |author=Cohen AS, Goadsby PJ |title=Functional neuroimaging of primary headache disorders |journal=Curr Pain Headache Rep |volume=9 |issue=2 |pages=141–6 |year=2005 |pmid=15745626| doi = 10.1007/s11916-005-0053-0 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
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]].{{Fact|date=April 2008}}
=== Depolarization theory ===
A phenomenon known as [[cortical spreading depression]] can cause migraines.<ref name="LauritzenM">{{cite journal |author=Lauritzen M |title=Pathophysiology of the migraine aura. The spreading depression theory |journal=Brain |volume=117 ( Pt 1) |issue= |pages=199–210 |year=1994 |pmid=7908596 |doi=}}</ref> In [[cortical spreading depression]], [[neuron|neurological activity]] is depressed over an area of the [[cerebral cortex|cortex]] of the brain. This situation results in the release of [[inflammation|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.<ref name="pmid18052951">{{cite journal |author=Denuelle M, Fabre N, Payoux P, Chollet F, Geraud G |title=Hypothalamic activation in spontaneous migraine attacks |journal=Headache |volume=47 |issue=10 |pages=1418–26 |year=2007 |pmid=18052951 |doi=10.1111/j.1526-4610.2007.00776.x}}</ref>
=== 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.<ref name="isbn0-446-67826-0"/>
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.<ref name="isbn0-446-67826-0"/>
The vascular theory of migraines is now seen as secondary to brain dysfunction.<ref name="isbn0-446-67826-0"/>
=== 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.<ref name="isbn0-446-67826-0"/> [[Triptan]]s activate serotonin receptors to stop a migraine attack.<ref name="isbn0-446-67826-0"/>
=== 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.<ref name="isbn0-446-67826-0"/>
=== 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<ref name="isbn0-446-67826-0"/>
== Epidemiology ==
[[Image:Migraine gender age.png|thumb|right|256px|Age-Gender Incidence]]
Migraine is an extremely common condition which will affect 12–28% of people at some point in their lives.<ref name="Stovner">{{cite journal |author=Stovner LJ, Zwart JA, Hagen K, Terwindt GM, Pascual J |title=Epidemiology of headache in Europe |journal=Eur. J. Neurol. |volume=13 |issue=4 |pages=333–45 |year=2006 |pmid=16643310 |doi=10.1111/j.1468-1331.2006.01184.x}}</ref> 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.<ref name="Stovner" /> 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.<ref name="pmid1451940">{{cite journal |author=Mortimer MJ, Kay J, Jaron A |title=Epidemiology of headache and childhood migraine in an urban general practice using Ad Hoc, Vahlquist and IHS criteria |journal=Dev Med Child Neurol |volume=34 |issue=12 |pages=1095–101 |year=1992 |pmid=1451940 |doi=}}</ref> There is then a rapid growth in incidence amongst girls occurring after puberty,<ref name="pmid2926969">{{cite journal |author=Linet MS, Stewart WF, Celentano DD, Ziegler D, Sprecher M |title=An epidemiologic study of headache among adolescents and young adults |journal=JAMA |volume=261 |issue=15| pages = e1197 |year=1989 |pmid=2926969 | doi = 10.1001/jama.261.15.2211 <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid557763">{{cite journal |author=Ziegler DK, Hassanein RS, Couch JR |title=Characteristics of life headache histories in a nonclinic population |journal=Neurology |volume=27 |issue=3 |pages=265–9 |year=1977 |pmid=557763 |doi=}}</ref><ref name="pmid14444681">{{cite journal |author=SELBY G, LANCE JW |title=Observations on 500 cases of migraine and allied vascular headache |journal=J. Neurol. Neurosurg. Psychiatr. |volume=23 |issue= |pages=23–32 |year=1960 |pmid=14444681 |doi=}}</ref> which continues throughout early adult life.<ref name="pmid16740819">{{cite journal |author=Anttila P, Metsähonkala L, Sillanpää M |title=Long-term trends in the incidence of headache in Finnish schoolchildren |journal=Pediatrics |volume=117 |issue=6 |pages=e1197–201 |year=2006 |pmid=16740819 |doi=10.1542/peds.2005-2274}}</ref> By early middle age, around 25% of women experience a migraine at least once a year, compared with fewer than 10% of men.<ref name="Stovner" /><ref name="pmid8502385">{{cite journal |author=Lipton RB, Stewart WF |title=Migraine in the United States: a review of epidemiology and health care use |journal=Neurology |volume=43 |issue=6 Suppl 3 |pages=S6–10 |year=1993 |pmid=8502385 |doi=}}</ref> 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%.<ref name="Stovner"/><ref name="pmid8502385" />
At all ages, migraine without aura is more common than migraine with aura, with a ratio of between 1.5:1 and 2:1.<ref name="pmid1525797">{{cite journal |author=Rasmussen BK, Olesen J |title=Migraine with aura and migraine without aura: an epidemiological study |journal=Cephalalgia |volume=12 |issue=4 |pages=221–8; discussion 186 |year=1992 |pmid=1525797| doi = 10.1046/j.1468-2982.1992.1204221.x <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid12950377">{{cite journal |author=Steiner TJ, Scher AI, Stewart WF, Kolodner K, Liberman J, Lipton RB |title=The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity |journal=Cephalalgia |volume=23 |issue=7 |pages=519–27 |year=2003 |pmid=12950377| doi = 10.1046/j.1468-2982.2003.00568.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> Incidence figures show that the excess of migraine seen in women of reproductive age is mainly due to migraine without aura.<ref name="pmid1525797"/> Thus in pre-pubertal and post-menopausal populations, migraine with aura is somewhat more common than amongst 15–50 year olds.<ref name="pmid16740819"/><ref name="pmid16864816">{{cite journal |author=Bigal ME, Liberman JN, Lipton RB |title=Age-dependent prevalence and clinical features of migraine |journal=Neurology |volume=67 |issue=2 |pages=246–51 |year=2006 |pmid=16864816 |doi=10.1212/01.wnl.0000225186.76323.69}}</ref>
There is a strong relationship between age, gender and type of migraine.<ref name="pmid1746521">{{cite journal |author=Stewart WF, Linet MS, Celentano DD, Van Natta M, Ziegler D |title=Age- and sex-specific incidence rates of migraine with and without visual aura |journal=Am. J. Epidemiol. |volume=134 |issue=10 |pages=1111–20 |year=1991 |pmid=1746521 |doi=}}</ref>
Geographical differences in migraine prevalence are not marked. Studies in Asia and South America suggest that the rates there are relatively low,<ref name="pmid12583837">{{cite journal |author=Wang SJ |title=Epidemiology of migraine and other types of headache in Asia |journal=Curr Neurol Neurosci Rep |volume=3 |issue=2 |pages=104–8 |year=2003 |pmid=12583837| doi = 10.1007/s11910-003-0060-7 <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid9399008">{{cite journal |author=Lavados PM, Tenhamm E |title=Epidemiology of migraine headache in Santiago, Chile: a prevalence study |journal=Cephalalgia |volume=17 |issue=7 |pages=770–7 |year=1997 |pmid=9399008| doi = 10.1046/j.1468-2982.1997.1707770.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> but they do not fall outside the range of values seen in European and North American studies.<ref name="Stovner" /><ref name="pmid8502385"/>
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.<ref name="pmid7969967">{{cite journal |author=Ottman R, Lipton RB |title=Comorbidity of migraine and epilepsy |journal=Neurology |volume=44 |issue=11 |pages=2105–10 |year=1994 |pmid=7969967 |doi=}}</ref>
== 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:
{{quote|Migraine attacks may be triggered by:
* [[Allergy|Allergic reaction]]s
* Bright lights, loud noises, and certain odors or perfumes
* Physical or emotional [[stress (medicine)|stress]]
* Changes in [[Sleep|sleep pattern]]s
* [[Smoking]] or exposure to smoke
* Skipping meals
* [[Alcohol]]
* [[Menstrual cycle]] fluctuations, [[Combined oral contraceptive pill|birth control pills]], hormone fluctuations during the [[menopause]] transition
* [[Tension headache]]s
* Foods containing [[tyramine]] (red wine, aged cheese, smoked fish, chicken livers, figs, and some beans), [[monosodium glutamate]] (MSG) or [[nitrate]]s (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<ref name=MedlinePlus>{{cite web |url=http://www.nlm.nih.gov/medlineplus/ency/article/000709.htm |title=MedlinePlus Medical Encyclopedia: Migraine |accessdate=2008-04-04 |format= | last = Kantor | first = D | date = 2006-11-21 |work=}}</ref>}}
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 [[correlation]]s 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. <ref>Houlding,C (2007).''Managing Migraines''[http://www.authorhouse.com/BookStore/ItemDetail~bookid~42158.aspx], AuthorHouse. [ISBN 1425974880][http://www.authorhouse.com/BookStore/ItemDetail~bookid~42158.aspx]</ref>
=== Food ===
A 2005 [[literature review]] found that the available information about dietary trigger factors relies mostly on the subjective assessments of patients.<ref name="FoodHolzhammer">{{cite journal |author=Holzhammer J, Wöber C |title=[Alimentary trigger factors that provoke migraine and tension-type headache] |language=German |journal=Schmerz |volume=20 |issue=2 |pages=151–9 |year=2006 |pmid=15806385 |doi=10.1007/s00482-005-0390-2}}</ref> 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#Tolerance and withdrawal|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.<ref>{{cite web| url = http://www.headaches.org/pdf/LowTyramineDiet.pdf | title = Low Tyramine Headache Diet| accessdate = 2008-04-04| year = 2004| format = PDF | publisher = National Headache Foundation }}</ref>
=== 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.<ref name="PrinceWeather">{{cite journal |author=Prince PB, Rapoport AM, Sheftell FD, Tepper SJ, Bigal ME |title=The effect of weather on headache |journal=Headache |volume=44 |issue=6 |pages=596–602 |year=2004 |pmid=15186304 |doi=10.1111/j.1526-4610.2004.446008.x |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0017-8748&date=2004&volume=44&issue=6&spage=596}}</ref> 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 wind]]s 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 [[ion]]s in the air.<ref name="CookeWeather">{{cite journal |author=Cooke LJ, Rose MS, Becker WJ |title=Chinook winds and migraine headache |journal=Neurology |volume=54 |issue=2 |pages=302–7 |year=2000 |pmid=10668687 |doi=}}</ref>
===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.<ref name="RavishankarHairwashheadache">{{cite journal |author=Ravishankar K |title='Hair wash' or 'head bath' triggering migraine - observations in 94 Indian patients |journal=Cephalalgia |volume=26 |issue=11 |pages=1330–4 |year=2006 |pmid=17059440 |doi=10.1111/j.1468-2982.2006.01223.x}}</ref>
== 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<ref name=Millichap >{{cite journal |author=Millichap JG, Yee MM |title=The diet factor in pediatric and adolescent migraine |journal=Pediatr. Neurol. |volume=28 |issue=1 |pages=9–15 |year=2003 |pmid=12657413| doi = 10.1016/S0887-8994(02)00466-6 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
=== 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.{{Fact|date=October 2007}}
For patients who have been diagnosed with recurring migraines, migraine [[abortive medication]]s 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.{{Fact|date=April 2008}}
====Paracetamol or Non-steroidal anti-inflammatory drug (NSAIDs)====
The first line of treatment is [[over-the-counter]] [[abortive medication]].
* Regarding [[non-steroidal anti-inflammatory drug]]s, a [[randomized controlled trial]] found that [[naproxen]] can abort about one third of migraine attacks, which was 5% less than the benefit of [[sumatriptan]].<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, ''et al'' |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=JAMA |volume=297 |issue=13 |pages=1443–54 |year=2007 |pmid=17405970 |doi=10.1001/jama.297.13.1443}}</ref>
* [[Paracetamol]], at a dose of 1000 mg, benefited over half of patients with mild or moderate migraines in a [[randomized controlled trial]].<ref name="pmid11112243">{{cite journal |author=Lipton RB, Baggish JS, Stewart WF, Codispoti JR, Fu M |title=Efficacy and safety of paracetamol in the treatment of migraine: results of a randomized, double-blind, placebo-controlled, population-based study |journal=Arch. Intern. Med. |volume=160 |issue=22 |pages=3486–92 |year=2000 |pmid=11112243| doi = 10.1001/archinte.160.22.3486 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
* Simple analgesics combined with [[caffeine]] may help.<ref name="pmid10524663">{{cite journal |author=Goldstein J, Hoffman HD, Armellino JJ, ''et al'' |title=Treatment of severe, disabling migraine attacks in an over-the-counter population of migraine sufferers: results from three randomized, placebo-controlled studies of the combination of paracetamol, aspirin, and caffeine |journal=Cephalalgia : an international journal of headache |volume=19 |issue=7 |pages=684–91 |year=1999 |pmid=10524663 |doi=}}</ref> 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.{{Fact|date=October 2007}} [[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{{Fact|article|date=April 2007}}.
Patients themselves often start off with [[paracetamol]] (known as acetaminophen in the USA), [[aspirin]], [[ibuprofen]], or other simple [[analgesic]]s 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".{{Fact|date=October 2007}}
====Analgesics combined with antiemetics====
[[Anti-emetic]]s 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 [[prokinetic]]s 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).<ref>{{cite book |title=[[British National Formulary]] |edition=55 |date=March 2008 |chapter=4.7.4.1 Treatment of acute migraine |pages=p.239}}</ref> 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).
====Serotonin agonists====
{{main|triptans}}
[[Sumatriptan]] and related selective [[serotonin receptor agonist]]s are excellent for severe migraines or those that do not respond to [[NSAID]]s<ref name="pmid17405970"/> or other [[over-the-counter]] drugs.<ref name="pmid11112243"/> [[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.
====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.
====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 headache]]s. Barbiturate-containing medications are not available in many European countries.
[[Narcotic]] pain killers (for example, [[codeine]], [[morphine]] or other [[opiate]]s) provide variable relief, but their side effects include the possibility of causing [[rebound headache]]s or analgesic overuse headache. Following an awareness campaign in the US there has been a major shift away from "toughing it out" in terms of pain control, and narcotics are much more widely prescribed than just a decade ago.{{Fact|date=April 2008}}<!-- Even so, the US government remains opiate-phobic and ever alert to the over-prescribing doctor, but in UK [[Migraleve]] widely and successfully used --> In the UK and New Zealand, the combination product [[Migraleve]] which uses both paracetamol and codeine phosphate is widely used and available both on prescription and as an [[over the counter drug]].
[[Amidrine]] (a cocktail of a pain reliever, a sedative, and a vasoconstrictor) is sometimes prescribed for migraine headaches.
[[Anti-emetic]]s may need to be given by [[suppository]] or [[medical injection|injection]] where vomiting dominates the symptoms.
=====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 migr., first line therapy usually consists of the parenteral administration of DHE or a neuromodulator (i. e. a valproic acid derivative or topiramate), followed by the institution of a prophylactic regimen. Alternative therapies have included parenteral narcotics, intravenous lidocaine, magnesium, serotonergic antiemetics such as promethazine or chlorpromazine, and corticosteroids. The latter is often advocated in the therapy of intractable headache resulting from medication rebound.
=====Herbal treatment=====
The herbal supplement [[feverfew]] (more commonly used for migraine prevention, see below) is marketed by the [http://www.gelstat.com/ GelStat Corporation] as an OTC migraine abortive, administered sublingually (under the tongue) in a mixture with [[ginger]].<ref>[http://www.migraines.org/new/otcfeb05.htm Migraine News for February 2005], accessed Jan. 4 2008</ref> An open-label study (funded by GelStat) found some tentative evidence of the treatment's effectiveness,<ref>{{cite journal | title=Gelstat Migraine (sublingually administered feverfew and ginger compound) for acute treatment of migraine when administered during the mild pain phase | author=RK Cady, CP Schreiber, ME Beach, CC Hart | journal=Medical Science Monitor | year=2005 | volume=11 | issue=9 | pmid=16127373}} See also [http://www.migraines.org/treatment/pdfs/CadyClinicalTrial.pdf summary poster].</ref> 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.{{Fact|date=July 2008}}
==== Comparative studies ====
Regarding comparative effectiveness of these drugs used to abort migraine attacks, a 2004 placebo-controlled trial<ref name="ASADiener">{{cite journal | author = Diener H, Bussone G, de Liano H, Eikermann A, Englert R, Floeter T, Gallai V, Göbel H, Hartung E, Jimenez M, Lange R, Manzoni G, Mueller-Schwefe G, Nappi G, Pinessi L, Prat J, Puca F, Titus F, Voelker M | title = Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks. | journal = Cephalalgia | volume = 24 | issue = 11 | pages = 475 | year = 2004 | pmid = 15482357 | doi = 10.1111/j.1468-2982.2004.00783.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> 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.<ref name="pmid17405970">{{cite journal |author=Brandes JL, Kudrow D, Stark SR, ''et al'' |title=Sumatriptan-naproxen for acute treatment of migraine: a randomized trial |journal=JAMA |volume=297 |issue=13 |pages=1443–54 |year=2007 |pmid=17405970 |doi=10.1001/jama.297.13.1443}}</ref>
=== 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.<ref name="AFP0601">{{cite journal | author = Modi S, Lowder D | title = Medications for migraine prophylaxis. | journal = American Family Physician | volume = 73 | issue = 1 | pages =72 | year = 2006 | pmid =16417067}}</ref> 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.<ref name="MOHlancet">{{cite journal | author = Diener H, Limmroth V | title = Medication-overuse headache: a worldwide problem | journal = The Lancet Neurology | volume = 3 | year=2004 | doi=10.1016/S1474-4422(04)00824-5 | pages=475}}</ref>
==== 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:
{{quote|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.|<ref name="AFP0601"/>}}
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.<ref name="pmid15106196">{{cite journal | author = Linde K, Rossnagel K | title = Propranolol for migraine prophylaxis. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003225 | year = 2004| pmid = 15106196 | doi = 10.1002/14651858.CD003225.pub2}}</ref>
* [[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.<ref name="pmid15266476">{{cite journal | author = Chronicle E, Mulleners W | title = Anticonvulsant drugs for migraine prophylaxis. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003226 | year = 2004| pmid = 15266476 | doi = 10.1002/14651858.CD003226.pub2}}</ref> However, concerns have been raised about the marketing of [[gabapentin]].<ref name="pmid16908919">{{cite journal | author = Steinman M, Bero L, Chren M, Landefeld C | title = Narrative review: the promotion of gabapentin: an analysis of internal industry documents. | journal = Ann Intern Med | volume = 145 | issue = 4 | pages = 284–93 | year = 2006 | pmid = 16908919}}</ref>
* [[antidepressant]]s 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.<ref name="pmid16034880">{{cite journal | author = Moja P, Cusi C, Sterzi R, Canepari C | title = Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD002919 | year = 2005| pmid = 16034880 | doi = 10.1002/14651858.CD002919.pub2}}</ref> 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.<ref name="pmid11448661">{{cite journal | author = Tomkins G, Jackson J, O'Malley P, Balden E, Santoro J | title = Treatment of chronic headache with antidepressants: a meta-analysis. | journal = Am J Med | volume = 111 | issue = 1 | pages = 54–63 | year = 2001 | pmid = 11448661 | doi = 10.1016/S0002-9343(01)00762-8 <!--Retrieved from CrossRef by DOI bot-->}}</ref> A [[randomized controlled trial]] found that [[amitriptyline]] was better than placebo and similar to [[propranolol]].<ref name="pmid3579659">{{cite journal | author = Ziegler D, Hurwitz A, Hassanein R, Kodanaz H, Preskorn S, Mason J | title = Migraine prophylaxis. A comparison of propranolol and amitriptyline. | journal = Arch Neurol | volume = 44 | issue = 5 | pages = 486–9 | year = 1987 | pmid = 3579659}}</ref>
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.
==== 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]] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15806385&query_hl=8&itool=pubmed_docsum]
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.
==== Herbal and nutritional supplements ====
===== 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.[http://www.webmd.com/content/article/98/105003.htm?z=1728_00000_1000_tn_04]
===== 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[http://www.gwpharm.com/research_migraine_removed.asp]
===== 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]],<ref name="CoenzymeRozen">{{cite journal | author = Rozen T, Oshinsky M, Gebeline C, Bradley K, Young W, Shechter A, Silberstein S | title = Open label trial of coenzyme Q10 as a migraine preventive. | journal = Cephalalgia | volume = 22 | issue = 2 | pages = 137–41 | year = 2002 | pmid = 11972582 | doi = 10.1046/j.1468-2982.2002.00335.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> 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.<ref>{{cite journal |author=Sándor PS, et al.|title=Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial |journal=Neurology |volume=64 |pages=713–715 |year=2005 |url = http://www.neurology.org/cgi/content/abstract/64/4/713|pmid=15728298|doi=10.1212/01.WNL.0000151975.03598.ED|doi_brokendate=2008-06-25}}</ref>
===== 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.<ref>{{cite journal | author=Pittler MH, Ernst E. | title=Feverfew for preventing migraine | journal=Cochrane Database of Systematic Reviews | year=2004 | issue=1 | pages=CD002286 | doi=10.1002/14651858.CD002286.pub2 | pmid=14973986}}</ref> However, since then, more studies have been carried out.<ref>For example: {{cite journal | title=Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention—a randomized, double-blind, multicentre, placebo-controlled study | author=Diener HC, Pfaffenrath V, Schnitker J, Friede M, Henneicke-von Zepelin HH | journal=Cephalalgia | year=2005 | volume=25 | pages=1031–41 | pmid=16232154 | doi = 10.1111/j.1468-2982.2005.00950.x <!--Retrieved from CrossRef by DOI bot-->}}</ref> As well as its prophylactic properties, feverfew is also touted as a migraine abortative.
===== 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.<ref name="MagesiumPeikert">{{cite journal | author = Peikert A, Wilimzig C, Köhne-Volland R | title = Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. | journal = Cephalalgia | volume = 16 | issue = 4 | pages = 257–63 | year = 1996 | pmid = 8792038 | doi = 10.1046/j.1468-2982.1996.1604257.x <!--Retrieved from CrossRef by DOI bot-->}}</ref>
===== Riboflavin =====
The supplement [[Riboflavin]] (also called Vitamin B<sub>2</sub>) has been shown (in a placebo-controlled trial)<ref>{{cite journal | author = J Schoenen, J Jacquay, M Lenaerts | year=1998 | title=Effectiveness of high dose riboflavin in migraine prophylaxis: A randomized controlled trial | journal=Neurology | volume=150 | pages=466–470}}</ref> to reduce the number of migraines, when taken at the high dose of 400 mg daily for three months.<ref name="Bianchi"/><ref>[http://www.uspharmacist.com/index.asp?show=article&page=8_1481.htm Riboflavin in Prophylactic Treatment of Migraine], EA Balbisi, EM Ambizas, ''U.S. Pharmacist'' Vol. 30, No. 05, accessed Jan. 4 2008.</ref>
===== Vitamin B12 =====
There is tentative evidence that [[Vitamin B12|Vitamin B<sub>12</sub>]] may be effective in preventing migraines.<ref name="Bianchi">{{cite journal | title=Role of Magnesium, Coenzyme Q10, Riboflavin, and Vitamin B12 in Migraine Prophylaxis | author=A Bianchi, S Salomone, F Caraci, V Pizza, R Bernardini, CC D'Amato | journal=Vitamins and Hormones | year=2004 | volume=69 | pages=297–312 | doi=10.1016/S0083-6729(04)69011-X}}</ref> 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.<ref>{{cite journal|author=P-HM van der Kuy, FWHM Merkus, JJHM Lohman, JWM ter Berg, PM Hooymans |year=2002|title=Hydroxocobalamin, a nitric oxide scavenger, in the prophylaxis of migraine: an open, pilot study|journal=Cephalalgia| volume=22 | issue=7 | pages=513–519 | doi = 10.1046/j.1468-2982.2002.00412.x}}</ref> Although the study was not placebo-controlled, this response is larger than the typical placebo effect in migraine prophylaxis.<ref>{{cite journal |author=P-HM van der Kuy, JJHM Lohman | year=2002 | title=A quantification of the placebo response in migraine prophylaxis | journal=Cephalalgia | volume=22 | issue=4 | pages=265–270 | doi=10.1046/j.1468-2982.2002.00363.x}}</ref>
==== Surgical treatments ====
[[Surgery]] may be used to treat migraines by severing the [[corrugator supercilii muscle]] and [[zygomaticotemporal nerve]].<ref>{{cite journal |author=Guyuron B, Tucker T, Davis J |title=Surgical treatment of migraine headaches |journal=Plast. Reconstr. Surg. |volume=109 |issue=7 |pages=2183–9 |year=2002 |month=June |pmid=12045534 | doi = 10.1097/00006534-200206000-00001 <!--Retrieved from CrossRef by DOI bot-->|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0032-1052&volume=109&issue=7&spage=2183}}</ref> The treatment may reduce or eliminate headaches in some individuals.<ref>{{cite journal |author=Guyuron B, Kriegler JS, Davis J, Amini SB |title=Comprehensive surgical treatment of migraine headaches |journal=Plast. Reconstr. Surg. |volume=115 |issue=1 |pages=1–9 |year=2005 |month=January |pmid=15622223 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0032-1052&volume=115&issue=1&spage=1}}</ref>
In 2005, research<ref name="PFOSchwerzmann">{{cite journal | author=Schwerzmann M, Wiher S, Nedeltchev K, Mattle HP, Wahl A, Seiler C, Meier B, Windecker S | title=Percutaneous closure of patent foramen ovale reduces the frequency of migraine attacks | journal=Neurology | year=2004 | pages=1399–401 | volume=62 | issue=8 | pmid=15111681}}</ref> 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.<ref>{{cite journal |author=Samton J, Mauskop A |title=Treatment of headaches with botulinum toxin |journal=Expert Rev Neurother |volume=6 |issue=3 |pages=313–22 |year=2006 |month=March |pmid=16533136 |doi=10.1586/14737175.6.3.313 |url=}}</ref> Its usefulness is uncertain with evidence suggesting it is not superior to [[placebo]] treatment<ref>{{cite journal |author=Cady R, Schreiber C |title=Botulinum Toxin Type A as Migraine Preventive Treatment in Patients Previously Failing Oral Prophylactic Treatment Due To Compliance Issues |journal=Headache |volume= 48|issue= |pages= 900|year=2007 |month=November |pmid=18047501 |doi=10.1111/j.1526-4610.2007.00953.x |url=}}</ref> and does not appear to be useful in the treatment of episodic migraine.<ref>{{cite journal |author=Schürks M, Diener HC, Goadsby P |title=Update on the prophylaxis of migraine |journal=Curr Treat Options Neurol |volume=10 |issue=1 | pages = 398 |year=2008 |month=January |pmid=18325296 | doi = 10.1007/s11940-008-0003-3 <!--Retrieved from CrossRef by DOI bot-->|url=http://www.treatment-options.com/1092-8480/10/20 |format={{Dead link|date=June 2008}} – <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AUpdate+on+the+prophylaxis+of+migraine&as_publication=Curr+Treat+Options+Neurol&as_ylo=2008&as_yhi=2008&btnG=Search Scholar search]</sup>}}</ref>
[[Spinal cord stimulator]]s are an implanted medical device sometimes used for those who suffer severe migraines several days each month.<ref name="SCSMatharu">{{cite journal |author=Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ |title=Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study |journal=Brain |volume=127 |issue=Pt 1 |pages=220–30 |year=2004 |month=January |pmid=14607792 |doi=10.1093/brain/awh022 |url=}}</ref>
==== Noninvasive medical treatments ====
[[Transcranial magnetic stimulation|Transcranial Magnetic Stimulation]] (TMS): At the 49th Annual meeting of the [[American Headache Society]] in June 2006, scientists from [[Ohio State University]] [http://medicalcenter.osu.edu/ 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.[http://technology.timesonline.co.uk/article/0,,20409-2237003.html]
In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light.[http://www.shns.com/shns/g_index2.cfm?action=detail&pk=MIGRAINES-06-22-06] 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.<ref name="TMSMohammad">{{cite conference
| first = Yousef
| last = Mohammad
| title = Magnets Zap Migraines
| booktitle = 49th Annual Scientific Meeting of the [[American Headache Society]]
| date = [[2006-06-22]]
| location = [[Los Angeles]], [[California]]
| url = http://researchnews.osu.edu/archive/headzap.htm
| accessdate = 2006-07-04 }}
</ref>
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.[http://medicalcenter.osu.edu/mediaroom/press/article.cfm?ID=4059]
[[Biofeedback]] has been used successfully by some to control migraine symptoms through training and practice.<ref name="Nestoriuc">{{cite journal |author=Nestoriuc Y, Martin A |title=Efficacy of biofeedback for migraine: a meta-analysis |journal=Pain |volume=128 |issue=1–2 |pages=111–27 |year=2007 |pmid=17084028 |doi=10.1016/j.pain.2006.09.007}}</ref>
[[Hyperbaric oxygen therapy]] has been used successfully in treating migraines.<ref name="Eftedal">{{cite journal |author=Eftedal OS, Lydersen S, Helde G, White L, Brubakk AO, Stovner LJ |title=A randomized, double blind study of the prophylactic effect of hyperbaric oxygen therapy on migraine |journal=Cephalalgia |volume=24 |issue=8 |pages=639–44 |year=2004 |pmid=15265052 |doi=10.1111/j.1468-2982.2004.00724.x}}</ref> 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 "[[decompression sickness|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<ref>Turville, A. E. (1934) "Refraction and migraine". ''Br. J. Physiol. Opt.'' 8, 62–89</ref> and another from 1956<ref>Wilmut, E. B. (1956) "Migraine". ''Br. J. Physiol. Opt.'' 13, 93–97</ref> 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 [http://www.essex.ac.uk/psychology/overlays/OPO.2002.22%20130-142.pdf] found that precision tinted lenses may be an effective migraine treatment. (Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can ''cause'' headaches.)
==== Behavioral treatments ====
Many physicians believe that [[exercise]] for 15–20 minutes per day is helpful for reducing the frequency of migraines.<ref>http://www.headachedrugs.com/pdf/HA2005.pdf] (PDF)</ref>
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 (nutrition)|Diet]], [[visualization (cam)|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.[http://www.medscape.com/viewarticle/533713]
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.
==== Alternative medicine ====
A number of forms of [[alternative medicine]], particularly [[bodywork (alternative medicine)|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.{{Fact|date=May 2008}} 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.{{Fact|date=May 2008}}
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.{{Fact|date=September 2007}}
Some migraine sufferers find relief through [[acupuncture]], which is usually used to help prevent headaches from developing.<ref name="facco">{{cite journal |author=Facco E, Liguori A, Petti F, ''et al'' |title=Traditional Acupuncture in Migraine: A Controlled, Randomized Study |journal=Headache |volume= 48|issue= |pages= 398|year=2007 |pmid=17868354 |doi=10.1111/j.1526-4610.2007.00916.x}}</ref> Sometimes acupuncture is used to relieve the pain of an active migraine headache.<ref name="pmid12542558">{{cite journal |author=Melchart D, Thormaehlen J, Hager S, Liao J, Linde K, Weidenhammer W |title=Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial |journal=J. Intern. Med. |volume=253 |issue=2 |pages=181–8 |year=2003 |pmid=12542558 | doi = 10.1046/j.1365-2796.2003.01081.x <!--Retrieved from CrossRef by DOI bot-->}}</ref>
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.{{Fact|date=February 2007}}
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.{{Fact|date=February 2007}}
[[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.<ref name="Mauskop">{{cite book |author=Alexander Mauskop; Fox, Barry |title=What Your Doctor May Not Tell You About: Migraines : The Breakthrough Program That Can Help End Your Pain (What Your Doctor May Not Tell You About...(Paperback)) |publisher=Warner Books |location=New York |year=2001 |pages=130 |isbn=0-446-67826-0 |oclc= |doi=}}</ref> However, some scents can be a trigger factor.
== 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. {{Fact|date=September 2007}}. 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 (symptom)|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{{Fact|date=September 2007}}. 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.
== 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,{{Fact|date=February 2007}} 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.
== 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.<ref name="BMJ2005">Etminan M, Takkouche B, Isorna FC, et al. Risk of ischaemic stroke in people with migraine: Systematic review and meta-analysis of observational studies. ''BMJ''. 2005;330:63. PMID 15596418</ref> 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.<ref>{{cite journal | first = T | last = Kurth | coauthors = Gaziano JM, Cook NR, Logroscino G, Diener HC, Buring JE | year = 2006 | month = [[July 19]] | title = Migraine and risk of cardiovascular disease in women | journal = Journal of the American Medical Association | volume = 296 | issue = 3 | pages = 283–91 | pmid = 16849661 | doi = 10.1001/jama.296.3.283}}</ref><ref name="BMJ2005"/> Migraine sufferers seem to be at risk for both thrombotic and hemorrhagic stroke as well as [[transient ischemic attack]]s.<ref name="RiskUK">Becker C, Brobert GP, Almqvist PM, Johansson S, Jick SS, Meier CR. Migraine and the risk of stroke, TIA, or death in the UK (CME). ''Headache''. 2007;47(10):1374–84. PMID 18052947</ref> 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.<ref name="WHI">Waters WE, Campbell MJ, Elwood PC. Migraine, headache, and survival in women. ''BMJ'' (Clin Res Ed). 1983;287:1442–1443. PMID 6416449</ref><ref>Kurth T, Gaziano JM, Cook NR, et al. Migraine and risk of cardiovascular disease in women. ''JAMA''. 2006;296:283–291.</ref>
==References==
<div class="references-small">
=== 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.
=== Treatment ===
* Pearce, J.M.S. (1994). ''Headache.'' ''Neurological Management'' series. ''Journal of Neurology Neurosurgery and Psychiatry.'' '''57''', 134–144.
* Mayo Clinic Staff. (2005). [http://www.mayoclinic.com/invoke.cfm?objectid=7B64CC94-AFDF-42DA-BE3EBAA687DE024A Migraine Headache]. Retrieved August 14, 2005
* Cathy Wong, ND. (2005). [http://altmedicine.about.com/od/popularhealthdiets/a/migrainediet.htm Migraine Elimination Diet] Retrieved August 14, 2005
* Treatment Articles (2005). [http://intelegen.com/nutrients/index.htm#Migraine_and_Headaches 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. . [http://www.izecksohn.com/leonardo/ Fluids' Hypertension Syndromes], ISBN 978-85-906664-0-0.
==== [[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.
=== General ===
* [[Sacks, Oliver]] (1999) ''Migraine'', Vintage ISBN 0-520-08223-0
* Relouzat, Raoul & Thiollet, Jean-Pierre, ''Vaincre la migraine'', Anagramme, 2006 ISBN 2-35035046
=== 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.
===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.</div>
==Footnotes==
{{reflist|2}}
==External links==
* {{DMOZ|/Health/Conditions_and_Diseases/Neurological_Disorders/Headaches/Migraine/}}
===General information===
* [http://www.ninds.nih.gov/disorders/headache/detail_headache.htm Migraine Information from the US National Institute of Neurological Disorders and Stroke]
* {{PDF|[http://216.25.100.131/upload/CT_Clas/diagnost.pdf Diagnostic criteria]|1.21 MB}}
===Organizations===
* [http://www.w-h-a.org World Headache Alliance]
* [http://www.blackwellpublishing.com/journal.asp?ref=0017-8748&site=1 Headache], a medical journal
{{Diseases of the nervous system}}
{{Antimigraine preparations}}
[[Category:Migraine|*]]
[[Category:Neurological disorders]]
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