Headaches are not uncommon. But the frequency and severity make a world of difference. This is where migraine fits in — primarily characterised by recurrent attacks of moderate to severe headaches, usually unilateral and pulsating, and associated with photophobia and phonophobia and nausea/vomiting. While the diagnosis and treatment of migraines have evolved over the years - targeted treatments and preventive therapies are here - this disabling headache disorder is being understood better including its impact on one’s working capacity resulting in lost workdays.
As the World Health Organisation, in its Atlas of Headache Disorders and Resources in the World 2011, pointed out that headache is felt, at some time, by nearly everybody, and almost half of the world’s adults at any one time have recent personal experience of one or more headache disorders. An article, “The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates”, stated that “each day, 15.8% of the world’s population had a headache”.
Migraines, in particular, could have a debilitating effect on an individual. One report, “Diagnosis and management of migraine in ten steps”, quoting the Global Burden of Disease study (GBD), said that migraine is the second most prevalent neurological disorder worldwide and is responsible for more disability than all other neurological disorders combined.
On taking a closer look at the findings of GBD 2019, researchers of another article - “Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD 2019” (The Journal of Headache and Pain) - said that migraine is a top cause of disability-adjusted life years in young women, a finding of profound significance. “No other disease, communicable or non-communicable, is responsible for more years of lost healthy life in young women, notwithstanding that migraine causes no premature mortality”, they said.
What is a migraine?
R. Lakshmi Narasimhan, Director and Professor of Neurology, Institute of Neurology, Madras Medical College, said the implications of migraine are far more complicated. “People do not realise the importance of treating migraine. Many consider migraines as a small entity. But migraine is one of the topmost reasons for lost workdays,” he said.
There are more than 70 to 80 migraine auras, he said, adding that even doppelganger phenomena, out-of-body experience and corona phenomena are migraine auras.
He goes on to elaborate: “Initially, it is episodic. Later on, frequency and severity keep increasing, and if we do not treat it, it will slowly become chronic migraine, and then chronic daily migraine, and subsequently, chronic persistent migraine. In chronic persistent migraine, the person will not be able to sleep; even resting the head on a pillow will be difficult. Usually non-painful stimuli - such as touching the hair - could trigger pain.”
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Roopesh Kumar, Director, Neurosurgery, at MGM Healthcare, said migraines were more common in women, and often seen in families. “Scientifically, migraines are called neurovascular headaches. Sunlight, menstruation, crowded places such as marriages and some food items can aggravate migraines,” he pointed out.
Migraines could have associated symptoms of nausea/vomiting and sensitivity to light. “This is mainly a clinical diagnosis. But other causes are ruled out by CT scan/MRI and other imaging. Aura is a warning sign of a headache. There could be visual disturbances, pain in the eyes, seeing stars or flashes of light,” M. Kodeeswaran, head of Department of Neurosurgery, Government Kilpauk Medical College Hospital, added.
He raises a key point: “You have to maintain a headache diary to check the trigger factors and try to avoid it. Lifestyle modifications, proper sleep habits, healthier eating habits, stress management and weight loss will help.”
He added that for medical treatment of migraines, there are beta blockers, antidepressants and a few anticonvulsants that will also be useful in low dosage. Botox injections are also an option for recurrent resistant headaches, he said.
Management of migraines has evolved on all fronts — prevention, treatment for acute attacks and modalities for imaging, Dr. Lakshmi Narasimhan added.
Treatment of migraines is of two types - one to treat acute attacks and the other to prevent attacks (prophylactic), he said, adding: “So, there is one group of drugs during acute pain and another to prevent attacks, and there have been advancements in both. Non-pharmacological therapy for headaches has also improved. There are a lot of experiments using virtual reality in the treatment of headaches. For instance, if you have severe pain, and using virtual reality, you are immersed in a pleasurable environment; it could be something you like such as music or ocean life. This will bring down the pain.”
In a study, “Preventive oral treatment of Episodic Migraine: an overview”, he and a team of doctors reviewed the oral treatment used in the prevention of episodic migraine. The various classes of drugs that are established to be useful in the oral preventive treatment of migraine are antihypertensive agents, antidepressants and antiepileptics. They noted that a carefully chosen oral preventive therapy in consensus with the patient can help decrease the frequency and intensity of headaches, improve the response to acute therapy and reduce disability. It was necessary to consider the comorbidity that the patient has in considering the choice of the drug.
There are monoclonal antibodies against Calcitonin Gene-Related Peptide (CGRP). He said that CGRP medications block CGRP by attaching to the protein or blocking receptor sites. “Blocking CGRP helps prevent inflammation in the membranes covering the brain, which can help manage migraines,” he said. There are triptans (a class of medications to treat migraines) as well as nasal sprays.
Orthodontist and Orofacial pain specialist at Dr. Dilip Dental Centre, Dhivya Dilipkumar, who did a fellowship in orofacial pain, temporomandibular joint disorder and sleep disorders in the U.S., said she has treated several patients with headaches, facial pains, temporomandibular joint pains and migraines using trigger point injections. “Lignocaine injections are a regular procedure in dentistry where we give 1.5 to 2 ml injection in the nerve to numb it. Here, in trigger point injections, we administer only 0.2 ml of lignocaine in the muscle which is safe,” she said.
Migraine, tension type headache and myofascial pains are all similar types of pains with a variation in which component causes them, she said, adding: “For example, muscle, nerve and vessel components are involved in causing facial pains. If the muscle component predominates, we treat the muscle with trigger point injections. All patients with facial pain have a varying percentage of each of the components. Diagnosis is the key.”
She added that two facial muscles - lateral pterygoid and anterior digastric - cannot be reached directly for trigger point injections for which ultrasound guided trigger point injections in collaboration with a musculoskeletal radiologist is performed.
Published - July 07, 2023 03:05 pm IST
