Migraine Headache

Perspectives for Better Neurological Care
: C. Robert Adams, M.D.; Board Certified Neurologist

CEPHALGIC CONTROL

C. Robert Adams, M.D.

Board Certified Neurologist

I. CLASSIC MIGRAINE (Migraine with aura)

A. Four distinct but overlapping phases

i. Premonitory Phase – Characterized by changes in mood & behavior that may extend from depression to excitation, food cravings to anorexia, fluid retention to diuresis, and constipation to diarrhea. Photophobia, phonophobia, stiff neck, and peripheral vasoconstriction or Raynaud’s phenomenon may be part of the picture.
Premonitory features may relate to changes in the hypothalamus which plays a prominent role in mood regulation and motivated behaviors and fluid balance.

ii. The Aura – Accompanying focal neurologic features including visual scotomas (areas of graying out of vision), photopsia (spots of light), fortification spectra, motor symptoms (hemiparesis or aphasia) and brain stem disturbances (ataxia, diplopia, tinnitus, vertigo and dysarthria).

iii. The Headache Phase – Unilateral (sometimes bilateral) moderately severe pain often accompanied by GI tract symptoms, visual disturbances, sensory change, vertigo, fatigue, irritability and depression.

iv. The Postdrome Phase – Non-specific accompanying symptoms including irritability, listlessness, weakness and sometimes euphoria or hypomania.
A triad of vascular or blood vessel tone changes, electrical cortical changes, and neurotransmitter chemical changes play a role in the complex progression of the migraine headache.

The end result can be “central sensitization” where the brainstem is prompted to send out bad messages (allodynia).

II. MIGRAINE CONTIUM – In every day clinical medicine the migraine is often characterized by a variety of types of presentations.

A. “Common Migraine”

B. “Sinus Headache”

C. “Tension Headache”

D. “Stress Headache”

E. “Autonomic symptoms of nausea, vomiting, dizziness, vertigo, sleepiness, abdominal pain, etc.”

III. WORK UP AND DIAGNOSIS OF HEADACHES

A. A CT scan of the head with contrast may be in order if there remains the consideration of aneurysm, arterial-venous malformation, hydrocephalus, intracranial bleeding or neoplasm. The CT scan is the gold standard for ruling out blood and it should be the initial test in case of trauma and stroke.

B. The MRI with contrast is better for posterior fossa (brainstem) lesions and in differentiating small vessel angiopathy (“mini-stroke”) from demylinative disease (multiple sclerosis).

IV. HEADACHE PROVOKERS

A. Strong and unusual odors.

B. Bright lights and loud noises.

C. Changes in weather or altitude (mountain sickness).

D. Alteration in sleeping pattern.

E. Variation in stress (weekend let down headache).

F. Hormonal influence as with menstrual period or oral contraceptives.

G. Exercise, including sexual activity.

H. Food triggers of migraine.

i. Alcoholic beverages especially red wine

ii. Aspartame (NutraSweet)

iii. Monosodium glutamate (MSG)

iv. Nitrates (as in hotdogs and cured meats)

v. Aged cheeses

vi. Caffeine

vii. Chocolate

viii. Soy sauce

ix. Brewer’s yeast (bread and beer)

x. Fruits (figs, papaya, avocado, lentils, raisins, etc)

V. ABORTIVE TREATMENT IS MOST SIMPLE AND DIRECT AND “CLEAN”

A. Imitrex tends to be the void of major troublesome side effects, in particular, sleepiness or drowsiness. They can be taken at work or when operating dangerous machinery.

B. A variety of preparations are available including not only the 100 mg oral tablet but the
20 mg nasal insufflations and the 6 mg subcutaneous injection.

C. The nasal insufflation is very helpful in conditions of nausea and vomiting. On the other hand, it does cause a very bitter taste and something sweet as a piece candy should always be held in the mouth before snuffing it.

D. The subcutaneous injection of Imitrex is very effective but does have the odd symptoms of dizziness, paresthesia and chest tightness.

E. Imitrex is classified as “Class C” for pregnancy but there are concerns as regards to effect on circulation of the placenta, etc.

F. Flexibility, rather than rigidity, is necessary in the clinical assessment of headaches.

VI. PROPHYLACTIC TREATMETN IS NEEDED IN “STUBBORN” CASES

A. Beta Blockers (Propranolol)

B. Calcium channel (blocker (Verapamil)

C. Antidepressants (amitriptyline, Effexor)

D. Anticonvulsants (Depakote, Topamax)

Rev. 10/22/07 #2