Migraine: A Pulsating Pain

Migraine, a word so brief, yet behind it lies a world of pain, misunderstood by many but intimately familiar to those who endure its grasp. Imagine a pain so crippling that it halts the flow of life around you; this is the actual reality for those who navigate through the turbulent waters of migraines.

The journey into understanding this health issue is akin to exploring a labyrinth, where every turn reveals new insights and every corridor holds echoes of pain and hope.

Migraine, the second most common cause of headache, and the most common headache related, cause of disability in the world. We should remember that the migraine is just beyond a normal headache, it is usually an episodic headache associated with certain features such as sensitivity to light, sound or even movement, nausea and vomiting often accompany the headache.

A migraine attack has usually three phases: prodrome, headache phase, and postdrome, each with different disabling symptoms. Some percentage of patients have a fourth phase as well, known as the ‘aura’ phase. Migraine is well recognized by its stimulating factors, whom we call as ‘triggers’. The headache is initiated or amplified by various trigger factors like glare, bright lights, sounds, movements or even hunger, stress, physical exertion, atmospheric changes (like pressure changes) , hormonal fluctuations, lack of sleep, alcohol etc. It's of utmost importance for a patient to have the knowledge of the trigger factors, and hence can be useful in management strategies.

Delving into the heart of migraine's mystery requires us to navigate the intricate pathways of pathogenesis, where the intersection of biology, environment, and genetics paints a vivid picture of this debilitating condition.

The journey of understanding migraines takes us deep into the cellular landscapes and neural circuits, where the dance of ions, neurotransmitters, and inflammatory molecules choreographs the pain and symptoms experienced by millions.

The sensory sensitivity which is characteristic of migraine is probably due to dysfunction of monoaminergic sensory control systems, activation of cells in Trigeminal nucleus results in the release of Vasoactive neuropeptides, particularly calcitonin gene-related peptide (CGRP).

CGRP emerges as a pivotal player in the migraine saga, a molecular messenger that carries the tales of pain and inflammation within the brain's intricate networks. This neuropeptide, flourishing within the central and peripheral nervous system, acts as a double-edged sword: essential for normal neurological function yet capable of triggering the cascade of events leading to the intense, debilitating pain characteristic of migraines.

Other brainstem regions likely to be involved in descending modulation and of Trigeminal pain include the nucleus locus coeruleus in the pons and rostral ventromedial medulla. Different pharmacological modalities have been developed around the given scenario and hence improving the chances to treat the disabling condition in the best possible way.

Dopamine's role in migraines is increasingly recognized, with symptoms like yawning, nausea, and vomiting induced by dopaminergic stimulation. Targeting dopamine receptors with pharmacological treatments has shown effectiveness.

Genetic factors also play a significant role, with mutations in genes like CACNA1A, ATP1A2, and SCN1A linked to Familial Hemiplegic Migraine. Migraines are complex neurological events characterized by various symptoms, including pulsating pain localized to one side of the head, visual disturbances, nausea, photophobia, lightheadedness, and vomiting. Recognizing these symptoms is crucial to avoid mistaking migraines for normal headaches and delaying treatment. Migraines with aura are termed "Classical Migraine," while those without aura are known as "Common Migraine."

A simple criteria to diagnose migraine includes:-

Repeated attacks of headache lasting 4-72 hours in patients with a normal physical examination, no other cause for headache and- at least 2 of the following features : Unilateral Pain, Throbbing pain, Aggravation by movement, Moderate or Severe intensity. Plus at least 1 of the following features: Nausea/Vomiting, Photophobia and Phonophobia.

Strongest predictors of Migraine diagnosis-

Photophobia (Light aggravating the headache), Impairment(headache limiting or affecting daily activities), Nausea (Feeling of Vomiting when having a headache).

Managing Migraine:

First and foremost, lifestyle modifications such as prioritizing good sleep, regular exercise, maintaining a balanced diet, and effective stress management offer a proactive approach to reducing the frequency and severity of migraine attacks.

Pharmacological treatments for acute migraine attacks include NSAIDs like Ibuprofen, Naproxen, and Paracetamol with caffeine, which can reduce attack severity and duration if taken early. Other options include 5HT 1B/1D receptor agonists (Sumitriptan, Almotriptan, Eletriptan, Zolmitriptan), Ergotamine, and Dihydroergotamine.

Antiemetics like Metoclopramide and Prochlorperazine help manage nausea and vomiting. Preventive medications like Valproate, Propranolol, Metoprolol, TCAs (Amitriptyline), and others can reduce the frequency of attacks.

Alternative therapies such as neuromodulation, cognitive-behavioral therapy (CBT), acupuncture, and biofeedback relaxation training may also provide relief. Newer treatments like monoclonal antibodies to CGRP receptors (e.g., Erenumab) or peptides (e.g., Eptinezumab, Framanezumab) have shown efficacy and tolerability.

Migraine research is a rapidly evolving field, with scientists and clinicians worldwide dedicated to unraveling its complexities and developing new treatment modalities. While a complete cure has not yet been found, promising advancements in controlling symptom severity and duration continue to emerge.

To those who suffer from migraines, remember that there is always hope. With ongoing advancements in research and medicine, a future where migraines have less power over daily life is within reach.

Hold onto hope, for it is the guiding light through even the darkest of times.
Keep Spreading Awareness, Keep Spreading Knowledge.

By Fizah Hamid

Fizah Hamid is an MBBS Graduate