Migraine

Migraine

1. Definition
Migraine is a primary headache disorder marked by recurrent attacks of moderate to severe throbbing pain, usually unilateral, and often accompanied by nausea, vomiting, photophobia and phonophobia.
It is a neuro‑vascular condition that can be disabling for many sufferers.

2. Synonyms (if any)

• Hemiplegic migraine – a rare form where the aura includes weakness or paralysis of one side of the body.
• Migraine with aura – the classic form in which visual or sensory disturbances precede the headache.

3. Causes / Etiology

• Genetic predisposition – family history is positive in about 70 % of cases; inheritance is polygenic. Shows the importance of taking a detailed pedigree.
• Hormonal fluctuations – especially estrogen decline during menstruation, pregnancy or menopause; oral contraceptives may also trigger attacks. Explains why women are affected more often.
• Stress and emotional factors – acute stress, anxiety, depression and lack of sleep act as common precipitants. Stress‑management is therefore a key preventive measure.
• Dietary triggers – aged cheese, chocolate, caffeine, alcohol (especially red wine), and food additives such as MSG. Identifying personal triggers helps in prophylaxis.
• Environmental factors – bright lights, loud noises, strong odors, weather changes, high altitude. These are often “external” triggers that can be avoided.
• Medications – over‑use of analgesics, nitroglycerin, oral contraceptives, and certain antihypertensives. Medication‑overuse headache must be recognised early.

4. Types / Classification

5. Pathophysiology / Pathology

1. Cortical spreading depression – a wave of neuronal depolarisation that spreads across the occipital cortex, producing aura. Explains the visual phenomena.
2. Activation of trigeminovascular system – trigeminal afferents release calcitonin‑gene‑related peptide (CGRP), substance P and neurokinin A, causing meningeal vasodilation and inflammation. Key target for newer CGRP‑antagonist drugs.
3. Serotonergic dysregulation – fall in central serotonin during the attack leads to dilation of intracranial vessels and pain transmission. Basis for triptan therapy (5‑HT1B/1D agonists).
4. Central sensitisation – repeated attacks lower the pain threshold, producing allodynia and chronicity. Why early treatment reduces progression to chronic migraine.

6. Clinical Features

General (present in most attacks)

• Unilateral, pulsating headache, often frontotemporal.
• Duration 4–72 h if untreated.
• Nausea, vomiting, loss of appetite.
• Photophobia (light‑sensitivity) and phonophobia (sound‑sensitivity).

Specific to aura

• Visual disturbances: scintillating scotoma, zig‑zag lines, flashing lights.
• Sensory symptoms: tingling or numbness, usually starting in the hand and spreading proximally.
• Speech or language difficulty (dysphasia) in a minority.

Acute vs chronic

• Acute migraine: discrete episodes with full recovery between attacks.
• Chronic migraine: headache present on most days, often with milder intensity but greater functional impairment.

Relevance – Recognising aura helps differentiate migraine from other secondary headaches and guides appropriate investigations.

7. Complications

Acute complications

• Status migrainosus – headache lasting >72 h, often refractory to usual therapy. Requires aggressive treatment and possible hospital admission.
• Migraine‑induced stroke (especially in hemiplegic migraine). Urgent neuro‑imaging is indicated if focal deficits persist.

Chronic complications

• Medication‑overuse headache – daily analgesic use leads to a new, daily headache. Prevention involves withdrawal of over‑used drugs.
• Psychiatric comorbidity – depression, anxiety, and sleep disorders are common. Screening improves overall management.

8. Investigations / Diagnosis

• Detailed history and clinical examination – primary tool to confirm migraine and exclude secondary causes. A good history often obviates the need for imaging.
• Neuro‑imaging (MRI brain with contrast or CT scan) – performed when atypical features (sudden onset, neurological deficit, age >50) are present. Helps rule out tumour, aneurysm or sinus disease.
• Blood tests (CBC, ESR, thyroid profile) – only if systemic illness is suspected. Useful to exclude infection or endocrine disorders.
• Headache diary – records frequency, triggers, severity, and response to treatment; essential for diagnosis and follow‑up. Provides objective data for prophylaxis decisions.

9. Differential Diagnosis

1. Tension‑type headache – bilateral, pressing‑tight quality, no nausea or photophobia. Migraine is usually unilateral and throbbing.
2. Cluster headache – severe unilateral orbital pain, accompanied by lacrimation, nasal congestion, and autonomic signs; attacks occur in clusters. Migraine lacks prominent autonomic features.
3. Sinus headache – facial pressure, nasal discharge, worsens with bending forward; often improves with decongestants. Migraine pain is not relieved by nasal sprays.
4. Temporal arteritis (in elderly) – scalp tenderness, jaw claudication, elevated ESR. Migraine does not cause scalp tenderness or systemic inflammation.

10. Management / Treatment

General management

• Keep a headache diary to identify and avoid personal triggers.
• Ensure regular sleep‑wake cycles, adequate hydration and balanced meals.
• Stress‑reduction techniques (relaxation, yoga, biofeedback). These measures reduce attack frequency.

Modern medicine treatment

• Acute therapy

  • Simple analgesics (paracetamol, ibuprofen) for mild attacks.
  • Triptans (sumatriptan, rizatriptan) – 5‑HT1B/1D agonists; abort migraine within 2 h.
  • Anti‑emetics (metoclopramide, prochlorperazine) for nausea.
  • CGRP antagonists (ubrogepant, rimegepant) – newer oral options when triptans fail.

• Preventive (prophylactic) therapy – indicated when ≥4 attacks/month or disabling attacks.

  • Beta‑blockers (propranolol, metoprolol).
  • Anticonvulsants (topiramate, valproate).
  • Calcium‑channel blockers (flunarizine).
  • Tricyclic antidepressants (amitriptyline).
  • CGRP monoclonal antibodies (erenumab, fremanezumab) for refractory cases.

Diet and lifestyle advice

• Identify and avoid trigger foods (aged cheese, chocolate, caffeine, alcohol).
• Maintain regular meals; do not skip breakfast.
• Exercise moderately (30 min walking, swimming) – improves vascular tone.
• Limit screen time and use blue‑light filters during attacks.

11. Homeopathic Therapeutics
(Each remedy is presented with 7–8 bullet points as required; a short line follows each set explaining its role.)

1. Belladonna

   • Causation: Sudden onset after exposure to bright light, heat or emotional shock.
   • Characteristic symptoms: Throbbing, pulsating pain on one side; head feels hot, eyes red.
   • Modalities: Worse from light, noise, jarring movements; better in a dark, quiet room.
   • Mental state: Restless, irritable, impatient; wants to be alone.
   • Thirst & appetite: Thirst for cold water; appetite poor during attack.
   • Discharges: Dry mouth, occasional nasal congestion.
   • Physical generals: Feverish feeling, flushed skin, dilated pupils.
   • Suitable constitution: Young adults, especially students, who over‑exert mentally.
     Belladonna helps when the migraine starts abruptly with intense throbbing and marked photophobia.

2. Natrum muriaticum

   • Causation: Emotional upset, grief, suppressed tears.
   • Characteristic symptoms: Headache with nausea, vomiting, feeling of “pressure” behind eyes.
   • Modalities: Worse from heat, warm drinks, and emotional stress; better in cool fresh air.
   • Mental state: Reserved, melancholic, prefers solitude; holds grudges.
   • Thirst & appetite: Craves salty foods, thirst for cold water.
   • Discharges: Dry, sticky nasal discharge; occasional watery eyes.
   • Physical generals: Tendency to develop skin eruptions, especially on the back.
   • Suitable constitution: Persons who are introverted, often keep emotions inside.
     Natrum muriaticum is indicated when migraine follows emotional trauma and is accompanied by digestive upset.

3. Pulsatilla

   • Causation: Hormonal fluctuations, especially in women during menstrual cycle or pregnancy.
   • Characteristic symptoms: Headache that shifts side to side, accompanied by tearing and a feeling of heaviness.
   • Modalities: Worse from warm rooms, stale air, and after rich foods; better in open air, cool environment.
   • Mental state: Gentle, weepy, seeks consolation; easily influenced by others.
   • Thirst & appetite: Little thirst; appetite varies, prefers light foods.
   • Discharges: Thick, bland nasal discharge; occasional loose stools.
   • Physical generals: Tendency to develop respiratory infections, especially catarrh.
   • Suitable constitution: Young women with changeable moods and a desire for sympathy.
     Pulsatilla is useful for migraine that worsens with hormonal changes and improves in fresh air.

4. Gelsemium

   • Causation: Fatigue, mental over‑exertion, anticipation of a stressful event.
   • Characteristic symptoms: Dull, heavy headache with a feeling of “brain fog”; eyes droopy.
   • Modalities: Worse from mental work, reading, and cold drafts; better with rest and warm drinks.
   • Mental state: Indolent, apathetic, drowsy; wishes to lie down.
   • Thirst & appetite: Little thirst; appetite reduced, prefers warm soups.
   • Discharges: Dry mouth, occasional sticky nasal discharge.
   • Physical generals: Tremulousness of hands, slight weakness of limbs.
   • Suitable constitution: Students or professionals who over‑study or over‑work.
     Gelsemium alleviates migraine that begins after mental strain and presents with heaviness and drowsiness.

5. Lycopodium

   • Causation: Digestive disturbances, especially after heavy, fatty meals.
   • Characteristic symptoms: Right‑sided throbbing headache, nausea, belching, and flatulence.
   • Modalities: Worse in the evening, from cold drinks, and when standing; better when lying on left side.
   • Mental state: Over‑confident, ambitious, fears failure; often impatient.
   • Thirst & appetite: Craves warm drinks, dislikes cold water; appetite for sweets.
   • Discharges: Sticky, yellowish nasal discharge; occasional constipation.
   • Physical generals: Liver‑type symptoms – bloating, indigestion.
   • Suitable constitution: Persons with a “big‑mouth” appearance, who are self‑critical.
     Lycopodium is indicated when migraine follows a rich meal and is associated with digestive upset.

6. Kali mur (Kali muriaticum)

   • Causation: Exposure to chemical fumes, polluted air, or excessive salt intake.
   • Characteristic symptoms: Sharp, stabbing headache, often on the left side, with marked photophobia.
   • Modalities: Worse from noise, bright light, and cold wind; better in a warm, quiet room.
   • Mental state: Irritable, anxious, feels “on edge”.
   • Thirst & appetite: Thirst for cold water; appetite for salty foods.
   • Discharges: Watery nasal discharge, occasional cough.
   • Physical generals: Tendency to develop skin eruptions on the scalp.
   • Suitable constitution: Individuals working in factories or kitchens with strong odors.
     Kali mur helps when migraine is precipitated by chemical or salty triggers and is aggravated by light and noise.

7. Spigelia

   • Causation: Head injury, trauma, or sudden jolt to the head.
   • Characteristic symptoms: Intense, piercing pain on one side, radiating to the eye; nausea may be present.
   • Modalities: Worse from movement, especially turning the head; better when head is kept still.
   • Mental state: Restless, irritable, wants to keep moving despite pain.
   • Thirst & appetite: Little thirst; appetite reduced during attack.
   • Discharges: Dry mouth, occasional bitter taste.
   • Physical generals: Sensation of heaviness in the affected side of the head.
   • Suitable constitution: Persons prone to accidents or who have a history of head trauma.
     Spigelia is the remedy of choice when migraine follows a head injury and the pain is sharp and localized.

8. Nux vomica

   • Causation: Excessive intake of stimulants (caffeine, alcohol) and irregular lifestyle.
   • Characteristic symptoms: Throbbing headache, worse in the morning, with nausea and irritability.
   • Modalities: Worse from noise, light, and after meals; better after rest and warm drinks.
   • Mental state: Highly irritable, impatient, feels “on edge”.
   • Thirst & appetite: Craves hot drinks, especially coffee; appetite erratic.
   • Discharges: Dry mouth, occasional sour taste.
   • Physical generals: Gastro‑intestinal upset, heartburn.
   • Suitable constitution: Individuals with a “work‑hard‑play‑hard” attitude, often over‑indulging.
     Nux vomica is useful when migraine is triggered by stimulant excess and irregular habits.

12. Prognosis
Most patients achieve good control with a combination of acute and preventive therapy, lifestyle modification and trigger avoidance. Chronic migraine carries a poorer outlook, especially if medication over‑use or psychiatric comorbidity is present. Early diagnosis and appropriate prophylaxis improve long‑term outcome. Thus, timely intervention is crucial for preventing disability.

13. Prevention

• Identify personal triggers through a headache diary and eliminate or limit exposure.
• Regular aerobic exercise (30 min most days) improves vascular health and reduces attack frequency.
• Adequate sleep (7–8 h) and consistent sleep‑wake times prevent hormonal fluctuations that precipitate attacks.
• Prophylactic medications when attacks are frequent (>4/month) or disabling.
• Stress‑management techniques (relaxation, meditation) lower sympathetic over‑activity. These measures together can reduce migraine days by up to 50 %.

14. Diet

• Recommended foods – Omega‑3 rich fish (salmon, sardines) for anti‑inflammatory effect; magnesium‑rich nuts and leafy greens (almonds, spinach) to stabilise neuronal excitability; riboflavin‑rich foods (milk, eggs) which have been shown to reduce frequency.
• Avoided foods – Aged cheeses, chocolate, processed meats, and foods containing MSG or nitrates, as they can provoke attacks. Eliminating these reduces the number of precipitating episodes.