Staying a step ahead of migraines

Nursing, Nov 2003 by Bruegel, Carla

light, zigzag lines, and hemianopia (blindness in half the visual field). Sensory symptoms include unilateral paresthesia and hypesthesia. These neurologic symptoms, which are usually reversible, develop over 5 to 20 minutes and usually last less than 60 minutes.

* Pain in the head or neck during the headache phase of migraine is unilateral in 60% of cases, but it can be bilateral. The pain can be moderate to severe with a pulsating or throbbing quality and is aggravated by routine physical activity. The headache may begin at any time but most often occurs after awakening. Gradual in onset, the headache may last up to 72 hours without treatment. Associated systemic symptoms during the headache phase include nausea, vomiting, and extreme sensitivity to sound, light, and odors. A headache that persists for more than 72 hours with or without treatment is called status migranosus and is usually treated with corticosteroids and antiemetics.

* During the postdrome or recovery phase, the pain gradually subsides. Symptoms similar to those that occurred during the prodrome may last for a few hours or up to 2 days.

Making the diagnosis

A diagnostic workup includes a thorough medical, family, and headache history, plus a detailed neurologic and physical exam. Family history is positive in 50% to 60% of patients with migraine.

When taking the patient's headache history, ask about:

* circumstances and suddenness of headache onset

* intensity and character of pain

* frequency and duration of attacks

* location of pain

* preceding and accompanying neurologic or other physical signs and symptoms

* symptom progression

* provoking or aggravating factors (triggers)

* seasonal variations

* current and past medications and other treatments, whether effective or not

* sleep patterns

* occupation

* emotional profile (migraines are more common in persons with affective and anxiety disorders)

* extent to which migraine attacks impair activities of daily living and social life.

To make a diagnosis of migraine, the health care provider must rule out other disorders that could cause similar symptoms. Examples include cerebrovascular disease, brain tumors, temporal arteritis, traumatic injury, infectious or metabolic disease, and disorders of the head and neck.

Certain headache characteristics warrant further investigation with neuroimaging or lab tests, including:

* abrupt onset of first or worstever headache

* onset of new headache after age 50

* headache progressing in intensity and frequency

* headache associated with abnormal neurologic or physical exam or with the patients report of numbness, tingling, or projectile vomiting

* headache associated with trauma or a concomitant systemic illness, such as hypertension or a seizure disorder

* headache differing from the patient's usual pattern

* occipitonuchal location

* history of lack of coordination

* history of headache that wakes the patient from sleep.

Which medications when

Antimigraine medications cause vasoconstriction of cranial vessels, inhibit neurogenic inflammation or central pain transmission, or activate various serotonin receptors. Effective migraine management uses abortive treatment for acute headache, prophylactic treatment, or a combination.

Abortive treatment blocks pain once it's anticipated or reverses it once it's begun. This type of treatment may be indicated if attacks are infrequent or if the patient can't maintain a daily medication regimen. Ergots such as dihydroergotamine and triptans such as sumatriptan are the most effective agents for abortive treatment. Potent vasoconstrictors, ergots can cause nausea and vomiting and may be prescribed with an antiemetic. Both ergots and triptans, which are better tolerated by some patients, are most effective when administered at the outset of an attack.

However, many patients respond well to simple analgesics, such as aspirin, nonsteroidal antiinflammatory drugs, or mixed analgesic compounds. Some analgesic compounds can be habit-forming or cause rebound headache if abused.

Prophylactic treatment is used to reduce headache frequency, severity, and duration. It's indicated if migraines occur more than two times per week or are increasing in frequency, the attacks are disabling, the patient has uncommon conditions (such as hemiplegic migraine or prolonged aura), or abortive drugs are ineffective or contraindicated. Standard migraine prophylactic medications include beta-blockers, calcium channel blockers, anticonvulsants, and antidepressants.

The only medication developed specifically for migraine prophylaxis is methysergide, an ergot derivative and serotonin antagonist effective in 60% or more of cases. Because it shouldn't be used with triptans and has potentially serious fibrotic adverse effects, it's reserved for patients who haven't found relief with standard prophylactic treatment.

Botox (botulinum toxin type A) injections into pericranial muscles have been tested for migraine relief with mixed results. Magnesium and riboflavin also are effective alternative prophylactics.