Introduction
Migraine is a common type of headache disorder which is characterized by moderate to severe recurrent headache. Migraine headaches are generally severe and could last up to 3 days, wherein the pain affects half of the head but the pain is pulsating in nature. People with acute migraine headache may have suffer from sensitivity to light, vomiting, nausea, and sensitivity to smell and sound. In some cases, the pain may become severe and worsen after physical activity. In 1/3rd of patients with migraine, a short period of visual disturbance or aura occurs which is an indication that the pain could occur anytime soon. In most typical cases, an aura would occur without or little headache (Chowdhury 2012).
The cause of migraines is multivariable but current evidence suggests that genetic and environmental factors often lead to pulsating and short-term headaches. In 2/3rd of cases, migraine headaches run in families and thus is known to be genetically-oriented. There is clear evidence that migraine may be associated with the change in hormone levels in the body. For example, migraines are more common and severe in boys than girls prior to puberty while in adulthood it is more severe in women than men. Migraines are uncommon during pregnancy and rarely affect women who are lactating. However, there is no scientific rationale to this phenomenon. Some researchers suggest that there are specific blood vessels and nerves in the brain that may have altered during pregnancy (Sacco, Ricci, Degan, & Carolei, 2012). Moderate to severe migraine headaches can be easily treated and managed with the help of both, pharmacological and non-pharmacological interventions. It is estimated tha nearly 15% of people around the globe suffer from migraine while it is most common during middle age and onset after puberty (Gupta & Bhatia 2011). Migraines often decrease in women reaching menopause. Migraines have been known to be described in ancient Egyptian culture, i.e. Ebers papyrus, which is around 1500 BCE. This paper provides an overview of migraine headaches.
Causes of Migraine Headaches
Migraine has been derived from the Greek word ‘hemikrania’, wherein hemi relates to half and krania relates to the skull. It signifies pain on one side of the head which is clinical characteristic of migraine headaches (El-Sherbiny, et al. 2015). The underlying causes of migraine remain unclear till date but many researchers suggest a combination of environmental and genetic triggers/factors (Salman, et al. 2015). However, migraines may not necessarily occur due to a single gene defect while a few psychological disorders such as depression, bipolar disorder, and anxiety may co-exist. There is a strong association that genetics plays a key role in migraine headaches while familial traits are common among individuals with severe to moderate headaches. In a recent study, a team of researchers have reported 38 genomic loci in humans that increase the risk of migraine. The researchers have also stated that severe migraines of known familial traits are associated with polygenic disorders. However, there is no clear evidence of which genes could cause migraine since genetic mappings have identified over 100s of genetic variation that may increase the risk of migraine (Gormley, et al. 2016). In a recent review, a team of experts have identified a single gene disorder that may cause migraine termed as familial hemiplegic migraine (FHM). Till date, only 4 genes have been identified to cause FHM which is general inherited in the autosomal way (Rudkjobing, Esserlind, & Olesen 2012). Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL syndrome) another genetic disorder that affects people with migraine headaches (Choudhary, McLeod, Torchia, & Romanelli 2013).
In a few cases, migraine headaches can be caused due to external triggers but have limited evidence or scientific rationale. In most cases, people are expected to experience symptoms at least 24 hours prior to onset migraine headaches. The triggers could vary from patient to patient while for familial migraine it appears to be a common environmental trigger. Most common triggers include smoke, alcohol, certain food products, sounds, lights, atmospheric changes, and odours (Hoffmann & Recober 2013). In some cases, physiological triggers such as fatigue, hunger, and stress could cause tension or migraine headaches. Substance abuse and post-traumatic stress disorder (PTSD) may also contribute to symptoms of migraine headache. In women, menstruation may often cause migraine headaches while in later stages of life, specifically during menopause there is a steep decline in migraine attacks (Schwedt 2013). Hormonal changes in the body have a primary role in migraine attacks, wherein women are more susceptible to developing headaches compared to men due to varying hormonal changes in the body (Ripa, et al. 2015). Food allergies or certain food items may increase the risk of migraine in certain people. In a recent review, more than 60% of people with migraine have accounted diet or food items to have cause headaches (Rist, Buring, & Kurt 2015). However, the underlying physiological cause of food triggers and migraine headaches remains unclear. Food-based migraine attacks can only be self-reported and its clinical manifestations are undefined. Artificial food items and additives such as monosodium glutamate (MSG) are reported to have caused migraine (Obayashi & Nagamura, 2016).
Pathophysiology of migraine headaches
Migraine is not a result of mental health problem but a manifestation of neurovascular disorder. There is clear evidence that migraines commence in the brain and eventually spread through blood vessels. Based on a recent report, researchers suggest that neuronal mechanisms may have a primary role in the development of migraine in humans while a few blood vessels may add to the migraine attack (Goadsby 2012). In contrast some researchers suggest that an abnormal excitability within the cerebral cortex could play a key role in migraine attacks. Most of the abnormal activity is associated with uncontrolled pain in neurons within the trigeminal nucleus located in the brain stem. The overall pathophysiology of migraine is complex and multivariable. Researchers suggest that there could be multivariable reasons that may cause migraine and that a single predictor for migraine cannot be ruled out (Burstein, Noseda, & Borsook 2015). In a recent clinical evaluation, researchers have reported that people with moderate to severe migraine may have high levels of serotonin (5-hydroxytryptamine) and can act as a predictor to the underlying pathophysiology of migraine headaches. There is a substantial increase in the rate of calcitonin gene-related peptide (CGRP) in people with severe migraine (Aggarwal, Puri, & Puri 2012).
The pathophysiology of migraine can be associated with aura or pain, each having their distinct clinical presentation. Aura refers to the cortical spreading of depression which is accompanied by an uncontrolled neuronal activity (Burstein, Jakubowski, & Rauch 2011). People who have migraines with an aura have similar clinical presentation. Calcium imbalance and the NMDA receptors are reported to play a key role in aura migraines while the depolarization effect could lead to never impulses being sent from the head and neck region. (Goadsby 2012). The second form of migraine, wherein the sudden outburst of pain is reported, the underlying pathophysiological findings remain unclear. The brainstem and diencephalon within the central nervous system may play a role in intensifying pain within the head. Some researchers also suggest that an abnormal peripheral activation could also lead to sudden onset migraine headache (Espinosa-Sanchez & Lopez-Escamez, 2015). The dural arteries, pial arteries and extracranial arteries may contribute to pain during migraine while vasodilation of a few arteries outside the skull may trigger pain symptoms (Noseda & Burstein 2013).
Diagnosis of migraine headaches
Diagnosis of migraine by a healthcare professional is often associated by assessing the signs and symptoms (Holle & Obermann 2013). In rare and advance cases, a physician may recommend the use of neuroimaging to assess serious causes of headache. There are different criteria laid down by the International Headache Society that helps physicians and psychologist to assess if a patient is suffering from migraine. (a) If there are more than 5 attacks of migraine, a patient is most likely suffering from aura migraine (b) Migraine confirmed if pain is for more than 4 hours and lasts for more than 3 days (c) If there are two or more attacks it could lead to unilateral pain (only one side of head pains), pulsating pain, moderate to severe pain, and worsened pain accompanied by physical activity (d) Migraine confirmed if pain in the head is accompanied with nausea/vomiting or sensitivity to sound (phonophobia) or light (photophobia). The diagnosis of migraine headache is more likely to be confirmed with a person who suffers from nausea/vomiting or sensitivity to sound (phonophobia) or light (photophobia) compared to those with moderate onset acute pain extending for 2-3 days.
Classification of migraine headaches
Migraine headache was first classified in 1998 while its recent classification criteria was modified in 2004 by the International Headache Society. Some researchers and healthcare providers are expecting a comprehensive and updated version of migraine classification by the end of 2017 owing to extensive research and diagnostic advancement (Schwedt, et al. 2015). Migraines are a type of headache and are broadly classified with other types such as cluster and tension headaches. Based on the recent classification by the International Headache Society, migraines are classified into 6 distinct categories: (a) Migraine without an aura: It is a common type of migraine wherein an individual experiences headache without aura (b) Migraine with aura also referred to as classic migraine. It rarely occurs and is distinguished by the absence of headache. Most people with aura migraine may complain of motor weakness. Familial hemiplegic migraine and sporadic hemiplegic migraine are common sub-categories of migraine with aura (c) Childhood periodic syndromes is coined as a precursor to late adulthood migraine and is often accompanied with benign paroxysmal vertigo, abdominal migraine/pain, and cyclical vomiting (d) Retinal migraine involves visual disturbances followed by migraine headaches. In severe cases, migraine could cause temporary blindness or visual disturbances (e) Complicated migraines are often cases wherein the duration of migraine headaches and aura or combination of both are inconsistent, abnormally frequent, extended hours of head pain and body weakness, and/or lesions in the brain accompanied with acute seizure (f) Probable migraine is a condition wherein a physician or healthcare professional assess key characteristics or predictors of migraine. However, these symptoms could be associated with underlying health issues not related to migraine. Thus, the term probable migraine and (h) Chronic migraine is a severe and life-threatening condition wherein the diagnosis of migraine is confirmed but the onset is long-lasting without any relief from conventional treatment and management strategies. Physicians classify patients with chronic migraine when the headache is for more than 15 days a month or lasts for more than 3 months (Manzoni, et al. 2011). In a recent study, a team of researchers have also classified a new type of migraine, i.e. abnormal migraine, wherein patients may experience severe pain/migraine in the abdominal region without head pain. These types of migraines maybe considered as a precursor to migraine and cannot be scientifically classified as migraine (Van Hemert, et al. 2014).
Treatment of migraine headaches: Pharmacological approaches
The treatment and management of migraine is highly recommended for patients with moderate to severe head pain. The treatment goal for migraine is to alleviate the symptoms and reduce the risk of future onset migraine headaches. The pharmacological approach to migraine should be based on providing individualized care to the patient (Reddy 2013). The use of acute or abortive treatment for patients with acute or mild migraine is highly recommended. The abortive approach often includes the following drugs: nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, antiemetic agents, ergot derivatives, -hydroxytriptamine (5-HT) receptor agonists (triptans), and other traditional but older drugs. In most patients, a combination of these drugs is used to relieve or prevent migraine attacks (Weatherall, 2015). Most healthcare professionals and pharmacists would recommend these drugs to prevent the risk of complications and reduce acute migraine attacks (Estemalik & Tepper 2013).
Analgesics are the first-line treatment for migraine headaches and are often used as monotherapy. Analgesics have minimal side-effects and can be used on a larger population. Some researchers suggest the use of a combination of analgesics for better outcomes but it depends on the individual’s medical history and co-existing illnesses. Most common analgesics include acetaminophen, aspirin (acetylsalicylic acid, ASA), or NSAIDs (Malone, Bhowmick, & Wachholtz, 2015). The use of acetaminophen as monotherapy may not have the desired outcomes and hence a combination therapy is ideal. However, aspirin has been reported to have better clinical outcomes than acetaminophen with respect to monotherapy. NSAIDs are also a good option for patients with acute migraine (Miller 2012). However, the use of NSAIDs should be avoided in patients with gastrointestinal (GI) problems such as nausea or vomiting due to NSAID-induced GI. Barbiturate Analgesics can also be considered a good treatment option for mild to severe acute migraine pain, Opioid analgesics may have a short-term effect but long-term effects could lead to abuse or addiction (Gelfand & Goadsby (2012).
Isometheptene/Dichloralphenazone/Acetaminophen (Midrin) is another classical drug that has a long history for use in acute migraine. Physicians should be aware of the severe and life threatening drug interaction of Midirn with monoamine oxidase inhibitors (MAOIs). In rare cases, physicians may also recommend the use of serotonergic drugs due to the disruption in serotonin (5-HT) regulation among patients with acute migraine (Malone, Bhowmick, & Wachholtz, 2015). Ergotamine tartrate (ET) and dihydroergotamine mesylate (DHE) are common ergot alkaloids that can be used to the treatment of severe acute migraine. In the past decade, Triptans: 5-Hydroxytriptamine (Serotonin Receptor Agonists) have emerged as an ideal option for the management of acute migraine headaches. The mechanisms of action of triptans and ergots are same but triptans have better efficacy and lower side-effects. The phenothiazines, butyrophenones, and metoclopramide (Reglan) are an alternative option that can be used other than abortive agents (Miller 2012).
Treatment of migraine headaches: Non-pharmacological approaches
Most healthcare professionals recommend a combination of pharmacological and non-pharmacological approached for holistic care and enhanced improved among patients with migraine headaches. Non-pharmacological approaches often have limited or no side-effects and in turn offer relief from the adverse/long-term effects of drugs. Patients who may suffer from drug side-effects may benefit from non-pharmacological approaches. In some cases, patients may benefit directly from non-pharmacological approaches (Al-Quliti, & Assaedi 2016). Based on current evidence, there are around 14 non-pharmacological approached which are follows: (a) Acupuncture: It is traditional Chinese medicine that uses tiny needles at specific points to ease out pain, specifically headaches (b) Biofeedback: Physical changes in the body such as increased heart rate or tensed muscle may cause migraine. Biofeedback is a process that involves the use of sensors to measure the changes while a specific tone or light is placed during these shifts. This causes the body to stay calm and relax thus preventing headaches (c) Massage therapy: It is a common belief that massage helps relieve stress which in turn may help prevent headaches. It cannot be used to control pain during headaches (d) Vitamin and mineral supplement: Intake of vitamin B12, magnesium, and coenzyme Q10 is may help prevent new onset migraine. However, these supplements may take several weeks to months to show their effect and used in combination with certain drugs (e) Relaxation techniques such as yoga and breathing exercises may help prevent stress and decrease the rate of headaches (f) Exercise: Regular cardiovascular exercises are generally good for health but are recommended for people who are prone to migraine (g) Spinal manipulation: It is an emerging technique for headaches to ease stress and anxiety, A well-trained chiropractor is highly recommended (h) Talk therapy is a form of Cognitive-behavioural therapy that helps manipulate a person’s actions and thoughts which would prevent stress and headaches (i) Transcranial Magnetic Stimulation (TMS) involves transmission of painless magnetic pulses which is helpful for patients with migraine and aura (j) Diet plays a key role in the management of acute migraine headaches. Certain foods such as caffeine, chocolate, alcohol, and canned foods may increase the risk of migraine attacks. Hence diet plan or modifications are highly recommended (k) Herbal/Ayurveda remedies may have clinical benefits to patients who have migraine and sensitivity to light (l) Simple pressure techniques such as gentle press around the eyebrows, massage on the skull, and wearing head warps may decrease the pain (m) It is important to get adequate rest and sleep and (n) Lifestyle modifications such as exercise, proper diet, and staying healthy is a key to prevent and manage migraine headaches (Antonaci, et al. 2016). Thus, the non-pharmacological approaches can benefit a large group of patients suffering from various types of migraine headaches.
Defined choice of treatment option: Peer-review evidence
Based on current evidence, the use of abortive (acute) pharmacological treatment is suggested for the treatment and management of migraine. The abortive approach would comprise of analgesics such as acetaminophen, aspirin (acetylsalicylic acid, ASA), or NSAIDs. A combination of acetaminophen with an NSAID would be recommended while the use of aspirin for patients with GI issues is recommended. The choice of analgesics over opioids, barbiturates, and triptans was suggested to avoid the risk of contradictions, complications, and risk of substance abuse or toxicity. Since analgesics have a safer profile and similar efficacy, they should be considered as the first choice of treatment for migraine headaches (Birru, et al. 2016). In terms of non-pharmacological approaches, the use of acupuncture and transcranial magnetic stimulation (TMS) is suggested. Based on a recent evidence, researchers state that acupuncture have similar benefits and efficacy compared to prophylactic drug therapy and may also be considered as a first-line treatment (Molsberger 2012 and Li, et al. 2012). In a recent study a team of researchers support the use of TMS with respect to safety, efficacy, and tolerability for patients with moderate to severe migraine (Zardouz, Shi, & Leung 2016).
Management of migraine headaches: Care plan and follow-up
Nurses play an integral and challenging role in the care and management of patients with acute moderate to severe migraine headaches. Nurses should ensure that the patient is receiving appropriate medications and non-pharmacological care (Weatherall 2015). The effect of prophylactic drug therapy should be checked regularly while diet, exercise, and lifestyle modifications would help in preventing migraine attacks. The care plan should address the pathophysiological symptoms of pain such as infections, stress, hypertension, allergies, or trauma (Estemalik & Tepper 2013). The nurse should assess the patient for non-verbal signs of pain such as posture, facial expression, grimacing, restlessness, and breathing. The care plan should also involve assessment of potential triggers such as food, allergies, stress, anxiety, or fatigue. The prophylactic drug therapy should be based on the patient’s co-existing illnesses and other drug therapies. Patient education on self-care and self-report is the key to successful management of migraine headaches. The use of alternative non-pharmacological approaches such as biofeedback, TMS, exercise, and talk therapy should be added to the patient’s overall care plan. A specific diet plan, exercise regimen, and overall lifestyle modification would help in faster recovery and decrease the chances of recurrent migraine attacks. The patient should be advised for follow-up care with the physician and consultants involved in non-pharmacology management. A 3-month follow-up is ideal for patients with moderate to severe acute migraine headaches (Brown, Newman, Noad, & Weatherby 2012).
Migraine is a common type of headache disorder which is characterized by moderate to severe recurrent headache A combination of pharmacological and non-pharmacological approaches is ideal for patients with co-existing illnesses and other complications. Regular assessment, adherence to medications, and follow-up is key strategy to prevent and control migraine headaches among adults (Malone, Bhowmick, & Wachholtz 2015).
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