What happens during an attack
Previously, migraine was explained by spasm and dilation of blood vessels. Today it is known that the primary activity here is the excitation of the nervous structures: the trigeminovascular system is activated, substances are released that cause inflammation around the vessels of the meninges and increased sensitivity of the pain pathways. This is why light, sound and smells interfere during an attack - the brain perceives ordinary stimuli as excessive.
The attack develops in stages, and recognizing the early stages makes it possible to take the drug on time - this is the key to effective treatment.
- Продром: за часы или сутки появляются зевота, сонливость, раздражительность, тяга к сладкому, отёчность.
- Аура (не у всех): зрительные нарушения — мерцающие зигзаги, выпадение участка поля зрения; реже онемение руки и лица, трудности с речью. Длится 5–60 минут.
- Головная боль: пульсирующая, чаще односторонняя, усиливается при движении, сопровождается тошнотой и непереносимостью света и звука.
- Разрешение и постдром: после боли остаётся разбитость, «туман в голове», которые могут держаться сутки.
How is migraine different from other headaches?
The most common mistake is to consider any severe pain a migraine, and treat tension headaches with triptans. The differences are quite clear.
- Migraine: pulsating, usually on one side, moderate to high intensity, worsens with normal activity, nausea and photophobia
- Tension headache: squeezing, like a hoop, on both sides, mild to moderate, not worsened by walking, usually no nausea
- Cluster pain: extremely intense pain strictly around one eye with redness and lacrimation, attacks in a series of 15–180 minutes
- Secondary headache: a consequence of another disease - increased blood pressure, infection, injury, tumor; “red flags” are important here
Triggers: what starts an attack
Triggers are individual, and there is no universal list of prohibitions. The point of searching for them is not to give up everything at once, but to find your two or three and manage them.
- Disturbed sleep patterns - both lack of sleep and “sleeping in” on weekends
- Skipping meals, dehydration
- Stress and, characteristically, the decline after stress - “weekend migraine”
- Hormonal fluctuations: menstruation, taking contraceptives
- Alcohol, especially red wine; sometimes aged cheeses, citrus fruits, glutamate
- Bright flickering light, pungent odors, stuffiness, changing weather
The best tool here is a headache diary: date, duration, intensity, what preceded it, what drug and how long it took to take effect. Two to three weeks of recordings give the doctor more than any study.
Are MRI and CT necessary?
The diagnosis of migraine is made based on the clinical picture: the image of a typical migraine is normal, and it is pointless to “look for the cause” in it. Neuroimaging is not needed for everyone, but under certain circumstances.
- The appearance of “red flags” from the list above
- Changing the usual nature of pain, increasing frequency and strength
- First attack after 50 years
- Aura lasting more than an hour, or always the same side
- Focal neurological symptoms outside of an attack
- Seizures, behavior changes, persistent vomiting
Treatment: two different directions
Migraine treatment is divided into attack relief and prevention. These are fundamentally different tasks, and they should not be confused: drugs for pain relief do not reduce the number of attacks, and preventive drugs do not help if you take them during pain.
- Treatment: simple analgesics and NSAIDs for a mild attack; specific drugs (triptans) - for moderate and severe
- Should be taken in the first hour of pain: the later, the lower the effect
- Antiemetics - for severe nausea, they also improve the absorption of the analgesic
- Prevention is prescribed for 4 or more attacks per month, or when attacks are severe and difficult to relieve
- Preventive regimens include drugs from several groups, are selected individually and evaluated no earlier than after 2–3 months
- Non-medicinal: sleep schedule, regular nutrition, aerobic exercise, stress management
Migraine in women and pregnancy
Migraines occur about three times more often in women, and for many, attacks are clearly related to their cycle. During pregnancy, the picture often changes: for a significant proportion of women, attacks become less frequent in the second and third trimesters.
The selection of medications during pregnancy and breastfeeding is different, and self-medication is unacceptable here. Migraine with aura requires special attention in combination with combined oral contraceptives and smoking - this combination increases vascular risks and requires discussion with a doctor.