ALLOPATHY HELPLINE ---- OM SAI RAM
Respected Manmeet ji,
Migraine and its basic underlying cause have been misunderstood by many over the past several years. It was several years ago believed to be due to the spasm and subsequent expansion of blood vessels lining the brain. Some continue in this belief. The reality is however that true Migraine is a genetic disorder where
Spontaneous over activity and abnormal amplification in pain and other, predominantly sensory, pathways in the brainstem, leads to migraine.
Current opinion opinion favours a primarily neural cause, involving feedback loops through innervation of cranial arteries in the trigeminovascular system (a nerve Pathway). It is thought that a relative deficiency of 5-HT (serotonin) and a calcium like peptide hormone leads to this disabling headache. It is thought that as many as 10 people out of 100 suffer from this disorder. The main type of migraine is thought to be polygenic ( affecting a series of genes ).
Initially it is important to confirm the diagnosis. Migraine may be mis-diagnosed whereas the individual may be suffering from a different cause for headache. This is done by a good clinical documentation of actual symptoms, including trigger factors and associated symptoms, followed by a thorough general and neurological examination. The commonly similar headaches that are thought to be migraine but are not truly so are TTH (Tension Type Headache).I do not mean tension as in stress but spasm of the scalp muscles. The second possibility is that of cluster headaches a relatively rare condition which often present with disabling unilateral headache and are associated with autonomic dysfunction.
(Sweating, flushing, nausea etc...).The third more challenging is MOH, namely Medication Overuse Headache. This typically complicates migraine which is then transformed into a chronic daily headache similar to chronic TTH often with some migrainous features. As you can see arriving at the appropriate diagnosis may not be that simple.
So what are the symptoms of migraine?
International Headache Society Diagnosis Criteria for Migraine
• Without aura
o 1. At least 5 attacks fulfilling 2-4
o 2. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
o 3. Headache has at least two of the following four characteristics:
- unilateral location
- pulsating quality
- moderate or severe intensity which inhibits or prohibits daily activities
- aggravated by walking stairs or similar routine physical activity
o 4. During headache at least one of the two following symptoms occur:
- nausea and/or vomiting
- photophobia and phonophobia
o 5. At least one of the following three characteristics is present:
- history and physical and neurological examinations do not suggest one of the disorders listed in 5-11
- history and/or physical and/or neurological examinations do suggest such a disorder, but it is ruled out by appropriate investigations
- such a disorder is present, but migraine attacks do not occur for the first time in close temporal relation to the disorder
• With aura
o 1. At least two attacks fulfilling 2
o 2. Headache has at least three of the following four characteristics:
- one or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain stem dysfunction
- at least one aura symptom develops gradually over more than 4 minutes, or tow or more symptoms occur in succession
- no aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased
- headache follows aura with a free interval of less than 60 minutes (it may also begin before or simultaneously with the aura)
o 3. At least one of the following three characteristics is present:
- history and physical and neurological examinations do not suggest one of the disorders listed in groups 5-11
- history and physical and neurological examinations do suggest such a disorder, but it is ruled out by appropriate investigations
- such a disorder is present, but migraine attacks do not occur for the first time in close temporal relation to the disorder.
There are other forms of migraine but I am trying to keep it as simple as possible, and therefore have omitted these. As it is this post appears very complicated, however if you read it you will understand. I have tried my best to keep it as simple as possible.
DO YOU REQUIRE TESTS OR SCANS?
Well to be honest many physicians have or do not spend time in history and clinical examination and there are some who would like to be defensive against any form of future litigation. There is also the pressure from the patient or immediate relatives itself to get a scan, as they fear something more sinister and hence frequently request for a scan. A CT Scan is invariably done in these settings; however for scientific purposes MRI scanning is preferable. However if the history and clinical examination are carried out thoroughly the need for a scan is questionable. Given the commonality of migraine just imagine the huge number of scans, most of which are unnecessary.
PREVENTION AND TREATMENT ?
Put very simply, non-pharmacological management of migraine helps identify things that make the problem worse and encourages them to modify these. It is important to explain that the tendency to suffer an attack probably varies because of some cycling changes in the brain that are not well understood. This is why avoiding things on some days will prevent attacks and, perversely, enjoying the same things on other days produces no headache. Rather than make a long list of things to avoid you should first be encouraged to have regular habits and not to exceed their limits.
Regular sleep, exercise, meals, work habits, and some time for relaxation will be very rewarding in terms of reducing headache frequency. Avoiding what regularly triggers attacks (and not being disturbed when the long list of advice in the magazine is not useful) are good general advice for migraineurs. Migraineurs are individuals; encourage them to individualize their trigger avoidance. Extensive and exclusive dietary advice is rarely useful; the decision to start a patient on a preventive drug requires input from both doctor and patient. The basis for considering preventive treatment from a medical viewpoint is a combination of acute attack frequency and attack tractability. Attacks those are unresponsive to acute attack medications are easily considered for prevention at almost any frequency, whereas simply treated attacks probably do not provide candidates for prevention. The other part of the equation relates to the natural history.
If a patient diary shows a clear trend for increased frequency it is probably better to get in early with prevention than wait for the problem to become intractable.
A simple rule for frequency might be that:
(i) For one or two headaches per month there is usually no need
to start a preventive.
(ii) For three or four headaches per month it may be needed, but not necessarily.
(iii) For five or more headaches per month prevention should definitely be on the agenda for discussion.
There are medications that are simple analgesics and these may be sufficient. If however they are not then the use of Sumatriptan may abort an attack.Prophylactic treatment with beta blockers may be needed if the frequency of attacks are unbearable. Drug therapy should always be instituted under the guidance of a good physician whom you have personal rapport with or good faith in as drug therapy in a particular situation is best determined by a qualified person.
There is some evidence that as the age of the person increases they may have complete remission from migraine, they are curable!!!
I am not going into the various drugs for reasons of safety. Generally the MIDAS (Migraine Disability Assessment scale) guides the modality of therapy.
However like I have written before make sure that your headache is indeed a migraine first. Baba with his grace will surely ensure your rapid improvement. I strongly believe that vibhuthi in a glass of water and devout thought of him will be immensely helpful.
I would also be wrong if I do not mention that as I am a Cardiologist despite a background of Internal Medicine, I had to do some studying and discussions with some neurology colleagues prior to posting this broad outline.
Baba has been again very merciful. I hope you have a general outline manmeet sir. If there are any specific queries please do not hold back.
Vishwanath
Servant of Baba
Topic: ALLOPATHY - HELP LINE (Read 82277 times)