The migraine is a condition that affects the central nervous system, it is in the form of headache or intense, recurring headache, usually pulsatile associated with different autonomic symptoms (Buonannotte and Buonannotte, 2013).
It is a medical condition that usually appears in the form of temporary crises, lasting for hours or days. Within its clinical course, some of the signs and symptoms that accompany migraines are nausea, vomiting or sensitivity to light, among many others (Mayo Clinic, 2013).
Specifically, migraines are one of the most frequent types of headache, along with tension headaches. Thus, more than 15% of the general population presents the diagnostic criteria for this pathology (Riesco, García-Cabo and Pascual, 2016)
Migraine is a pathology that is within the group of diseases that are more prevalent or common among women. In addition, its prevalence tends to decrease with age (Riesco, García-Cabo and Pascual, 2016).
Despite the fact that the etiological cause of migraine is not known exactly, for several decades, it has been associated with the dilation and / or constriction of cerebral blood vessels (Cleveland Clinic, 2015). However, there are currently other positions in the research phase.
The diagnosis of migraine is usually made based on clinical criteria. This pathology is a recurrent condition in emergency medical services, so the first phase of medical management is the precise identification of the signs and symptoms present in each case.
In the case of treatment, there are numerous medical interventions for the control of the clinical picture associated with migraine, pharmacological and non- pharmacological therapies . In addition, different interventions aimed at preventing migraine attacks or attacks have also been described.
The pain that affects the brain or the cephalic “limb” is called headache. This type of disorder is one of the problems for which the human being has been historically concerned, since more than 3,000 years before Christ (Buonannotte and Buonannotte, 2013).
Headache is a medical condition that has been referenced at a clinical level in findings as old as the Ebers Papito, the writings of Hippocrates or Galen, among many others (Buonannotte and Buonannotte, 2013).
Currently, headaches or recurrent headaches are considered one of the most frequent pathologies that affect the central nervous system (WHO, 2016).
The World Health Organization notes that approximately half of the adult population has suffered at least one episode of headache during the last year (WHO, 2016).
In addition, he points out that headache is a significantly painful and disabling medical condition, among which migraine, migraine, tension headache and cluster headache can be found (WHO, 2016).
The headache can have a primary origin, without an etiological medical cause, or secondary in which an associated pathology can be identified.
Specifically, most headaches of primary origin are due to the condition of a migraine.
As we have pointed out, migraine is a type of headache. It is considered a complex neurological disorder that can systematically affect the entire organism, giving rise to a wide variety of symptoms (Migraine Action, 2016).
It is a pathology that can occur differentially among those affected, so that its signs and symptoms can be overlooked or confused with other types of diseases (Migraine Action, 2016).
Although the clinical characteristics of migraine have been described accurately, it remains a little-known disease. In addition, in the majority of people who suffer from it, it remains undiagnosed and consequently untreated.
Migraine presents with a severe and intense headache, accompanied by symptoms such as nausea, vomiting, eye pain, vision of spots or spots, sensitivity to light / sound, etc. (Nall, 2015).
Normally, it appears as an attack or temporary crisis, however, migraine is considered a public health problem with significant social and economic costs (Migraine Action, 2016).
Most of the headaches have a primary origin, that is, without an explicitly associated cause or medical pathology (Riesco, García-Cabo and Pascual, 2016).
Specifically, numerous studies have indicated that more than 90% of all cases of headache or primary headache are due to migraines and / or tension headaches (Riesco, García-Cabo and Pascual, 2016).
Migraine is the third most frequent disease in the world. In the United States, it has been estimated that approximately 18% of women, 6% of men and 10% of children, suffer from migraine (Migraine Research Foundation, 2016).
Although, the figures on the prevalence and incidence of this pathology are not precise, it has been indicated that approximately 15% of the population of the world can meet the criteria for the establishment of a diagnosis of migraine (Riesco, García -Cabo and Pascual, 2016).
Thus, different institutions have indicated that this neurological disease has a worldwide frequency of approximately 38 million affected (Migraine Research Foundation, 2016).
In terms of gender distribution, migraine is more frequent in women than in men, about double or triple, mainly due to hormonal influences (WHO, 2016).
On the other hand, in relation to the typical age of presentation, it usually appears in the period between puberty and adolescence. In addition, it usually affects especially people who are between 35 and 45 years old (WHO, 2016).
In addition, it is a pathology whose frequency tends to decrease as the age advances, more significantly after 50 years of age (Riesco, García-Cabo and Pascual, 2016).
Health records indicate that, in the United States, every 10 seconds a person goes to the emergency services with severe or persistent headache
(Migraine Research Foundation, 2016).
In addition, although those affected by migraine usually present these attacks once or twice a month, approximately 4 million suffer from it chronically, presenting signs and symptoms at least 15 days a month (Migraine Research Foundation, 2016).
Signs and symptoms
Migraine is usually associated with the suffering of a throbbing headache, intense and recurrent, restricted to one side of the head.
Despite the fact that the characteristic signs of this pathology are described in different clinical classifications, the symptoms can occur in innumerable ways, varying significantly among all affected people (Buonannotte and Buonannotte, 2013).
Thus, although the common factor is pain, alterations restricted to other areas such as sensory and sensory, cognitive, affective, autonomic or motor manifestations have been described (Buonannotte and Buonannotte, 2013):
Headache is defined as discomfort or pain that can be located in any part of the head (Cristel Ferrer -Mapfre Salud, 2016).
In this way, headache or headache is the central symptom of migraine. Normally, this symptom is described as throbbing, however, not all patients perceive it in the same way.
In the emergency medical services, many affected refer sensations of oppression, weight, tear or tension in the head, especially in the initial moments.
The intensity of this discomfort is variable, between episodes and among those affected, as well as its duration, which is modified depending on the administration or not of an adequate treatment.
Normally, episodes of pain present a temporality of hours or days and usually appear unilaterally, that is, it is more common to affect one side of the head.
Regarding its precise location, a higher prevalence of fronto-temporal pain has been observed, that is, behind the eye or around it.
In addition, another important aspect is the association of increased pain with movement, which is why patients tend to be quiet and seek rest situations.
Alterations and autonomic changes can occur both in the course of an episodic, and in the resolution of these.
Normally, the headache is accompanied by paleness, sweating, tachycardia, cold hands, hiccups, or hypertension or bradycardia.
In addition, the gastrointestinal discomfort is another of the most common findings in migraines. Nausea and vomiting may appear before or after pain, however, they are much more frequent at the end of the crisis.
Other less common gastrointestinal signs and symptoms are constipation, bloating or diarrhea.
In addition, fluid retention and weight gain is a frequent situation in the moments prior to the development of a migraine episode, especially in women.
On the other hand, it is also common for patients to report a feeling of dizziness during crises, mainly associated with the intensity of pain and the presence of other symptoms such as vertigo.
Although some of the sensory manifestations may be overshadowed by the headache, these may be visual, somatosensory, olfactory, auditory and / or gustatory.
Specifically, in about 80% of the affected people there is usually excessive sensitivity or intolerance to intense light, brightness or shine. Similarly occurs with raised sounds, or typical of a conversation between several people.
Regarding the olfactory manifestations, in some cases the presence of osmophobia has been observed, that is, aversion to certain odors, as well as hyperosmia or an increase in the general sensitivity to odors.
In addition, the presence of positive symptoms has also been described, especially in the visual area. Many patients report that they see bright spots or spots , especially in the stages of greater intensity of pain.
On the other hand, in the case of the somatosensory sphere, the development of tingling sensations and paresthesia in the extremities is possible.
The alterations related to the psychological and cognitive sphere of the affected people are varied and can appear in any of the phases of migraine episodes or crises.
The main cognitive changes have been related to the presence of space-time disorientation, confusion and / or executive dysfunction.
In addition, in the most disabling stages of migraine attacks, those affected can show alterations related to language, specifically a significant difficulty appears for the articulation of words and / or simple sentences.
On the other hand, regarding the manifestations related to the psychological sphere, it has been observed the presence of anxiety, hostility, anguish, feelings of depression, irritability, tendency to isolation, feeling of fatigue, etc.
As we have indicated previously, the increase of the severity and intensity of the pain can be associated with the performance of motor activities and acts, for this reason it is common to observe motor inactivity or akinesia in the crisis phases.
In addition, in severe cases, the development of temporary muscle paralysis, especially in the extremities, has been described.
How long and what are the phases?
Migraine is constituted by a headache that varies from moderate to intense, occurs in a pulsatile manner and usually affects only one side of the head.
Normally, migraine is temporary, so attacks or episodes usually last for a period of 4 to 72 hours (National Institute of Neurological Disorders and stroke, 2015).
Regarding the time of appearance, it has been observed that this type of headache is more frequent during the morning, in the first moments of the day, especially when waking up (National Institute of Neurological Disorders and stroke, 2015).
In addition, in many people who suffer from migraine the time of presentation is predictable, since they are associated with specific events or circumstances that we will describe later.
On the other hand, as we have indicated, migraine is a medical condition that appears as an episode or crisis, so during its clinical course, several phases can be differentiated (National Institute of Neurological Disorders and stroke, 2015).
In this way, migraine attacks are basically composed of 3 main phases: a) prodrome, b) aura and c) headache (Riesco, García-Cabo and Pascual, 2016).
The prodromal phase is the one that precedes the symptoms and / or characteristic of migraine and can last a period ranging from a few hours to 2 days.
Normally, the most common symptoms in the prodromal phase include inhibitory and excitatory alterations:
- Inhibitory alterations : reduction in processing speed, attentional difficulties, generalized mental slowness, asthenia (weakness, fatigue or fatigue) or anorexia (inappetence or lack of appetite).
- Exciting alterations : irritability, recurrent yawning, feeling of euphoria or aversion for certain foods.
The aura phase occurs in approximately one third of people who suffer from migraine episodes. This phase is characterized by a focal symptomatology that immediately precedes the headache or coincides with its onset.
The symptoms of the aura phase are usually transient and progressive, being present approximately 60 minutes.
As in the previous phase, it is possible to distinguish negative and positive symptoms:
- Positive symptoms : perception of spots or flashes, colored images in zigzag, photopsies, tingling, paresthesia, etc.
- Negative symptoms : light sensitivity, ataxia, muscle weakness, altered level of consciousness, etc.
This is the phase, in which the headache develops completely. Normally, this symptom tends to last approximately 4 hours when there is a treatment, while it can last up to 72 hours if no type of therapeutic intervention is performed.
Apart from this, other authors such as Blau (1987), perform another type of classifications of the stages of migraine attacks, in this case, one characterized by 5 fundamental phases (Buonannotte and Buonannotte, 2013):
- Prodrome : phase characterized by the appearance of premonitory signs and symptoms. The characteristic courses of this phase can include systemic, physical, psychological findings, etc., they have to be presented temporarily, several days before the development of the migrainous crisis.
- Aura : this phase has a sudden presentation and its characteristic signs and symptoms are usually established in just minutes. Specifically, it is defined as an episode of brain dysfunction that occurs in the moments before the presentation of the headache or in the initial phases .
- Headache : the headache is the cardinal symptom of this pathology and as we have indicated previously, the duration of this phase will vary according to the therapeutic measures that are adopted.
- Resolution : this is the phase, in which the most intense symptoms begin to subside, reducing the severity significantly.
- Posdromo or final phase : the last phase of a crisis of sight can last brief moments or reach several hours. In most cases, patients feel tired and / or exhausted, unable to perform their usual work and personal activities. In other cases, patients may suffer from various body pains, euphoria, anxiety or symptoms of anorexia.
Types of migraine
The National Institute of Neurological Disorders and Stroke (2015) states that migraine attacks are usually classified into two main types:
- Migraine with aura : in this type of migraine, formerly known as classic migraine headache is accompanied by sensorial alterations predecesoras, especially visual.
- Migraine without aura : this type is the most frequent form of migraine. Headache occurs without predecessor symptoms, suddenly and abruptly. In this way, the intensity of the pain usually appears accompanied by nausea, vomiting, light sensitivity, etc.
In addition to these basic types of migraine, others have been described such as abdominal migraine, basilar-type migraine, hemiplegic migraine, migraine associated with menstruation, migraine without headache, ophthalmoplegic migraine, retinal migraine and Migraineous status (National Institute of Neurological Disorders and Stroke, 2015).
The specific causes of migraine are not known exactly, although it is known that they are related to various alterations or changes in brain and genetic (Cleveland Clinic, 2015)
Migraine is classified within the primary headaches, that is, those headaches in which it is not possible to identify a specific etiological cause and whose diagnosis is based on the preparation of the clinical history, physical examination and compliance with a list of criteria and clinical characteristics (Riesco, García-Cabo and Pascual, 2016).
Thus, the search for the specific etiological causes of migraine has passed through its history through different stages and phases (Sánchez-del-Rio González, 2013):
In the first decades, exactly in the eighties, the etiological theory that was considered more plausible was the vascular one. This was based on the presence of various alterations in the cerebral blood vessels that were considered fundamental for the development of headache.
Thus, for many years both medical specialists and researchers thought that migraines were specifically associated with the dilation (expansion) and constriction (narrowing) of blood vessels that are located on the brain surface (Cleveland Clinic, 2015)
However, around the nineties, the neuro-vascular theory was proposed. Specifically, this theory proposed the trigeminal system as the responsible one, formed by the trigeminal nerve and the parasympathetic area of the facial nerve that, when activated, gives rise to the dilatation of cranial blood vessels sensitive to pain.
Despite this, in recent years an attempt has been made to generate a more integrative and complex model or theory, from which the trigeminal system functions as an anatomical substrate to give an explanation to the pathophysiology of migraine. However, it is conditioned by the presence of different genetic, epigenetic, internal / external factors that favor the activation of the pain mechanism.
In this way, current research has indicated that this medical condition, migraine, has a strong genetic and / or hereditary component (Riesco, García-Cabo and Pascual, 2016).
At least 3 genes have been identified related to a particular variant, familial hemiplegic migraine. Specifically, the existence of mutations in these genes implies the intracellular and extracellular increase of different substances (calcium, potassium and glutamate), which leads to a stage of cellular hyper-excitability and, therefore, to the development of the characteristic signs and symptoms of the different phases of migraine (Riesco, García-Cabo and Pascual, 2016).
In general, specialists and researchers point out that it is possible that migraine is an entity with a multiple character, that is to say, that its expression is due to the presence of diverse genetic changes that interact reciprocally with certain environmental factors (Riesco, García -Cabo and Pascual, 2016).
Most common migraine triggers
As we have indicated in the previous section, the exact causes of migraine attacks are not known precisely, however, their occurrence has been associated in many cases with the presence of certain events or events (National Institute of Neurological Disorders and Stroke , 2015):
In most cases, crises or episodes of migraine have to occur in the first moments of the day, in the morning upon awakening.
However, this is not the only predictable moment, since many others affected point to the occurrence of headache attacks associated with menstruation or stressful work.
Although the factors that can trigger a migraine episode can vary considerably among the people affected, some of the most common have been registered :
- Sudden climatic and meteorological changes.
- Lack or excessive hours of sleep.
- Presence of strong odors, chemical substances, gases or fumes.
- Sudden emotional changes.
- Episodes of high tension and stress.
- Excessive or unusual physical or mental effort.
- Presence of loud, constant or sudden noises.
- Episodes of dizziness and loss of temporary consciousness.
- Low blood glucose levels.
- Alterations and hormonal changes.
- Lack of food
- Consumption / abuse of drugs.
- Presence of intense or intermittent lights.
- Withdrawal of substances (tobacco, caffeine, alcohol, etc.).
- Consumption of certain foods (cheeses, nuts, chocolate, fermented products, pickles, cured or processed meats, etc.)
With regard to statistical data, approximately 50% of people suffering from migraine associate their episodes with the consumption of certain foods or the presence of certain odors.
Currently, there is no test or laboratory test that indicates the unambiguous existence of migraine.
Normally, the health worker diagnoses the migraine based on the clinical findings. In this way, the realization of the family and individual medical history , the questionnaire about the presence and development of the symptoms and the physical examination is fundamental (National Institutes of Heatlh, 2014).
Thus, the purpose of these initial interventions will be to determine the presence / absence of a set of defined clinical criteria for the medical diagnosis of migraine.
The International Classification of Headaches offers the following diagnostic criteria for migraine without aura phase (Riesco, García-Cabo and Pascual, 2016):
a) Presence of at least 4 crisis and BD criteria
b) Episodes of recurrent headache lasting between 4 and 72 hours.
c) Recurrent headache or headache present with at least two of the following characteristics:
- Restricted to only one side of the head (unilateral location).
- Pulsatile feeling.
- The intensity of pain can vary from moderate to severe.
- The intensity of the pain is conditioned or worsened by habitual or routine physical activity.
d) At least one of the following events during the headache phase:
- Nausea and / or vomiting
- Sensitivity to light (photophobia) or sound (phonophobia).
e) There is no other diagnosis and / or medical condition that explains this situation.
In addition to the fulfillment of these diagnostic criteria, the use of various laboratory tests is possible to rule out the presence of other types of pathologies: computerized tomography, magnetic resonance or electroencephalogram (National Institutes of Heatlh, 2014).
On the other hand, it is also common the use of a specific neuropsychological, to determine the presence of other types of complications such as memory problems, attention, problem solving, orientation, etc.
There is no type of curative treatment for migraine, however, a wide variety of specific therapeutic interventions have been designed for the treatment of their crises.
Generally, the treatments used in migraine are based on the prescription of drugs to relieve pain or to prevent the occurrence of seizures.
The specific choice of therapy depends fundamentally on the characteristics of the affected person and the episodes of migraine. In addition, it will be essential to consider the presence of other medical conditions.
Thus, the Mayo Clinic (2013), makes a description of the most used therapeutic measures:
Drugs for the treatment of pain
The drugs used to treat pain are usually used during the migraine attack phase and the main objective is to alleviate and stop the progression of the symptoms that are already present.
Some of the most commonly used drugs are analgesics (aspirin or anti-inflammatories), triptans, ergotamine, anti-nausea drugs, opioid drugs or glucocorticoids.
Drugs for the prevention of crises
In this case, the medications used for the prevention of seizures are usually prescribed for regular consumption, usually taken daily to reduce the frequency of migraine in the most severe cases.
Some of the most commonly used drugs include cardiovascular medication, antidepressants or antiepileptic medication, among others.
In addition to pharmacological treatments, other types of therapeutic interventions have also been described with the fundamental objective of modifying various life habits and, in addition, avoiding exposure to triggering events.
Normally, experts recommend performing muscle or respiratory muscle relaxation exercises, having a good night’s sleep with sufficient hours, avoiding stressful situations, avoiding the consumption of harmful substances, etc.
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In addition, it is also recommended to prepare a crisis diary, in which the symptoms, intensity and frequency of migraine attacks are recorded , since they will be useful for the elaboration of an individualized therapeutic intervention and as effective as possible.