A migraine is a complex, chronic neurologic disorder characterized by recurrent moderate to severe headaches. The diagnosis of a migraine is subdivided into “migraine without aura” (formerly common migraine), and “migraine with aura” (formerly classic migraine). (1) “Aura” is the collection of autonomic nervous system symptoms that occur immediately prior to the headache. (2) Aura symptoms may include visual disturbances, extremity paresthesias, nausea, vomiting, and hypersensitivity to light or sound.
Early explanations for migraine headaches focused on cerebrovascular vasoconstriction with subsequent vasodilation. (3) A migraine is now recognized as a more complex series of neurologic and vascular events wherein vasodilation may or may not be present. Evidence suggests that a migraineur’s brain is hyperexcitable and uniquely predisposed migraine headaches in much the same way that an epileptic is susceptible to seizures.
The incidence of migraine without aura peaks in boys at age 10 and in girls age 17. (13) Interestingly, the incidence of migraine with aura peaks almost 5 years earlier for both sexes. (13) Before puberty, migraine is more common in boys. At puberty, this ratio flips, and adult females are three times more likely than their male counterparts to experience migraine. Migraine prevalence peaks in the third decade, and attacks generally decrease in severity and frequency after age 40. The onset of a new migraine headache after age 50 is rare. (15)
What are the risk factors?
Various risk factors have been identified for the development of this disorder. Migraine headaches demonstrate a strong genetic component. Having a first-degree relative with migraine increases one’s risk fourfold. If one parent has migraines, the child has a 50% risk of developing the disorder. If both parents are affected, the risk climbs to 75%. Overweight patients are more susceptible to a migraine. Vascular risk factors include hypertension, hypercholesteralemia, impaired insulin sensitivity, coronary artery disease, and a history of stroke. Medication overuse is one of the more important risk factors for migraine progression. Migraines tend to become “chronic” following overuse of acetaminophen, naproxen, aspirin, opiates, barbiturates, and triptans. One study demonstrated that NSAIDs were beneficial when used less than 10 days a month but induced migraine progression to a chronic state when used at a higher frequency.
Migraines have triggers
The (hyperexcitable) migraineur brain is succeptible to various “triggers”. Migraines develop when the number of triggers exceed a critical threshold for a given patient. Known triggers include: stress, smoking, strong odors (i.e. perfumes), bright or flickering lights, fluorescent lighting, excessive or insufficient sleep, head trauma, weather changes, motion sickness, cold stimulus (i.e. ice cream headaches), lack of activity/exercise, dehydration, hunger or fasting, and hormonal changes, including menstruation, and ovulation. Upper cervical tension or the presence of a cervicogenic headache may be a trigger for a migraine.
Certain medications, including estrogen, oral contraceptives, vasodilators nitroglycerine, histamines, reserpine, hydralazine, and ranitidine are known triggers. Food triggers are inconsistent among migraineurs, but the following foods are regularly implicated: alcohol (especially beer or red wine with tannins), excessive caffeine, artificial sweeteners, MSG, soy sauce, citrus foods, papayas, avocados, red plums, overripe bananas, dried fruits with sulfites (figs, raisins, etc), sour cream, buttermilk, nuts, peanut butter, sourdough bread, aged meats and cheeses, processed meats, and anything fermented, pickled or marinated. It is unclear whether chocolate is a trigger to migraine, or a craving brought on at the onset of an attack.
How do I know if I am having migraines or just a bad headache?
According to the International Headaches Society, the diagnosis of migraine requires at least five episodic headaches, each lasting four to 72 hours associated with nausea/ vomiting or photophobia/ phonophobia and at least of two of the following characteristics: moderate to severe intensity, unilateral presence, pulsating quality, and aggravated by physical activity. Although the aforementioned criteria “define” migraine, it is important to note that not all patients meet these criteria. Forty-one percent of migraine patients report bilateral pain, and 50% report “non-pulsating” pain.
Researchers have identified the presence of nausea, disability, and photophobia as the most significant predictors for migraine. A self-administered screening tool called ID migraine ® poses the following questions:
1. Are you nauseated or sick to your stomach when you have a headache?
2. Has the headache limited your activities for a day or more in the last three months?
3. Does light bother you a lot more when you have a headache?
An affirmative response on 2 of 3 questions suggests a high likelihood of a migraine.
How can chiropractic and physical therapy help?
Soft tissue manipulation and massage therapy have demonstrated success in the treatment of migraine headache. Upper cervical hypertonicity or joint dysfunction is thought to be a trigger for headaches, including a migraine and cervical manipulation is a helpful therapy. Additionally, stengthening the muscles of the neck frequently reduces headache frequency.
What can you do at home?
Self-management should focus on trigger avoidance and stress management. A headache diary is essential to help identify and eliminate triggers. No specific diet has been shown to help a migraine, but patients should be coached to identify and eliminate their unique food triggers. Patients with medication triggers, including oral contraceptives and hormones should consult with their medical provider about changing or discontinuing those drugs. Exercising for 40 minutes, three times per week, has shown similar benefit to a proven prophylactic medication. Overweight migraineurs should be given dietary advice. Migraineurs with aura should be counseled on the increased risk of stroke associated with smoking and oral contraceptive use. Limited data supports the use of Feverfew (125mg/ day), riboflavin (400mg/ day), and Magnesium (400-600mg/ day) for the prevention of migraine in non-pregnant patients.
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