Migraine: definition, symptoms, types and treatment

By Cristiano Antonino On Apr 27, 2023

Migraine is the best known and most common form of headache, after tension headache. Let’s see what it is in detail and how to deal with it effectively

Migraine, what is it?

Migraine is a very common form of headache, which causes painful attacks that occur with a very variable frequency from person to person: in some cases, there are only a few episodes in a year, while in others, attacks occur several times a week.

Like the other forms of headache, it can be episodic or chronic: in the first case, the pain attacks are sporadic, occurring less than fifteen days a month; in the second, they appear for at least fifteen days a month, for more than six months, without responding to treatment and often associated with depression and disability.

Migraine is the most easily chronic form of headache.

Considered the most affected age group, according to the WHO (World Health Organisation) migraine is a greater cause of disability than other serious neurological diseases, such as epilepsy, multiple sclerosis and Parkinson’s disease.

Migraines, the symptoms

Migraines cause intense pain of a throbbing nature.

Sufferers describe it as a real pounding.

It generally begins in a progressive manner: first it involves the frontal region above the eye, then the ‘pulsations’ intensify and eventually also involve the entire forehead and temple.

Usually, it affects only one side of the head (only in 20% of cases the pain is bilateral).

If the pain caused by tension headache benefits from movement, the pain that characterises migraine worsens with movement, to the point that the patient cannot perform daily activities and in some cases avoids them.

Typically, the pain is also associated with other symptoms, such as nausea, vomiting, photophobia (discomfort to light), phonophobia (discomfort to sounds), osmophobia (discomfort to noises), chills and paleness. Not only that.

Some people are prone to so-called ‘prodromal symptoms’: a series of complaints that herald a migraine attack and recur regularly before each crisis, even the day before.

The most common are irritability, tiredness, drowsiness and a tendency to change mood.

The duration of the crisis is variable.

In some cases the migraine attack lasts a few hours, in more serious cases it can last for several days (up to three days).

It often appears upon waking.

Those who experience very frequent attacks, in the time between migraine attacks, frequently also suffer from tension headaches.

Migraine with aura

1-2% of the population is affected by a particular form of migraine: migraine with aura.

In practice, in these cases 10 to 30 minutes before or concomitant with the onset of the actual crisis, a series of reversible neurological symptoms occur.

They are bound to regress spontaneously, leaving no sign or residue.

The most frequent complaints are visual: the person may gradually develop small glares, very similar to those that appear when staring at a light source for a long time; shimmering flashes; darkening or blurring of the visual field; loss of vision in a limited area of the visual field.

The aura can also be more complex, i.e. characterised by more extensive disturbances, such as tingling sensation and numbness in one arm and speech disturbances (such as difficulty in expressing oneself).

These symptoms arise gradually and disappear completely in less than an hour.

Sometimes, the aura is isolated, i.e. it is not followed by migraine.

Migraine, causes

Even today, the causes of migraine are not clear.

According to one of the most widely accepted hypotheses, there is a neurovascular disorder at its basis: in practice, during a migraine attack there would first be a narrowing and then a dilation of the lumen of arterial vessels in particular areas of the brain.

The chemicals released during these changes would irritate the local nerve endings, triggering the painful stimulus.

Malfunctioning of the area of the brain responsible for pain control and linked to the structures responsible for the onset of certain symptoms, such as nausea and vomiting, also seems to play a role.

Migraine could also be the end result of a concatenated series of events, occurring in genetically predisposed individuals.

The ‘fuse’ would be triggered by an exaggerated stimulation of the trigeminal nerve fibres surrounding the meningeal vessels, which, in turn, initiates a pain response that reaches the brain centres, from where it is sent back to the meningeal vessels, activating a vicious circle.

According to another hypothesis, migraine would be linked to a functional deficiency of the antinociceptive system, which has the task of counteracting painful stimuli by means of cells scattered throughout the nervous system.

Finally, it has also been hypothesised that migraine may be a defensive reaction to external and internal stimuli that upset the body’s balance and overexcite the brain.

Migraine triggers

Over time, a number of triggering factors have been identified, i.e. elements that can promote the initiation of a pain crisis.

The most common are:

stress: generally, headache attacks occur when the stressful situation that provoked them is over;
hormonal imbalances. The period most at risk is the menstrual cycle, so much so that it has come to be recognised that menstrual migraine exists;
the consumption of foods to which the subject is particularly susceptible or which contain substances that have the capacity to trigger migraine pain triggering mechanisms (e.g. containing nitrates, such as cold cuts)
exposure to sun, wind, cold, altitude, pollution;
staying in rooms with stale air;
excessively intense physical activity;
smoking and alcohol consumption;
exposure to intense perfumes, bright lights, deafening noises, sudden sharp sounds, pungent aromas;
fasting;
alterations in the sleep-wake rhythm.

Types of migraine

In addition to migraine proper and migraine with aura, there are other, less frequent types of migraine:

retinal migraine, which involves the loss of vision in one eye, fortunately temporary;
the ophthalmoplegic migraine, which is associated with a deficit of the third, fourth and sixth cranial nerves (oculomotor nerves) and causes momentary attacks of diplopia, a visual defect whereby a subject perceives split images. It is very rare;
childhood migraine syndromes, typical of childhood and characterised by dizziness, abdominal colic and vomiting (also called migraine equivalents).

Treatment for migraines

Usually, migraine attacks always require treatment.

The most commonly used drugs are triptans, the only molecules specifically designed for this problem.

While common analgesics only reduce the pain, these drugs act on the causes and mechanisms of the migraine attack: in particular, they are able to block the dilation of vessels that occurs during the attack and prevent the pain from spreading.

They also improve the symptoms associated with migraine, such as nausea, vomiting, and discomfort from lights and sounds.

The triptan class consists of many drugs that differ in their absorption characteristics and duration of activity on pain

The choice of the type of molecule or mix of molecules must be made by the doctor, depending on the course of the attack, its intensity and duration.

While waiting for the drug to take effect, to mitigate symptoms, it may be useful to lie down in a quiet place, away from light, sound and olfactory stimuli, and avoid moving.

As an alternative to triptans, the doctor may prescribe non-steroidal anti-inflammatory drugs (e.g. indomethacin, ketoprofen, naproxen) or ergot derivatives, which are, however, not without side effects.

There are also various pharmacological approaches, particularly indicated in forms that are non-responsive to symptomatic treatments and in those with a high frequency of crises.

The most effective drugs belong to the category of calcium antagonists, beta-blockers and also include some anti-epileptics.

More recently, other particularly effective possibilities have been introduced, such as the use of botulinum toxin and antibodies capable of modulating the activity of a substance, calcitonin gene-related peptide, involved in the genesis of migraine symptoms.

To prevent migraine attacks, it is important to avoid risk factors as much as possible.

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