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Canada Food Guide Revisited
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Debunking Diabetes Myths
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Tune up Your Diet
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Family Health Online / Pharmacy at Safeway
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Family Health Magazine - FAMILY MEDICINE

Managing Migraines
How to cope with this disabling condition

If you suffer from migraines, you know firsthand just how disabling the pain can be. This common headache disorder affects 18 per cent of women and six per cent of men. The impact of migraine on patients and their families is extreme. The severity of migraine pain can be disabling and result in lower quality of life. Society also pays a price for migraines, in direct medical expenses and indirect costs linked to low productivity and lost work time.

Often, migraine is not correctly diagnosed. As a result, about half of people who have migraines stop seeking medical care for the problem. When properly diagnosed, migraine can usually be effectively treated or managed.

The Various Types of Headaches -

Criteria for Diagnosis

Migraine Headache
without Aura

Lasts 4 to 72 hours if not treated or not treated successfully.

Pain Characteristics (at least two)
• located on one side of the head
• throbbing quality
• moderate to severe intensity
• made worse by walking stairs or similar physical activity

Associated Symptoms (at least one)
• nausea, vomiting or both
• light or noise sensitivity
The doctor will ask questions and do a physical exam to check that nothing else is wrong. At least five attacks meeting the above criteria are necessary.

Migraine Headaches with Aura

The criteria for the migraine without aura above must be met, plus:

Aura Characteristics (at least three)

  • one or more fully reversible aura symptoms (see 'What is an aura?') indicating focal cerebral cortical or brain stem dysfunction
  • at least one aura symptom develops gradually over four minutes, or two or more symptoms occur in succession
  • No single aura symptom last more than 60 minutes
  • headache begins within 60 minutes from the start of the aura

The doctor will ask questions and do a physical exam to check that nothing else is wrong. At least two total
attacks meeting the above criteria are necessary.

Tension Headache

Lasting 30 minutes to seven days if not treated successfully

Pain Characteristics (at least two)

  • located on both sides of the head
  • pressing (non-throbbing quality)
  • mild to moderate intensity
  • not made worse by walking stairs or similar physical activity
  • any associated symptoms should be mild, including nausea and light and noise sensitivity

The doctor will ask questions and do a physical exam to check that nothing else is wrong. At least ten attacks meeting the above criteria are necessary.

Cluster Headache

Lasting 15 to 180 minutes if not treated successfully

Pain Characteristics

  • severe, often boring, poking or sharp
  • over one portion of the head, either around the eye or temple

Associated symptoms are on the same side of the face (at least one)

  • eye redness
  • nasal congestion
  • runny nose
  • forehead and face sweating
  • pupil constriction (small in size)
  • eyelid droop
  • eyelid edema (puffiness)

The doctor will ask questions and do a physical exam to check that nothing else is wrong. The frequency of attacks varies from one every other day to eight per day during the cluster period.

What is migraine?

Migraine is not just a headache or a reaction to stress. It is a true disorder of the nervous system. Scientific evidence points to an abnormality in the brainstem area of the brain, which acts as a migraine generator. Most people who suffer with migraines, and others who have never experienced one, have the potential to develop a migraine syndrome. Hormone changes, lack of sleep, alcohol intake, and mental stress can all be migraine triggers.

What are the phases of migraine?

The five main phases of migraine include prodrome (early symptoms), aura, headache, associated symptoms, and postdrome (after the headache). Not all people experience all phases. A migraine can last several days or just a few hours. Prodrome and postdrome symptoms vary between patients. However, the sufferer usually experiences similar symptoms each time.

What is an aura?

About 25 per cent of people who have migraines experience auras. An aura may take many forms, but usually involves visual distortion. These can include scintillations (shimmering, zig-zag lines) or scotomas (loss of vision within a spot). An aura can be sensory (a tingling feeling), or motor (such as arm heaviness). Auras can also be psychiatric, summoning up a feeling of deja vu (already seen) or jamais vu (never seen before). Symptoms can include eye tearing, facial swelling, or nasal congestion. The aura may also affect language in some cases, leading to problems with speaking (aphasia).

How does migraine progress?

Before the aura, many people experience early (prodrome) symptoms. These symptoms may include nausea, food cravings, loss of appetite, heightened senses, fatigue, changes in mood or behaviour, or a feeling of apathy. Describing any prodrome or aura symptoms to your doctor can help in making a proper diagnosis.

Headaches may develop during or after the aura phase. Migraine pain is usually throbbing or pulsating. It has also been described as tightening, pressing, pounding, burning or even stabbing. Migraine headache is usually felt on one side of the head (unilateral), although the pain may occur on both sides (bilateral). Frequently, migraines may start on one side, then shift to the opposite or include both sides. Since other kinds of headache are unlikely to do this, this is a helpful symptom to point out to your doctor.

Most migraines are at least moderate in intensity of headache. If you must stop your activities during a migraine, chances are the intensity is moderate or severe. In migraine, activity makes headache pain worse. For instance, check how you feel when you climb stairs during a migraine, and give a description to your doctor.

A feeling of nausea (not just a lack of hunger) can occur with the headache. Some experience vomiting. Others are sensitive to light (photophobia), noise (phonophobia) or odor (osmophobia), and need to rest in a dark, quiet room. Make sure to discuss these symptoms with your doctor.

After-headache symptoms can include feelings of depression, euphoria, hunger, and excitement.

How is migraine diagnosed?

Criteria composed by the International Headache Society (see table 1) can be very useful in diagnosing migraine. If these criteria have been met, diagnostic imaging such as magnetic resonance imaging (MRI) is rarely needed. The diagnosis for migraine with aura uses the same criteria for the headache portion, but aura criteria must also fit. Tension and cluster are two other types of headache that can be confused with migraine.
To help your doctor in diagnosing migraine, keep a diary of your symptoms, their frequency and duration.

What if the headache is not a migraine?

Other conditions do mimic migraine. The doctor will keep these conditions in mind, along with their signs and symptoms, when making an assessment.

How can migraines be managed?

Depending upon how many migraines are suffered, either prophylactic (preventative) or abortive (relief) therapy may work best for the migraine patient. In general, preventive medications are best suited for those who have more than three migraines per month. For those with three or fewer migraines each month, abortive therapy is best. However, some people do best using a combination of the two therapies.

Which preventive therapies can be considered for migraine?

Preventive therapies must be taken daily to work well for migraine or other headache illnesses. Therapy can also be individually tailored, especially for someone requiring medication for both migraine and another condition such as hypertension, epilepsy, asthma or lower back pain. If you are concerned about or are attempting to lose weight, this can be considered in the choice of medication. Riboflavin (vitamin B2) or magnesium sulphate can also be good options for those who do not want to take drugs.

If your migraines are linked with menstruation, avoiding drugs containing estrogen may help. Using abortive or preventive agents around the time of menstruation often works. For instance, ibuprofen can be taken for seven days, beginning two days before menstruation. Both menstrual migraines and pre-menstrual symptoms often subside.

What abortive therapies can be considered for migraine?

Abortive agents should be taken as soon as a migraine begins. Some might take it when they notice an aura. Others use it when a headache actually starts. If taken later, headache therapies do not work as well.
Many abortive agents for migraine exist. Try them during different stages to discover which works best.

Acetaminophen and non-steroidal anti-inflammatory agents such as ibuprofen are good first choices. Some respond to a combination of acetaminophen, acetylsalicylic acid (ASA or Aspirinª), and caffeine (the appropriate use of these can be discussed with your doctor). Other abortive therapies include prescription medications, such as the triptans and ergots. If the pain is bad enough to warrant a trip to the emergency room, other medications are available there.

Triptan medications affect the brain chemistry and nerves that set up migraine attacks. They also prevent some of the widening of blood vessels inside the skull, which can cause some of the headache pain. Triptans can be taken using different methods. Subcutaneous injections (just under the skin), pills, oral wafers, and nasal spray are all options. An injection gives the fastest effect, but not all patients are comfortable with it. Oral wafers are a good option for those with nausea, as medication is placed on the tongue and enters the bloodstream directly, bypassing the stomach. Nasal forms work for some but may lead to nasal congestion.

Migraine is a disorder of the nervous system, not just a headache. Proper diagnosis of migraine helps to correctly manage it, preventing disability and suffering. Managing migraine involves reducing headache frequency and severity, often by finding medication that works quickly with few side effects. If you have migraine, talk with your doctor about signs and symptoms, migraine frequency, and other medical conditions. Together, you can explore suitable therapies.

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FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
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