Diagnostic of migraine

• Usually, migraines mainly affect only one side of the head (hemicrania) but a bilateral pain can also be observed.
  
  
• They are usually severe but not always
  
  
• They are most often associated to lack of appetite, nauseas, vomiting but there are exceptions.
  
  
• They can also be associated with neurovegetatives troubles of perception, and of behaviour. For 70% of people who suffer from migraines, there is a family migraine history. However, its absence should not eliminate a migraine diagnosis.

Migraine without aura (common migraine)

Repeated crisis (at least 4/month) of headache with a duration of 4 to 72 hours, chracterised by at least two of the following items :

• Unilaterality (pain in half of the head)
• Throbbing pain (beating at the rhythm of the heart)
• Mild to severe intensity
• Aggravation by physical effort

• Nauseas or sickness (or both)
• Photophobia, phonophobia
• No signs of a sub-jacent disease.

Migraine with aura

• Headache similar to the migraine without aura, but sometimes preceded or accompanied by an aura with transitory visual or sensorial symptoms.

Triggering factors :

• First, stress periods, then rest periods
  
  
• Fatigue, excess or lack of sleep
  
  
• Ingestion of an excessive quantity of caffeine or lack of caffeine.
  
  
• Menstruation, ovulation period, oral contraception.
  
  
• Ingestion of alcohol or food containing tyramine (some cheeses) or phenylethylamine (chocolate) or nitrate's derives (bacon, salami) or sodium's glutamate (Asiatic food).
  
  
• Variations of weather with a fall of the atmospheric pressure.

Factors facilitating crisis ignition :

Associated symptoms :

• Lack of appetite
• Intolerance to brightness, to noise, to smells
• Nausea, vomiting
• Feeling of imbalance
• Shivers
• Need to urinate
• Diarrhoeas

Many theories tried in turn to explain the workings of migraine's crisis :

Vascular theory
Vasoconstriction of intra-cerebral vessels makes the brain suffer. In consequence, it orders the vasodilatation of extra-cerebral arteries, which is the cause of the headache. This is what has been called the "vascular storm" of migraine.

Serotoninergic theory
Serotonine plays a leading role in a migraine's crisis. In fact, crisis are accompanied by a sharp fall of this neurotransmitter very prevalent in human body, notably in blood's platelets and which has, among others, a role against the pain.

Migraine results from the dilatation of extracerebral's vessels which become the seat of a sterile inflammation (c'est à dire without germs).

In fact, dilatated, they become "porous", and diffuse into surrounding cells molecules causing pain, such as histamine or kinins.

Trigeminovascular theory
According to a recent theory, when the trigeminal system (trigeminal nerve) is activated, there is secretion of a substance called "P"(PAIN) for central and peripheric transmissions.

It is unilateral, which is specific of migraine's headache.

The trigeminal nerve endings reach out to the brain's vascular network, and the P substance, which is released in proximity of blood's vessels, is the cause of the dilatation and inflammation of those vessels.

These vascular changes then stimulate all nervous fibres going back to the trigeminal nerve, thus inducing a painful influx, which, when it hits the cerebral trunk, is the cause of the headache.

A vicious circle is thus created, which explains the tenacity of the migrainous pain.

Every headache is not a migraine. Migraine represents, in fact, only 15% of chronic headaches. While the hypothesis of a cerebral tumor always worries suffering people, its percentage is infinitesimal (less than 1%) and doesn't justify the increase of complementary exams, such as scanner.

Three questions are yet often sufficient to identify a headache: since when? Where? How ?

Categories of headheache according to origin and frequency

Three main groups of headaches can be identified.

By frequency's order, headaches linked to :

Localized issues :

• Depression
• Anxiety
• Stress
• Post-trauma

Vascular issues :

• Migraine (10%)
• Facial cluster headache
• Arterial problems (from a general disease)
• Venous (or effort)

Locales :

• Cervicalgias
• Nevralgias
• Illness of eyes, teeth, sinus, nose or ears
• Cerebral and neurological illness: tumor, vascular malformations…(less than 1%)

The Physician will look into the following items :

• Headache's installation mode (sudden or progressive)
• Evaluative profile (acute or constant)
• Triggering factors (changing of position, effort, medicines, food, menstruation)
• Releasing factors (rest, analgesics, lying position) and its timetable (morning, evening or night)
• Accompanying signs (vomiting, inconvenience to light, pins and needles, visual troubles)
• Major antecedents (high blood pressure, medicines taken, traumatisms, family history)
• Presence of infection's signs
• Psychological issues (nervous breakdown)

• Signs pointing towards a psychological headache : serious psychological troubles such as a nervous breakdown, family, conjugal or professional conflicts, or a permanent feeling of stress. Furthermore, pain subsides only with sleep and it concerns the whole skull.

• Signs pointing towards a vascular headache: four signs are usually present : it is a mainly unilateral pain rises by peaks. It is preceded by warning signs. There is a history of headache or vascular diseases or sleep troubles in the family.
  
  
• Signs pointing towards a local headache: pathological signs during the clinic examination (neck, eyes, teeth …), abnormal biological or check-up signs, usually mostly concentrated in a particular zone of the skull or of the face.

Nevralgia of trigemminal nerve
Very easy to identify, it's an electric discharge atrociously painful, though it lasts only a few seconds, in a part of or in half of the face. It reiterates at the least stimulus of a very precise zone called "trigger zone" and provokes a violent and involontary contraction of the muscles in one side of the face.

Headaches called "specialist's headache"
They are headaches caused by disease of the eyes, sinus or teeth.

Ophtalmic cause
myopia, presbytia, convergence troubles.
The pain is light, localised in the forehead ; it appears in the evening after reading or long working sessions and goes away with rest.

Teeth cause
The pain is more acute, localised, very oftenly responsible for insomnia. It increases when drinking hot or iced beverages.

Sinusitis
Pain is here very intense in the forehead maxillaries and is exacerbated by cough, efforts, leaning over. It can be felt as early as the morning, and is sometimes soothed by a purulent nasal discharge.

Cervicalgy
Pain happens by paroxystic outbreaks, and is favorised by weather and humidity changes. It is acute, coming from the back of the neck to the top of the skull, sometimes with vertigo.

Chemically induced headache
Quite widespread, it is due to a too regular use of analgesics or antimigranous substances. The body gets accustomed to drugs and phenomena of accoutumance and dependence occur.

Headache requiring an emergency examination
Headaches are a frequent cause for medical examinations. They can reveal many diseases and the physician preliminary enquiry is a fundamental step, aiming at eliminating five emergencies: intracranious hypertension, meningeal syndrom, headache with fever, Horton disease, acute glaucoma.

Intracranious hypertension
One should think of it when facing a progressive headache, going "crescendo", or becoming stubborn to analgesics, triggered by a change of position, or awakening the patient early in the morning, with great vomiting acting as a painkiller. A cerebral scanner or MNR is necessary.

Meningeal syndrom
Headache is intense, as a pressure helmet, with photophobia and vomiting. The examination, which must includ temperature measure, finds stiffness of the neck and imposes a lumbar ponction. Diagnosis is established in function of the results (analysis of cephalous rachid liquid) and after a cerebral tom densitometry (scanner).

Headache with fever
It is a great emergency which imposes a lumbar ponction after cerebral tododensitometry seeking for a meningitis and/or cerebral abscess.

Horton disease
Among elders, headaches associated to general troubles can hint to Horton disease, especially if sedimentation velocity is high. As there is a risk of cecity, a biopsy of the temporal artery must be quickly realised. Treatment is urgent and is done by corticotherapy that will be continued for more than one year.

Acute glaucoma
This is another great emergency. Pain is unilateral and centered on the eye, which is red and swollen. Pain is very strong, acute and becomes worse very quickly with a marked fall of the vision, often associated to vomiting.

10% of the human kind is migrainous, of which 2/3 are women: this means than more than 25 millions of women are suffering of migraine, (only considering industrialized countries!). Woman life and migraine go very often together.

Migraine and hormonal life

For a woman, there is without doubt a clother relationship between migraine and hormonal life. Physicians working on migraine have tried, over the years, to understand episodes of migraine connected to key periods of hormonal life: puberty, cycle of menstruation, pregnancy, menopause and post menopause.

Let's first see schematically how this relationship evolves during a woman's life.

Often preceded during childhood by misleading equivalents, migraine begins in fact in the first times of adolescence: puberty is the period during which the first true crisis of migraine appears.

Migraines will then follow a menstrual rhythm, occurring either during the menstruation, or during the ovulation, or irregularly but more and more severe and intense during those "privileged" hormonal periods of female cycle.

When grown-up, if a migrainous woman becomes pregnant, there is a disappearance of migraine attacks during the pregnancy in 80% of cases. But alas, the crisis usually come back after the birth.

At last menopause, though it is frequently preceded by a temporary increase of the illness, generally brings a durable respite, and indeed a definitive amelioration.

Contraceptive pill among migrainous woman

Migrainous children do not fake it. Its diagnosis is dependent on questioning and its treatment is easy. But children's migraine is often misdiagnosed and mistreated because it is most often underestimated.

Migraine concerns 5% of children under 5 years old (as many boys as girls).

The main sign is a headache. Pain is acute and bring about half of the time tears and crying. Because movement increases the headache, the child tends to stop his games and goes alone in a dark room (to be protected of noise and brightness). Headache is frequently associated with nauseas and vomiting, which may be the only symptoms!

Important: in childhood, the pain of migraine most often disappears with sleep Dihydroergotamine yet remains the treatment of reference for migrainous children (even if flunarizine is sometimes recommended)

For a long time, migraine was not believed hereditary but only a family's problem

Besides, it was one of the diagnosis criteria to have an ancester, mainly the mother, a descendant, or a brother or sister who was migrainous too.

During the VIth Congress of the International Headache Society in1991 in Paris, a French team mentioned the possibility of hereditary character for a very rare kind of migraine (family hemiplegic migraine). It was confirmed by the discovery and localization of a specific gene of this illness on the chromosome 19.Scientific research is still growing in this direction.

So migraine's heredity is now quasi proved, but much work remains to be done because it seems that we are going towards a "genetic heterogeneity". If it takes at least three differents genes to obtain this very rare kind of migraine (family hemiplegy), how many are necessary for the courant kind? So migraine's genetic future is rich! (more and more with the current genome research).

ANY PERSON LOOKING FOR A MEDICAL REMEDY TO HIS CRISIS OF MIGRAINE MUST CONSULT A PHYSICIAN TO GET APPROPRIATE TREATMENT AND MUST ALSO KEEP CONSULTING HIM SO HE CAN SURVEY ANY REACTION OR SIDE EFFECT.