Migraine brain: A holistic view of migraine.

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In the world, migraine affects 12% of the population, which in Chile represents a total of 2,200,000 patients, a very significant number and which also entails personal, social and economic costs for society and the patient himself.

 

Although it is true that migraine was born with the human species, and the first descriptions appear in the Sumerian culture, the importance that society has given to this pathology is strangely deficient, which is even more evident nowadays. Recent clinical epidemiological, pathophysiological and new therapy studies are numerous and valuable, but carried out by a select group of interested physicians and scientists, but most of society does not consider it important and tends to forget it, a phenomenon present even among headache patients, because there is no culture on the subject, but social, academic and medical discrimination, whose cause is not understandable. Everything described above influences the care of migraine patients to be incredibly defective and migraine sufferers are misdiagnosed, poorly treated, poorly medicated and discriminated against socially, at work and even in the family, turning their lives into an ordeal.

 

Even so, migraine confronts us with the need to update ourselves, since science finds every day physiopathological and therapeutic novelties, which, as described above, do not have the impact they should have because it is such a frequent and disabling pathology.

It is necessary to emphasize that in developed countries there is a concern for the subject, with its inclusion in governmental and university health policies, but in developing countries there is a total abandonment by governments and universities, and the few health professionals who are dedicated to breaking the paradigm, have not achieved the desired impact and our colleagues underestimate our dedication to an “easy and unimportant” pathology.

 

In this social medical context, we have developed a long trajectory in the care of patients with migraine and from the clinical observation of hundreds of cases we are convinced that migraine is not only headache but it is the clinical expression of multiple brain dysfunctions so we have come to conceive a global concept that seems relevant to us, the “migraine brain”.

 

This is based on the observation of several clinical, pathophysiological and pharmacological facts that we describe below.

 

It is known that migraineurs suffer headache crises of 4 to 72 hours duration, pulsatile, unilateral, severe, accompanied by nausea, occasionally vomiting, photophobia, sonophobia, osmophobia, but this brain activation expands and has an additional impact on the psychological, psychiatric, sleep, endocrine, gastroenterological, cardiac, musculoskeletal aspects, in addition to the side effects of drugs and other related diseases.

There are other clinical forms of migraine, such as migraine with aura without headache, described in the International Headache Society (IHS) Classification. However, in our experience we have observed other clinical manifestations (the so-called migraine equivalents).

 

These are migraine patients who, without headache, present recurrent nausea, with normal gastroenterological study, in whom antispasmodic drugs are not effective, but when a quick triptan is used, they improve completely. It has also presented as isolated severe photophobia and/or sonophobia, with successful response to triptans.

The human migraine sufferer presents particular personality characteristics. Since childhood he is methodical, very orderly, hard-working, responsible. When goals are set or proposed to him, he makes every effort to achieve them at any cost to himself. To achieve the goal is conceived as something normal, without a manifestation of joy when he achieves it. On the other hand, if he does not achieve what he planned, he becomes sad, bitter and frustrated.

 

Failure is not usually in the plans of people with this pathology. Of course he overcomes the frustration and soon takes on another challenge, in which he will put more effort, devote more time and more study to achieve success. This attitude is not done to compete with others and succeed; it is a challenge to himself and it is difficult for him to fully understand this behavior.

 

This attitude transforms him into a student and then into an outstanding worker. He will be respected and well considered by his bosses.

 

Another relevant fact is that migraineurs tend to suffer 7 times more depression than the general population. They present frequent depressive symptoms of variable intensity, which sometimes need psychiatric attention. When they suffer from chronic migraine (15 days or more with monthly crises for 3 or more months) or headache due to medication abuse, depression is even greater and anguish, insomnia and neck pain increase, resulting in a very poor quality of life, and this has led to chronic migraine being considered by the WHO as one of the 4 most disabling pathologies. Understanding chronic migraine, knowing its marked impact on patients’ lives and treating it adequately should be an obligation of physicians and health institutions in a country.

 

It is necessary to know that the use of preventive drugs for migraine in patients with depression, such as beta-blockers, calcium channel blockers and even topiramate, can induce or provoke severe depression.

 

Migraineurs suffer less frequently from anxiety disorders, which are more frequent in children.

Sleep is also affected in migraineurs. They frequently suffer from insomnia, they wake up with headache in the early morning or in the morning, especially if they are abusing analgesic or antimigraine medications, which severely impacts their work performance.

 

In women, hormones such as estradiol cause well-known disorders in the brain, and their decrease triggers menstruation and produces in migraineurs the usually severe menstrual migraine, for which we must use specific therapeutics. In pregnant migraineurs it is remarkable that migraine disappears during the second and third trimester in 90% of them and migraineurs remember it as 6 months of happiness.

 

However, in 10% of the cases it worsens or the first migraine of their life begins. The management of cases in which migraine persists with frequent and intense attacks during pregnancy is a challenge for neurologists and obstetricians, since a common therapeutic plan should be used.

 

Lack of concentration or attentional deficit is an element that is not investigated in the clinical history, but that migraineurs suffer from, altering their school and/or work performance. This symptom is very frequent in chronic migraine with medication abuse. A similar picture can cause the use of topiramate, as a side effect of this migraine prophylactic, which seems to be observed more in Latin Americans than in Europeans and/or Anglo-Saxons, to which the treating neurologist should be attentive.

 

Migraineurs frequently complain of cervical pain, in which imaging studies are normal and which is associated, although not always, with cervical myofascial syndrome, which is easily diagnosed, because in the cervical muscles such as the trapezius, sternocleidomastoid and levator scapulae very painful cords (trigger points) are palpated with shortening of them, which determines a severe limitation of neck movements and which the patient does not relate to his migraine. In addition, the masseter and temporalis muscles present pain on palpation, painful cords and trigger points generally associated with bruxism.

 

Contracture of the entire craniocervical musculature is very frequent, especially in chronic migraine and it is sometimes difficult to know whether it is the origin or the consequence of the chronification of the migraine.

 

These problems are observed in more than 90 % in chronic migraines and in headache due to medication abuse.

 

In any case, it is very important to approach and solve it with the combination of pharmacological and non-pharmacological methods and with the fundamental collaboration of the patient.

 

Everything described above shows that migraine is multifaceted in clinical and pathophysiological aspects, which could be the cause of its difficult global understanding, requiring an awareness campaign on this pathology at all social, educational and work levels, and especially in the medical field.