Headache and migraine

What headache is and what migraine is

Headaches fall into two large groups. Primary headaches are diseases in their own right: migraine, tension-type headache and cluster headache. Secondary headaches are a symptom of another disease, such as infection, bleeding, a tumor, trauma, severe hypertension or giant cell arteritis. The great majority of patients who see a doctor for headache have a primary form, and the doctor’s task is to make sure no secondary form is hiding.

Migraine is the most common primary headache with a significant effect on functioning, and affects about one in seven people, more often women, especially of reproductive age. According to the international classification (ICHD-3), a migraine attack lasts 4 to 72 hours and has at least two of these features: pain on one side, a pulsating quality, moderate to severe intensity, and worsening with routine physical activity; and at least one of these: nausea or vomiting, sensitivity to light (photophobia) and to sound (phonophobia). The mechanism is not fully clear: it involves activation of the trigeminovascular system and release of neuropeptides such as CGRP (calcitonin gene-related peptide), which cause neurogenic inflammation and dilation of meningeal vessels, together with an inherited sensitivity of the brain to various triggers.

How migraine appears

An attack can have four phases, though not every patient goes through all of them:

• Prodrome, hours or days before the pain: tiredness, yawning, thirst, food cravings, mood changes and neck stiffness.
• Aura, in about a third of patients: temporary, fully reversible neurological symptoms that develop gradually over 5 minutes or more and last 5 to 60 minutes. The most common is visual aura (zigzag lines, flashing lights, blind spots), but there may also be numbness and tingling on one side of the face or arm, or difficulty speaking. The mechanism is a slow wave of electrical inhibition spreading across the cerebral cortex (cortical spreading depression).
• Pain, pulsating, usually one-sided (but it can switch sides), worsened by movement, light or noise; the patient seeks a quiet, dark room.
• Postdrome: fatigue and a “hangover” feeling for a day.

About two thirds of patients have no aura. An aura lasting over 60 minutes, appearing for the first time after age 40–50 or with unusual content (one-sided weakness) needs more careful assessment to rule out stroke or another cause.

The most frequent triggers are stress and the letdown after stress, lack or excess of sleep, skipped meals, dehydration, alcohol (especially red wine), caffeine in large amounts or its withdrawal, hormonal changes (the menstrual cycle), weather changes and, more rarely, particular foods. Triggers are individual; there is no need to remove many foods without a documented link to your own attacks.

When to see a neurologist and which signs are alarming

Seek a visit if episodes recur, change character, interfere with work and sleep, or if you need analgesics more than two days a week. New headache in pregnancy or after delivery, and progressive worsening, are reasons for prompt assessment.

Some features are called “red flags” because they raise the likelihood of a secondary cause and need immediate investigation: a sudden “thunderclap” headache; new headache after age 50; pain that builds up over weeks; pain that worsens with coughing, bending or lying down (or wakes you at night); headache with fever, rash or a stiff neck; any neurological deficit (weakness, numbness, speech or visual disturbance, confusion); headache with jaw pain on chewing or scalp tenderness in an older person (possible giant cell arteritis, which needs urgent treatment to avoid vision loss); and headache after a head injury in the last 3 months.

How the diagnosis is made

The diagnosis of migraine is clinical: it rests on the description of the attacks and on the neurological examination, which in migraine is normal between attacks. The neurologist asks about duration, frequency, location, triggers, accompanying symptoms, the medicines you use, family history, sleep and mood.

Keep a headache diary for 4–8 weeks: date, time, duration, intensity from 0 to 10, suspected triggers, medicines taken and their effect. In practice this is the most valuable tool for diagnosis and for following treatment. Measuring blood pressure is part of the assessment.

Not every migraine needs a CT scan or MRI. Imaging is recommended when there are red flags, an abnormal neurological examination or an atypical pattern; it is performed at another center and we interpret it with you. Blood tests (for example ESR/CRP in older patients with suspected arteritis) are chosen according to the suspicion.

How it is treated

Treatment has two goals: relieving the attack and preventing future attacks.

Treating the attack

Drugs work best when taken early, at the start of the pain. For mild to moderate attacks, nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen, acetylsalicylic acid) or paracetamol are used, often combined with an antiemetic. For stronger attacks or when these fail, triptans are used: specific drugs that act on serotonin receptors in brain vessels and trigeminal nerve endings. Triptans are not given to patients with coronary disease, previous stroke or uncontrolled hypertension. Newer drugs, the gepants, are an alternative in selected cases.

Overuse of analgesics is itself a cause of headache. Taking simple analgesics on 15 or more days a month, or triptans and combination products on 10 or more days a month, for more than three months can lead to medication-overuse headache, which sustains and worsens the pain. A practical limit is to take analgesics on no more than two days a week. Do not increase medication on your own.

Preventive treatment

It is indicated when attacks are frequent (about 4 or more a month), prolonged, disabling or not responsive to acute treatment. Drugs are chosen according to coexisting conditions: beta-blockers (e.g. propranolol), antiepileptics (topiramate), amitriptyline, candesartan; in resistant cases monoclonal antibodies against CGRP are used, which the doctor refers to specialized centers. The effect is judged after 2–3 months and, if successful, treatment is reviewed every 6–12 months. Non-drug methods (relaxation, cognitive-behavioral therapy, regular aerobic activity) have a documented effect.

Women with migraine with aura should not take estrogen-containing contraceptives, because they raise the risk of stroke; the doctor proposes alternatives.

What helps in daily life

Regular sleep on a steady schedule, meals at regular times, adequate hydration, moderate caffeine and regular physical activity are the measures with the most evidence. Stress cannot be eliminated, but relaxation techniques can reduce attack frequency. Home blood pressure monitoring and treating coexisting conditions (hypertension, sleep apnea, depression) help control the pain. Regular check-ups, every 6 months to a year or sooner when the doctor considers it reasonable, assess the effect of treatment and the need to change it.

Care at Tirana Polyclinic: we offer neurology consultation and interpretation of tests and imaging performed at other clinics.