Migraine

Definition: 

Migraine is a neurological disorder or disease characterized by recurrent attacks of mild to severe headaches, typically felt as throbbing or pulsating pain always on one side and sometimes on both sides of the head. In medical literature and clinical practice, both terms i.e. disease or disorder, can be used to describe migraines. The International Classification of Headache Disorders (ICHD) categorizes migraines under headache disorders, emphasizing the symptomatic and diagnostic aspects, while the term "disease" highlights the relatively well known pathophysiology, chronicity and potentially disabling nature of migraines. These type of headaches can initiated by auras and accompanied by other symptoms such as nausea, dizziness, vomiting, and sensitivity to light (photophobia), sound (photophobia) , or odors (osmophobia). Migraine headaches can last from a few minutes to several days.

Although occasional migraine headaches can cause concern for both the patient and their parents, they may not always align with the specific criteria needed for a formal diagnosis of migraine disorder. In medical practice, physicians often encounter patients experiencing migraine either as a chronic disorder or as infrequent, sporadic episodes of paroxysmal headaches.

History:

The earliest known descriptions of migraine-like symptoms are from ancient medical texts from Mesopotamia, Egypt, and Greece. These texts often attributed headaches to supernatural causes or imbalances in bodily humor. In ancient Greece, Hippocrates, often called the "Father of Medicine," described a condition called "hemicrania," which is believed to be similar to migraine. He noted the one-sided nature of the headache and its association with nausea and sensitivity to light. During the Middle Ages, migraine continued to be associated with supernatural explanations. Remedies often included prayers, charms, or herbal concoctions. In the 19th Century, with the advancement of medical science, more detailed clinical descriptions of migraine emerged.

However, treatments remained limited, often involving bloodletting, purging, or various herbal remedies. In the 20th Century, significant advancements have been made in the understanding and treatment of migraines. The advent of neuroimaging techniques allowed researchers to investigate the neurological basis of migraine. In the mid-20th Century, the vascular theory of migraine gained prominence, suggesting that changes in blood flow to the brain were responsible for migraine attacks.

As research progressed, it became clear that migraine is a complex neurological disorder involving various pathways, including those related to neurotransmitters, cortical excitability, and genetic factors. In recent decades, there has been a growing recognition of migraine as a significant public health concern. Efforts to raise awareness, improve diagnosis, and develop effective treatments have intensified. The development of migraine-specific medications, such as triptans and calcitonin gene-related peptide (CGRP) inhibitors, has revolutionized migraine management.

Prevalence:

Migraine is one of the most chronic and frequent neurological disorders, affecting people of all ages, genders, and socioeconomic backgrounds. Migraine headaches are the most common cause of the attack-wise and recurrent headaches. World Health Organization (WHO) considers migraine as the third most prevalent medical disorder and the seventh highest specific cause of disability worldwide. It is more prevalent in women than in men. Hormonal variations, particularly fluctuations in estrogen levels, are contributing factors to the increased prevalence of migraine in women. It often worsens around menstruation and may improve during pregnancy or after menopause. Migraine can occur at any age, but it often begins during adolescence or early adulthood. The peak age of onset is between the ages of 25 and 55. In children, migraine prevalence increases with age, with estimates suggesting that around 3% of preschool-age children and up to 10-23% of adolescents experience migraine. The prevalence of migraine varies across different regions and countries.

While migraines are prevalent globally, some studies suggest that they may be more common in some geographical regions or ethnic groups. Migraines in 18-month-old toddlers have been observed. Communication difficulty and limited explanatory skills could be a couple of factors leading to underestimating migraine prevalence in infants and toddlers. Migraine headaches affect youngsters far more frequently than the general public is aware.

Pathophysiology:

A dysfunctional trigeminovascular system can cause migraine headache. The trigeminovascular system encompasses the cranial vessels, dura and their trigeminal innervation, forming a functional network that holds significant importance in the development of migraine headache. The trigeminovascular system's dysfunction can manifest in various ways, often involving an aberrant response to external stimuli or internal changes.

For example, fluctuations in blood flow, alterations in neurochemical signaling, or sensitization of trigeminal nerve fibers can all contribute to the initiation and propagation of migraine attacks. One of the hallmarks of migraine pathology is the phenomenon of cortical spreading depression, a wave of neuronal hyperactivity followed by suppression that propagates across the cerebral cortex. This event is closely intertwined with the trigeminovascular system, as it can trigger a cascade of inflammatory and vasoactive processes within the cranial vasculature, ultimately leading to the characteristic throbbing pain experienced during migraines.

Moreover, the trigeminovascular system's involvement extends beyond mere nociceptive signaling; it also intersects with various other pathways implicated in migraine pathogenesis. For instance, interactions with the hypothalamus, brainstem nuclei, and descending modulatory pathways further complicate the neurobiology of migraine, underscoring the multifaceted nature of this disorder.

Clinical manifestations:

Migraine headache is a neurological condition known for its intense, throbbing, and pulsing pain, usually concentrated on one side of the head. However, it is essential to know that migraines can also affect both sides of the head and accompany untypical symptoms in children, adolescents and adults.

Prodrome: Activation of the hypothalamus seems to have a role in prodrome symptoms. Physiological functions involving the hypothalamus include nociceptive processing, sleep-wake cycle control, eating, thirst, arousal, and the autonomic and neuroendocrine system regulation. A migraine attack's prodrome symptoms, such as nausea, fatigue, food cravings, and cognitive problems, can last far into the aura, headache, and even postdrome phases. Moreover, prodrome symptoms can persist throughout the different phases of a migraine episode, extending into the aura, headache, and even postdrome phases. This prolonged duration highlights the complex and multifaceted nature of migraine pathology, wherein the hypothalamus exerts a significant influence not only on the initiation but also on the duration and severity of migraine symptoms.

Aura: A migraine aura is a visual, sensory, or motor manifestation caused by a localized neurological disruption. It affects roughly 30% of patients and is clearly driven by brain activity. The fundamental pathophysiology behind the aura phase is thought to be cortical spreading depression.

Visual Aura

This is the most common type of aura associated with migraines. Visual disturbances can include:

Sensory Aura

These auras involve changes in sensation and can affect different parts of the body:

Speech and Language Aura

These auras can affect communication abilities:

Motor Aura

Less common and typically associated with a subtype of migraine called hemiplegic migraine:

Brainstem Aura

Associated with migraines that involve the brainstem, also known as basilar-type migraines:

Retinal Aura

A rare type of aura that affects only one eye:

Cognitive Aura

Involves changes in thinking or perception:

Auditory Aura

Ictal: Headache and other symptoms have been linked to several neuropeptides, including calcitonin gene-related peptide (CGRP). In addition to pulsating headache, different symptoms like comorbidities, such as photophobia, phonophobia, and cutaneous/mechanical allodynia, occurred. 

Postdrome: The symptoms experienced throughout the prodrome and postdrome periods are relatively similar. The precise pathophysiological events that underpin these symptoms, however, are unknown.

Exacerbating factors:

Emotional stress, including anxiety, tension, and high-pressure situations, is a well-known trigger for migraine attacks. Fluctuations in estrogen levels, particularly during the menstrual cycle, pregnancy, or menopause, can exacerbate migraine attacks in some individuals. Hormonal therapies or contraceptives may be used to help regulate estrogen levels and manage hormonal migraines. Irregular sleep patterns, insufficient sleep, or poor sleep quality can trigger or worsen migraines. The long list of foods and beverages, such as processed meats, aged cheeses, alcohol (especially red wine), caffeine, and artificial sweeteners, may trigger migraine attacks in susceptible individuals.

Environmental factors such as solid odors (perfumes, cigarette smoke), bright lights, loud noises, intense visual patterns, flickering lights, strenuous exercise, and weather changes (barometric pressure changes, high humidity, hot environments) can exacerbate migraines in some people. Certain medications, including some over-the-counter pain relievers (e.g., NSAIDs, decongestants), hormone therapies, and medications that dilate blood vessels (e.g., nitrates), can exacerbate migraines in susceptible individuals. Consulting with a healthcare provider and adjusting medications as necessary may help minimize medication-related exacerbating factors.

Migraine classification:

Classical migraine: Its clinical manifestations are divided into the following subsequently phases: Prodrome, aura, ictal and postdrome.

Vestibular migraine: Vertigo, osmophobia (sensitivity to smells), photic allodynia (light-induced pain), and cranial allodynia (sensitivity to touch on the head) are another symptoms of migraine. While some people may experience vertigo attacks without any accompanying headache, this can make diagnosis more difficult, especially when considering conditions like vestibular migraine. Vestibular migraine is a subtype of migraine where vertigo or dizziness is the main symptom.

However, for a diagnosis of vestibular migraine, there typically needs to be a history of migraine headaches at some point, even if they're not happening simultaneously with the vertigo attacks.

Ocular migraine: Ocular migraine (included retinal and ophthalmic migraine), is a neurological phenomenon characterized by temporary vision disturbances in one eye. These disturbances typically manifest as vision loss or blindness in one eye, often described as a flickering or shimmering effect, zigzag lines, or blind spots. The visual disturbances usually last for a relatively short duration, typically less than one hour, before resolving spontaneously. What sets ocular migraines apart from other types of migraines is their predominant manifestation as visual symptoms without necessarily being accompanied by severe headache pain.

However, in many cases, ocular migraines are associated with or followed by a headache, which may occur on the same side as the affected eye or on both sides of the head. The exact cause of ocular migraines remains unclear, but they are believed to result from temporary changes in blood flow or spasms of blood vessels within the retina or visual cortex of the brain. These vascular changes can disrupt standard visual processing and lead to the transient vision disturbances characteristic of ocular migraines.

It's essential to differentiate ocular migraines from other potentially serious conditions that can cause similar visual symptoms, such as retinal detachment, transient ischemic attacks (TIAs), or stroke. Therefore, individuals experiencing visual disturbances consistent with ocular migraines should seek prompt medical evaluation to rule out any underlying pathology and ensure appropriate management.

Retinal vs ophthalmic migraine:

Retinal migraines involve repeated attacks of monocular (affecting one eye) visual disturbances. These disturbances can include scintillations (flashing lights), scotomata (blind spots), or temporary blindness. The visual symptoms typically last between 5 minutes and an hour. Retinal migraines are often followed by a headache, which may or may not be typical. Ophthalmic migraines involve visual disturbances affecting both eyes. These disturbances include scintillating scotomas (shimmering or zigzag pattern), fortification spectra (castle-like outline), and visual field defects. The visual symptoms typically last from a few minutes to about 30 minutes. Ophthalmic migraines may or may not be followed by a headache, often a migraine headache.

Auditory migraine: Auditory or cochlear migraine is a rare but significant subtype of migraine disorder characterized by distinct auditory symptoms. The primary criteria for diagnosing auditory or cochlear migraine typically revolve around recurrent or fluctuating sensorineural hearing loss, which is often unilateral and may affect low frequencies or all frequencies. Importantly, this hearing loss occurs without vertigo or severe dizziness, distinguishing it from other vestibular migraine variants. Individuals with auditory migraine may experience various auditory symptoms, including sudden or gradual onset of hearing impairment, diminished hearing acuity, or a feeling of fullness or pressure in the affected ear. These symptoms may fluctuate in intensity and duration, ranging from temporary episodes to more persistent issues, but typically resolve spontaneously within a short period. Hearing loss's unilateral nature, which affects only one ear, is a crucial characteristic of auditory or cochlear migraine. This unilateral presentation helps differentiate auditory migraine from bilateral hearing disorders or conditions affecting both ears simultaneously.

While the exact mechanisms underlying auditory migraine remain incompletely understood, it is believed to result from transient disturbances in blood flow or vascular changes affecting the cochlea, the auditory portion of the inner ear, or the auditory pathways within the brain.

Hemiplegic migraine: Hemiplegic migraine stands out as a rare and distinctive subtype of migraine with aura, adding a layer of complexity to the already multifaceted spectrum of migraine disorders. This unique variant is defined by transient paresis or paralysis, typically affecting one side of the body, as a prominent manifestation during a migraine attack. Individuals experiencing hemiplegic migraine may encounter a sudden onset of weakness or paralysis in one arm, leg, or both, often accompanied by other neurological symptoms characteristic of migraine aura, such as visual disturbances, sensory changes, speech difficulties, or confusion. The motor weakness associated with hemiplegic migraine can vary in severity and duration, lasting from minutes to hours or, in rare cases, persisting for days.

The underlying mechanisms driving hemiplegic migraine are not fully understood but are believed to involve complex interactions within the brain's cortical and subcortical regions, as well as disruptions in ion channel function and neurotransmitter release. Genetic factors play a significant role, as specific mutations in genes regulate ion channel function have been identified in some individuals with familial hemiplegic migraine.

Diagnosing hemiplegic migraine requires careful evaluation by a healthcare professional skilled in migraine management and neurology. Clinicians must differentiate hemiplegic migraine from other conditions that can cause similar symptoms, such as transient ischemic attacks (TIAs), stroke, epilepsy, or other types of migraine with neurological manifestations.

Menstrual migraine: Menstrual migraines represent a specific subtype of migraine disorder intricately linked to the hormonal fluctuations occurring during the menstrual cycle. These migraines typically happen near menstruation, commonly starting up to two days before the onset of the menstrual period and continuing through the first three days of menstruation. The characteristic hallmark of menstrual migraines is their association with the hormonal changes accompanying the menstrual cycle, particularly fluctuations in estrogen and progesterone levels. These hormonal shifts can influence the sensitivity of the trigeminal nerve system, which plays a crucial role in migraine pathophysiology, leading to the onset of menstrual migraine attacks. Individuals experiencing menstrual migraines suffer from a range of symptoms that mirror those of typical migraines but may exhibit specific patterns or triggers related to their menstrual cycle.

Alongside the classic headache pain, which is often throbbing or pulsating in nature and typically localized to one side of the head, menstrual migraines may be exacerbated by movement, sensitivity to light, smells, or sound. The timing of menstrual migraines can vary among individuals, with some experiencing migraines only during menstruation, while others may encounter them in the days leading up to menstruation or even during ovulation. The precise triggers and patterns of menstrual migraines can differ from person to person, underscoring the complex interplay between hormones, genetics, and environmental factors in migraine pathogenesis. Diagnosing menstrual migraines involves a thorough assessment of the timing and characteristics of migraine attacks during the menstrual cycle. Healthcare providers may use tools like headache diaries or menstrual cycle tracking to identify patterns and establish a clear link between migraine onset and hormonal fluctuations.

Management of menstrual migraines often requires a multifaceted approach aimed at both acute symptom relief and prevention of future attacks. Treatment strategies may include medications to alleviate pain and other migraine symptoms, hormonal therapies to stabilize hormonal fluctuations, lifestyle modifications, and targeted interventions to address specific triggers associated with the menstrual cycle.

Abdominal migraine: Abdominal migraines (AM) represent a fascinating yet often overlooked facet of migraine pathology. Characterized by unprovoked episodes of central abdominal pain, AM is distinguished by its association with classic migraine symptoms, including sensory hypersensitivities to light and sound, vomiting, nausea, acute headaches, and general pallor.

While traditionally more prevalent among children, abdominal migraines are increasingly recognized as a rare but significant diagnosis in adults. The exact prevalence in adults remains uncertain due to underrecognition and underreporting, but studies suggest that a notable proportion of individuals may experience abdominal migraines well into adulthood. The clinical presentation of abdominal migraines can vary widely, adding to the diagnostic challenge. Some individuals may primarily experience abdominal pain, often described as dull or throbbing and centered around the midline, while others may exhibit a constellation of migraine symptoms alongside the abdominal discomfort. The association between abdominal migraines and classic migraine features underscores the shared pathophysiology underlying these conditions. Both are believed to involve dysregulation of neuronal pathways, altered neurotransmitter levels, and abnormal vascular responses, although the specific mechanisms linking abdominal migraines to gastrointestinal dysfunction remain an area of active research.

Despite its relative rarity in adults, abdominal migraines can significantly impact an individual's quality of life, leading to missed work or school days, social withdrawal, and impaired daily functioning. Moreover, the overlap with other gastrointestinal disorders, such as irritable bowel syndrome (IBS), can further complicate diagnosis and management. Given the complexity of abdominal migraines and their potential impact on patient's lives, a multidisciplinary approach to diagnosis and treatment is essential.

Comprehensive evaluation, including detailed clinical history, physical examination, and, when necessary, imaging studies or laboratory tests, can aid in establishing a timely and accurate diagnosis. The diagnosis of abdominal migraine should be made only after excluding other potential causes of abdominal pain. Treatment strategies for abdominal migraines often mirror those used for classical migraines, encompassing both acute symptom management and preventive measures. Lifestyle modifications, dietary changes, stress reduction techniques, and pharmacological interventions, such as antiemetics or migraine-specific medications, may all play a role in alleviating symptoms and improving overall well-being.

Basilar migraine: Basilar migraine, also known as migraine with brainstem aura or formerly as basilar artery migraine, is a type of migraine characterized by specific neurological symptoms originating from the brainstem or both hemispheres of the brain. This type of migraine can be particularly alarming due to its symptoms, so it is important to understand its features for proper diagnosis and management.

Basilar migraine is characterized by aura symptoms that precede the headache. These symptoms are believed to come from the brainstem and the posterior circulation of the brain. Common aura symptoms include: vertigo (a spinning sensation), double vision or vision loss, slurred speech, tinnitus (ringing in the ears), ataxia (lack of coordination), dysarthria (difficulty speaking), and umbness or tingling in the limbs or face.

 The headache phase of a basilar migraine typically follows the aura and shares characteristics with other types of migraines. It is often:

The aura symptoms usually develop over several minutes and can last up to an hour. The headache phase can last from a few hours to several days.

Differential diagnosis:

Trigeminal Autonomic Cephalalgias (TACs)

Trigeminal Autonomic Cephalalgias (TACs) are a group of primary headache disorders characterized by severe unilateral head pain associated with prominent cranial autonomic symptoms. TACs include several distinct headache syndromes, each with unique features, but they share common mechanisms involving the trigeminal nerve and autonomic nervous system. TACs encompass cluster headaches, paroxysmal hemicrania, SUNCT, and SUNA.

Cluster Headache:

Paroxysmal Hemicrania:

SUNCT and SUNA:

SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing) and SUNA (Short-lasting Unilateral Neuralgiform headache attacks with Autonomic symptoms) are rare types of primary headache disorders that fall under the category of trigeminal autonomic cephalalgias (TACs). These conditions are characterized by short, intense headaches accompanied by autonomic symptoms.

SUNCT: Attacks typically last from 5 to 240 seconds (5 seconds to 4 minutes), occurring up to hundreds of times per day.

SUNA: Similar duration and frequency as SUNCT, with attacks lasting 5 to 240 seconds and occurring multiple times daily.

SUNCT: The pain is typically unilateral (on one side of the head), severe, and often described as stabbing or piercing. The pain is localized around the eye, temple, or forehead.

SUNA: The pain characteristics are similar to SUNCT, involving severe, unilateral, stabbing pain around the eye or temporal region.

SUNCT: Characterized by conjunctival injection (eye redness) and tearing (lacrimation) on the affected side.

SUNA: Involves one or more cranial autonomic symptoms, which may include:

Conjunctival injection

Lacrimation

Nasal congestion or rhinorrhea (runny nose)

Eyelid edema (swelling)

Forehead and facial sweating

Miosis (constriction of the pupil) or ptosis (drooping of the eyelid)

Midfacial Segment Pain:

Midfacial segment pain is a type of facial pain that is localized to the middle region of the face. This pain can arise from various causes, including dental issues, sinus problems, nerve disorders, and more. Understanding the characteristics, potential causes, and treatment options for midfacial segment pain is crucial for effective management. The pain is typically situated in the mid-face area, which includes the cheeks, nose, upper jaw, and surrounding areas. The pain can vary widely, including sharp, stabbing, aching, burning, or throbbing sensations. It can be unilateral (affecting one side) or bilateral (affecting both sides), depending on the underlying cause. The duration and frequency of the pain episodes can also vary. It can be acute (short-term) or chronic (long-term). Midfacial segment pain can result from various conditions such as Dental Issues, Sinusitis, Trigeminal Neuralgia, Migraines, Cluster Headaches, Temporomandibular Joint (TMJ) Disorders, Neuralgias and Neuropathies.

Migraine and epilepsy:

Some types of epileptic seizures, particularly focal seizures, can present symptoms that resemble migraine headaches. Certain seizures (with sensory component) can cause significant head pain, which might be mistaken for a migraine, especially if the person has a history of migraines. Both conditions can present with an aura. In migraines, an aura typically consists of visual disturbances, sensory changes, or speech difficulties that precede the headache. In epilepsy, an aura can be a part of the seizure, manifesting as sensory changes, strange smells, or déjà vu experiences. After a seizure, individuals may experience a headache during the postictal state, which can resemble a migraine in terms of severity and symptoms.

Migralepsy: There is a specific condition known as migralepsy, where a migraine attack is immediately followed by an epileptic seizure. This term highlights the close relationship and potential overlap between the two conditions.

Sinus headache:

Sinus headaches are often mistaken for other types of headaches, such as tension-type headaches or migraines, because of the overlapping symptoms. However, sinus headaches arise from inflammation and congestion in the sinus cavities. The pain is typically localized around the sinuses forehead, cheeks, bridge of the nose, and sometimes behind the eyes. It is often described as a constant, deep pressure or throbbing sensation. It can worsen with sudden movements or straining.

A range of sinusitis symptoms, including nasal congestion, runny nose, facial swelling, and a feeling of fullness in the ears, typically accompany sinus headaches. Additional indicators may include a post-nasal drip and a diminished sense of smell or taste, providing a comprehensive picture of the condition. 

Tension headache:

Tension-type headaches, on the other hand, are usually described as a constant, dull ache on both sides of the head. They often feel like a tight band around the forehead or the back of the head and neck. These headaches are generally less severe than migraines and do not typically come with the additional symptoms of nausea or light sensitivity. In many cases, headaches are a combination of migraine and tension-type headaches. These hybrid headaches can present with symptoms characteristic of both types, making diagnosis and treatment more complex.

Patients with chronic tension headaches may develop more severe complications over time. One such complication is muscular inflammation surrounding the skull, which can exacerbate headache symptoms and contribute to a cycle of chronic pain. This muscular inflammation, often involving the neck and shoulder muscles, can lead to increased tension and pain, making the headaches more difficult to manage.

High intracranial pressure:

Headaches in patients with high intracranial pressure (ICP) are often a result of increased pressure within the skull that affects the brain and surrounding structures. These headaches can be severe and usually indicate a serious underlying condition. The headache is typically described as a constant, dull, or throbbing pain. It can sometimes be sharp and intense. It is often generalized across the entire head but can also be more intense in specific areas, such as the forehead or the back of the head.

The pain may worsen when lying down. The headache often becomes more severe when the patient lies down and may improve when sitting or standing. This is due to changes in pressure dynamics within the skull. These headaches are frequently worse in the morning upon waking, which is attributed to the natural increase in ICP during sleep.

Diagnosis:

Medical History:

The patient's symptom description is crucial in the diagnosis of migraines. It includes details such as the intensity, duration, frequency, location, and nature of the headaches (e.g., throbbing, pulsing). This information provides a comprehensive understanding of the patient's experience and aids in accurate diagnosis. Discussion of symptoms that accompany the headache, such as nausea, vomiting, sensitivity to light (photophobia), sensitivity to sound (phonophobia), and visual disturbances (aura). Inquiry about any family history of migraines or other headaches. Identify potential triggers like stress, certain foods, hormonal changes, and environmental factors. Patients are often advised to keep a headache diary, in which they document the timing, duration, intensity, and potential triggers of each headache. This diary is valuable for identifying patterns and potential triggers, which helps in the diagnostic process.

Additionally, a general physical examination is conducted to check for signs of other medical conditions that may be causing the headaches. A detailed neurological examination is also performed to assess brain function and check for any neurological abnormalities.

Diagnostic Criteria: The criteria from the International Classification of Headache Disorders (ICHD) to diagnose migraines include:

In order to make the most accurate diagnosis, doctors carefully consider different possible diagnoses and may order tests, such as blood tests or imaging studies, to rule out other conditions like sinus infections, brain tumors, or other types of headaches. Imaging studies like MRI or CT scans are generally unnecessary for diagnosing migraines. However, they may be ordered if the doctor suspects another condition or if the headache pattern is unusual or complex. Sometimes, the diagnosis is confirmed by the patient's response to migraine-specific treatments, such as triptans.

Treatment:

Migraine pharmacological treatment typically follows three main strategies:

Abortive treatment: Abortive treatment focuses on stopping a migraine attack once it has started, typically using medications such as triptans or nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen, Naproxen, Indomethacin and Diclofenac. Triptans work by constricting blood vessels and blocking pain pathways in the brain. NSAIDs reduce inflammation and pain associated with migraines. These medications are most effective when taken as soon as symptoms begin.

Periodic prophylactic treatment: Used for individuals who experience frequent or severe migraines, but not on a daily basis. Involves taking medications regularly during specific periods or triggers, such as menstruation or weather changes, to prevent migraine attacks with a low dosage of beta blockers or NSAID during a pre-migraine attack. Dosage and duration of treatment are individual.

Continuous prophylactic treatment: Prophylactic treatment aims to prevent or reduce migraine attacks, often involving daily medications like beta-blockers, antidepressants, or antiepileptic drugs. These drugs include:

Although migraine is not life-threatening, its treatment can be complex and challenging at times. Stressful circumstances, bright lighting, loud noises, and strong odors should all be avoided. Here are several non-pharmacological treatments for migraines: Regular sleep schedule, healthy diet, meditation, yoga, deep breathing exercises, regular exercise, cognitive behavioral therapy (CBT), biofeedback, staying hydrated, acupuncture, massage, supplements such as Magnesium, Riboflavin (vitamin B2), vitamin-D, Co-enzyme Q10, and herbal remedies.

In medical practice, there have been many efforts to use botulinum toxin against migraines. The short-term results have been good, while the long-term results have been controversial.

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