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Demythologising and diagnosing migraine

Manuela Fontebasso
MB ChB
GP and Clinical Assistant in Neurology

Jo Hemming
RGN
Specialist Nurse
Headache Clinic Department of Neurosciences, York District Hospital

Migraine is a common condition that affects 15-18% of women and 6% of men in the UK(1,2) and can be effectively managed in primary care.(3) It is more common than asthma, diabetes and epilepsy.
 
What is migraine?
In 1988, the International Headache Society (IHS) created a classification to facilitate the diagnosis of the different type of headaches (see Table 1),(4,5) but this is a spectrum and not everybody falls into this classification.

[[NIP02_table1_99]]

Migraine without aura is the most common form of migraine. Patients may describe a prodrome, such as yawning, tiredness, food cravings and mood swings before the onset of headache. The characteristic attack then develops, followed by the postdrome. During the postdrome the sufferer often feels either washed out and lethargic or full of energy and revitalised.(4-6)
Migraine with aura affects one in ten migraine sufferers.(4-6) The aura may be visual, motor or sensory. It is completely reversible and generally lasts for no longer than 60 minutes.
Migraine is, by definition, an episodic headache. Daily headache is not migraine. Tension-type headache (TTH) and chronic daily headache (CDH) may coexist with migraine.(6) TTH is an episodic headache of short duration that rarely has an impact on function. CDH is a headache that occurs for more than 4 hours on more days than not. CDH may represent up to 40% of ­referrals to specialist headache centres.
A careful headache history is the only way to make the correct diagnosis, especially in the presence of a mixed headache picture (see Table 2).

[[NIP02_table2_100]]

What causes migraine?
The current neurovascular hypothesis suggests that migraine is caused by the activation of the trigeminal nucleus, leading to dilatation of cranial blood vessels. This releases vasoactive neurotransmitter peptides that cause neurogenic inflammation of the cranial blood vessels.(9 )Serotonin levels fall in the brain during a migraine, which may cause the vessel dilatation that causes pain.
Temporomandibular disorder (TMD) is a collective term used to describe a variety of conditions involving the temporomandibular joint (TMJ) and surrounding tissues. Bruxism, teeth grinding and jaw clenching are viewed as possible causes of headache symptoms.(7,8) Bruxism may trigger new onset headache symptoms or aggravate pre-existing headache syndromes, especially in the presence of physical or psychological stress.(7,8)
Symptoms typically include: unilateral or bilateral ache over the TMJ or temple; excessive wear patterns found on teeth or loosening of teeth; facial pain; and earache.

What is the Quality of Life impact?
Migraine is a condition that has a significant quality of life (QoL) impact(10) and has direct and indirect cost implications.(11) Only 30% of migraine sufferers seek medical help or advice. When they do they are often at the end of their tether and need someone to listen and understand the impact of their attacks. Migraine sufferers lose an average of 6-9 working days each year, and in total up to 18m working days are lost annually. This figure does not include people at home. The estimated cost of migraine is up to £750m annually. Sufferers get an average 13 attacks per year, and each attack lasts on average 22 hours (range 4-72 hours). A total of 65% of patients with medication misuse headache (MMH) have migraine as primary headache.(12)
It is important to use the right treatment for the right headache, as failure can lead to CDH and MMH. Any analgesic has the potential for producing MMH.(12,13)
A detailed medication history must form part of any headache assessment, as 70% of migraine sufferers use over-the-counter medication.

The holistic approach to migraine management
Always ask about diet and lifestyle at the initial attendance. This includes the time when meal breaks are taken, type of food eaten, snacks and drinks consumed,  as well as sleep patterns, hobbies enjoyed and causes of stress or anxiety. A social history can be as revealing as a headache history. Empowering the individual to take control of their lives can allow them to initiate change and regain control over their headaches (see Table 3).

[[NIP02_table3_100]]

Counselling and providing support to patients that suffer from MMH is time-consuming but essential. They have to stop all painkillers in the knowledge that their headaches will get worse before they get better.(12,13)

Conclusion
Migraine is characterised by its effect on QoL. A recent study by the Migraine Action Association has shown that patients in primary care want health professionals to listen to them and understand that QoL impact. All members of the primary healthcare team have skills and expertise that may help in patient management.

References

  1. Lipton RB, Stewart WF. The epidemiology of migraine. Eur Neurol 1994;34 Suppl 2:6-11.
  2. Rasmussen BK, et al. Epidemiology of headache in a general population - a prevalence study. J Clin Epidemiol 1991;44:1147-57.
  3. GlaxoWellcome. Migraine: the patient's perspective. Data on file. 1992.
  4. Headache Classification Committee, International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8 Suppl 7:9-39.
  5. International Headache Classification Committee. Guide to the classification, diagnosis and assessment of headaches in accordance with the Tenth Revision of the International Classification of Diseases and Related Health Problems and its Application to Neurology. Cephalalgia 1997;17 Suppl 19:7-38.
  6. Steiner TJ, MacGregor EA, Davies PTG. BASH guidelines for all doctors in the diagnosis and management of migraine. London: BASH; 1998.
  7. Gibilisco JA, et al. Orofacial pain: ­understanding temporomandibular ­disorders. London: Quintessence; 1994.
  8. Lamey PJ, et al. Migraine and ­masticatory muscle volume, bite force and craniofacial morphology. Headache 2001;41:49-56.
  9. Goadsby PJ, Oleson J. Diagnosis and management of migraine. BMJ 1996;312:1279-83.
  10. Liddell J. Migraine: the patient's perspective. Rev Contemp Pharmacother 1994;5:253-7.
  11. Cull RE, et al. The economic cost of migraine. Br J Med Econ 1992;2:103-15.
  12. Antonacci F. Drug abuse headache: recognition and management. Cephalalgia 1998;18 Suppl 22:44-55.
  13. Silberstein SD. Drug induced headache. Neurol Clin North Am 1998;16(1):107-23.

Resources
The Migraine Trust
45 Great Ormond St
London WC1N 3HZ
T:020 7831 4818
W:www.migrainetrust.org

Migraine Action Association
178a High Road
Byfleet
Surrey KT14 7ED
T:01932 352468
W:www.migraine.org.uk

British Association for the Study of Headache
The Princess Margaret Migraine Clinic, Charing Cross Hospital
London W6 8RF
T:020 8846 1191
W:www.bash.org.uk

Migraine in Primary Care Advisors
c/o Margaret Adams
Woodstock
Tilford Rd, Hindhead
GU26 6SF

British Brain and Spine Foundation
7 Winchester Hse
Kennington Park
London SW8 6EJ
Helpline:0808 8081000
W:www.bbsf.org.uk