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Migraine: forms, symptoms, triggers

by Josephine Andrews
Published: Last Updated on 301 views

Index

Those affected by migraines suffer from mostly one-sided, severe headache attacks. Nausea, vomiting, and sensitivity to light and noise are also common. In some cases, the attacks are preceded by aura symptoms – neurological symptoms such as sudden visual disturbances. Read more about migraine symptoms, the different forms of migraine, and diagnosis, therapy and prognosis here.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

G43 R51

quick overview

  • What is migraine? Headache disorder with recurring, strong, mostly one-sided pain attacks
  • Forms: including migraine without aura (with sub-forms such as purely menstrual migraine without aura), migraine with aura (eg migraine with brainstem aura, hemiplegic migraine, purely menstrual migraine with aura), chronic migraine, migraine complications (such as migraine infarction )
  • Symptoms: attack-like, mostly one-sided headaches, nausea, vomiting, fear of light and noise; in migraine with aura also neurological symptoms such as visual disturbances; more rarely, the headache is absent in a migraine attack
  • Causes: not yet fully known; a genetic predisposition is suspected, on the basis of which various internal and external factors (“triggers”) trigger the pain attacks
  • Possible triggers: eg stress, certain foods and beverages , certain weather conditions, hormone fluctuations (eg in the course of the menstrual cycle)
  • Diagnostics: Collection of medical history (anamnesis), physical and neurological examination; if necessary, additional examinations (e.g. MRI)
  • Treatment: Acute therapy (medications such as pain relievers, triptans, anti-nausea and anti-vomiting drugs; general measures such as rest); Measures to prevent migraine attacks (eg avoidance of trigger factors, relaxation techniques, endurance sports, medication if necessary)
  • Prognosis: not curable, but the intensity and frequency of seizures can be reduced; often improves with age, sometimes disappearing in women after menopause.

Migraines: description

Headache attacks occur at irregular intervals in people who suffer from migraines. The pain usually affects only one side of the head and is described by sufferers as throbbing, throbbing, or nagging. It increases with physical exertion. Migraine headaches are often accompanied by various other symptoms such as nausea, vomiting or blurred vision.

The symptoms in acute cases can significantly affect those affected in their everyday life, especially in the case of severe migraines. The duration of a single attack is between 4 and 72 hours. Like the intensity of the symptoms, it may differ from attack to attack. The frequency of migraine attacks and the time between them may also vary.

Migraine is the second most common form of headache after tension-type headache. According to a 2016 Global Burden of Disease Survey, it is the sixth most common condition overall.

forms of migraine

The International Headache Society (IHS) differentiates between different forms of migraine. This includes:

1. Migraine without aura , with three sub-types:

  • Purely menstrual migraine without aura
  • Menstrual-associated migraine without aura
  • Non-menstrual migraines without aura

2. Migraine with aura , with various sub-forms such as…

  • Migraine with typical aura (subtypes: typical aura with headache and typical aura without headache)
  • Migraine with brainstem aura (formerly: basilar migraine)
  • Hemiplegic migraine
  • retinal migraine
  • Pure menstrual migraine with aura
  • Menstrual-associated migraine with aura
  • Non-menstrual migraine with aura

3. Chronic migraines

4. Migraine complications such as…

  • status migraenosus
  • migraine infarction
  • Epileptic seizure triggered by migraine aura

5. Probable migraine with or without aura

6. Episodic syndromes that can accompany a migraine , for example…

  • Recurring gastrointestinal disorders (e.g. abdominal migraine)
  • Vestibular migraine

The main forms are migraine without aura and migraine with aura.

Migraine sufferers do not always have to suffer from one and the same type of migraine. For example, someone who frequently experiences migraine attacks with aura may also have attacks without aura.

Below you will find more detailed information on selected forms of migraine:

Migraine without aura

Migraine without aura is the most common form of migraine. They are characterized by attack-like, one-sided, pulsating headaches of moderate to severe intensity. They are aggravated by routine physical activities (eg walking, climbing stairs) and last four (two in children and adolescents) to 72 hours. They are accompanied by nausea and/or sensitivity to light and noise.

Migraine without aura in menstruating women

In a few women, these migraine attacks occur in connection with menstruation. This allows the differentiation of sub-forms of the disease. All of them meet the criteria of “migraine without aura” above, but in addition:

  • Purely menstrual migraine without aura : Migraine attacks only occur two days before to three days after the onset of menstrual bleeding, in at least two out of three menstrual cycles. The rest of the cycle is always migraine-free.
  • Menstruation-associated migraine without aura : Here, too, the migraine attacks occur in at least two out of three cycles in the time window two days before and two days after the start of menstruation – but they can also occur at other times of the cycle .

Migraine attacks that occur during menstruation are generally longer in duration and accompanied by more nausea than off-cycle attacks.

Menstrual women with migraine attacks that meet the criteria for “migraine without aura” but neither those of purely menstrual nor menstrual-associated migraine without aura are also referred to as non-menstrual migraine without aura .

Experts still disagree on whether or not “menstrual-only migraine without aura”, “menstrual-associated migraine without aura”, and “non-menstrual migraine without aura” are actually separate forms of migraine.

Migraine with aura

This form of migraine, also called “migraine accompagnée” (from French accompagner = to accompany), is much rarer than migraine without aura.

Doctors call “aura” visual disturbances and other neurological symptoms that usually precede the headache phase, but can also occur together with it. Sometimes it is just the aura alone – without accompanying or subsequent migraine headaches (sub-form “typical aura without headache”, formerly also called “migraine sans migraine”).

The aura symptoms appear on only one side of the head, develop gradually and last for minutes (often up to an hour). After that, they recover completely. Typical aura symptoms that can occur individually or in combination are:

  • Visual disturbances (such as flashes of light, flickering, seeing jagged lines, loss of visual field = scotoma) – are the most common symptoms of a migraine aura
  • speech disorder (aphasia)
  • Abnormal sensations (sensory disturbances) such as numbness or tingling (eg in an arm)
  • incomplete paralysis (paresis)
  • dizziness

Aura or Stroke?

For medical laypeople, the symptoms that occur during the aura phase are almost indistinguishable from those of a stroke. However, an important feature of the aura is that the symptoms begin rather insidiously and slowly increase in intensity. In the case of a stroke, on the other hand, symptoms such as blurred vision and abnormal sensations usually start suddenly.

The symptoms of migraine aura are also temporary and, unlike a stroke, do not leave permanent damage.

In the hospital, computer tomography (CT) or magnetic resonance imaging (magnetic resonance imaging, MRI) can be used to determine exactly whether it is a stroke or migraine – more precisely symptoms of an aura.

Migraine with aura in menstruating women

Analogously to migraine without aura, migraine with aura that occurs in menstruating women can also be divided into the three sub-forms ” purely menstrual migraine with aura “, ” menstrual-associated migraine with aura ” and ” non-menstrual migraine with aura ” ( see above) . differentiate.

Migraine with brainstem aura

Migraine with brainstem aura is a form of migraine with aura in which the aura symptoms are clearly localized to the brainstem. Motor and retinal symptoms, on the other hand, are absent.

Brainstem aura symptoms can include:

  • speech disorder (dysarthria)
  • Dizziness (not drowsiness!)
  • ringing in the ears (tinnitus)
  • hearing loss
  • Double vision (no blurred vision!)
  • Movement coordination disorder ( ataxia )
  • disturbance of consciousness

Migraine with brainstem aura was formerly called basilar migraine, basilar migraine, basilar-type migraine, or basilar artery migraine. The background was the assumption that the basilar artery (an important cerebral artery) is involved in the development of the attacks. However, this is now considered unlikely, which is why the term “migraine with brainstem aura” is preferred today.

Hemiplegic migraine

Another form of “migraine with aura” is hemiplegic migraine (also called “complicated migraine”). Characteristic here is motor weakness as part of the aura. In addition, there are symptoms in the area of ​​vision, sensitivity and/or language or speaking.

The motor weakness associated with a hemiplegic migraine attack usually resolves completely within 72 hours. But sometimes it can last for weeks.

The term “hemiplegia” actually means complete paralysis in one side of the body. In most attacks of hemiplegic migraine, however, there is no such paralysis, but motor weakness.

subforms

sporadic hemiplegic migraine (SHM)first or second degree relative (e.g. mother, child, grandfather, brother) who also suffers from this form of migraine.

On the other hand, if at least two first- or second-degree relatives have migraine auras with motor weakness, doctors diagnose familial hemiplegic migraine (FHM) .

Symptoms other than the known ones rarely occur during an FHM attack: impaired consciousness (up to and including coma), confusion, fever and an increased number of cells in the cerebrospinal fluid (cerebrospinal fluid pleocytosis). In addition, chronic progressive cerebellar ataxia (a chronic progressive disorder of movement coordination originating in the cerebellum ) occurs in about half of all families with FHM independent of the migraine attacks.

retinal migraine

Retinal migraine (retinal migraine) is rare. It is characterized by repeated attacks of unilateral visual disturbances such as flickering in front of the eyes, visual field loss (scotoma) or – very rarely – temporary blindness. In addition, at least one of the following three criteria is met for this migraine of the eyes:

  • Symptoms develop gradually over five or more minutes.
  • They last for five minutes to an hour.
  • Migraine headaches also occur concomitantly or within 60 minutes.

This eye migraine is therefore not necessarily associated with migraine headaches – only the visual disturbances described can occur alone.

No migraines: Ophthalmic migraines

When it comes to an ocular migraine, the term “ophthalmoplegic migraine” (ophthalmoplegia = eye muscle paralysis) is often used. This old name stands for a disease that is no longer classified as a form of migraine by the International Headache Society, but is counted among the group of neuropathies and facial pain. It now bears the name “Recurrent painful ophthalmoplegic neuropathy”.

Those affected experience repeated attacks of paralysis in one or more of the cranial nerves responsible for eye muscle movementsresponsible for eye muscle movements (most frequently on the 3rd cranial nerve) with unilateral headaches.

According to some research data, headaches can also appear up to 14 days before the eye muscle paralysis.

chronic migraine

If someone has headaches* on at least 15 days per month for more than three months and they have the characteristics of migraine headaches on at least eight days per month, the doctor diagnoses chronic migraines. It can develop from a migraine without aura and/or a migraine with aura.

* This includes migraine-type and tension-type headaches, but not secondary headaches – ie not those that can be traced back to another illness or external influences (eg head injury, infection such as flu or meningitis, high blood pressure, tension in the neck muscles, alcohol or alcohol withdrawal, stroke, brain tumor, heat stroke).

status migraenosus

Status migraenosus (status migraenosus) is a migraine complication that can occur in both migraine with aura and migraine without aura. Sufferers experience a migraine attack that lasts longer than 72 hours and in which the headache and/or associated symptoms become severely debilitating for the sufferer.

migraine infarction

This migraine complication can occur with a migraine with aura. It is characterized by one or more of the aura symptoms lasting longer than 60 minutes. In addition, an imaging examination of the brain shows reduced blood flow in a relevant brain area. Due to this reduced blood flow, the brain cells in the affected area are no longer sufficiently supplied with oxygen and nutrients – they can no longer work and die (ischemic heart attack).

Epileptic seizure triggered by migraine aura

Another possible complication of migraine with aura is an epileptic seizure that occurs during or within an hour of a migraine with aura attack. This rare complication of migraine is sometimes called migraine.

Recurrent gastrointestinal disorders

Recurrent Gastrointestinal Disorders are another migraine category. Those affected repeatedly have attacks of abdominal pain and/or abdominal discomfort and/or nausea and/or vomiting. These attacks occur irregularly, chronically or at predictable intervals and can be associated with a migraine. The symptoms cannot be explained by another disease.

A subtype is abdominal migraine , which mainly affects children. Unexplained, moderate to severe abdominal pain attacks occur recurrently and last from two to 72 hours. They are accompanied by at least two of the following symptoms: loss of appetite, paleness, nausea, vomiting. Headaches do not occur during these attacks. In the time between two attacks, those affected are symptom-free.

Vestibular migraine

Vestibular migraines can occur in people who have or have had migraines with or without an aura. The “vestibular” here refers to the vestibular apparatus – the balance organs located in the inner ear . Accordingly, vestibular symptoms play a central role in this form of migraine.

This includes, for example, spontaneous vertigo, where you have the deceptive feeling that you are moving (internal vertigo) or that what you see around you is rotating or flowing (external vertigo). Positional vertigo is also an example of a vestibular symptom – as is head movement-triggered drowsiness with nausea (drowsiness in the sense of disturbed spatial orientation).

In people with vestibular migraines, such symptoms occur in episodes lasting five minutes to 72 hours and are moderate to severe in intensity. At least half of these episodes are associated with at least one of the following three migraine features:

  • Headache with at least two of the following four characteristics: unilateral, throbbing, moderate to severe in intensity, aggravated by routine physical activity
  • Aversion to light and noise ( photophobia and phonophobia)
  • visual aura (ie visual disturbances such as flashes of light)

Old names of vestibular migraines are migraine-associated vertigo, migraine-associated vestibulopathy, and migraine vertigo.

Duplicates with inner ear disease

There is an overlap between vestibular migraine and the inner ear disease Meniere’s disease. Since the latter sometimes manifests itself exclusively with vestibular symptoms (such as dizziness) in the early stages, it can be difficult to differentiate it from vestibular migraines.

There are also many patients who show characteristics of both diseases. So far it is unclear how the disease mechanisms of vestibular migraine and Meniere’s disease are related to each other.

migraines in children

In children, migraine headaches often occur on both sides and mainly affect the forehead and temples. But there are other differences to migraines in adults:

In children, migraine headaches are often less pronounced or absent altogether. On the other hand, dizziness, balance disorders and sensitivity to smells occur much more frequently in children than in adults as accompanying symptoms of migraine. Symptoms such as lethargy, tiredness, paleness, dizziness, abdominal pain, nausea, or vomiting are also more common in children with migraines.

This different symptom picture means that migraines in children often go undetected for a long time. In the case of small children, this is made more difficult by the fact that they are not yet able to adequately express their complaints.

Stress is often the trigger

Stress is a common trigger for migraines in children. This can be physical, for example due to overtiredness, exhaustion, sensory overload, insufficient fluid intake or not eating enough. Mental stress such as conflicts at home or arguments with classmates can also trigger migraine attacks in children.

Little medication

The treatment of migraines is also somewhat different in children than in adults. The focus here is on non-drug therapy. This includes a daily routine that is as regular as possible, learning a relaxation method or biofeedback. Such measures often work very well for children.

When supportive medication is needed, doctors often prescribe different medications for children than for adult patients.

For more detailed information on this topic, see the article Migraines in Children .

Migraine: Symptoms

The most important migraine symptom is a severe, mostly one-sided headache. In addition, other complaints such as photophobia or noise aversion occur. In addition, various neurological deficits (also known as aura) can announce or accompany the migraine headache. The headache is rarely absent from a migraine.

Four stages of migraine symptoms

A migraine can be divided into up to four different stages with different symptoms. They can express themselves differently in each phase from patient to patient. In addition, not every migraine attack goes through all phases. The four stages are:

  • preliminary phase (prodromal stage)
  • aura phase
  • headache phase
  • recovery phase

Symptoms in the migraine preliminary phase (prodromal phase)

Sometimes, hours to two days before a migraine occurs, signs will appear that herald the coming attack. These include, for example:

  • Mood swings, mood changes
  • Cravings or loss of appetite
  • Difficulty reading and writing
  • increased yawning
  • increased urination (polyuria)
  • increased thirst (polydipsia)

Migraine symptoms in the aura phase

Sometimes a migraine is associated with aura symptoms that precede or coincide with the headache phase. Experts distinguish the following types of aura symptoms:

visual symptoms: Such visual disturbances are the most common aura symptoms. Those affected often see a jagged figure, the shape of which is reminiscent of earlier fortifications (forts) and is therefore called fortification. The zigzag figure slowly spreads to the right or left. While the edge zone flickers, a visual field loss (scotoma) can occur in the center – ie a black or gray “spot”. In the affected area of ​​the visual field, the patient is either unable to perceive objects at all (absolute scotoma) or only to a limited extent (relative scotoma).

A visual field defect can also occur with a migraine aura without jagged lines or figures.

Sensory symptoms : After visual disturbances, sensory disturbances in the form of pinprick-like abnormal sensations (paraesthesia) are the second most common aura symptom. This discomfort spreads slowly from the point of origin and can eventually affect more or less part of one side of the body (including, for example, the tongue).

Symptoms related to speech and/or language

Motor symptoms : Rarely (eg in familial hemiplegic migraines) the aura is accompanied by disturbances in movement. Those affected report weakness or paralysis in one arm, for example.

Brainstem symptoms : They are typical signs of migraine with brainstem aura (see above). These include ringing in the ears (tinnitus), double vision, speech and consciousness disorders. In familial hemiplegic migraines, too, brainstem symptoms often appear during the aura phase.

retinal symptoms : In retinal migraine, the aura includes retinal symptoms such as sudden flickering in front of the eyes, loss of visual field and even blindness.

If two or more aura symptoms occur during a migraine attack, they usually occur consecutively and not at the same time. For example, visual symptoms may develop first, then sensory disturbances, and then speech disturbances.

Migraine symptoms in the headache phase

The duration of migraine headaches varies from a few hours to up to three days. The period of time can change again and again from seizure to seizure.

Severe, one-sided headache: The main symptom of migraine is the attack-like, often severe headache that usually only affects one side of the head. It manifests itself individually in different regions of the head, but mostly behind the forehead, on the temples or behind the eyes. Affected people often describe it as pulsating, boring or pounding. Typically, the intensity of the headache slowly increases over the course of hours.

Unilateral migraine headaches can switch sides of the head during an attack or from attack to attack.

Nausea and Vomiting: Common accompanying symptoms of migraines are nausea and vomiting. Scientists suspect the reason for this is the disturbed serotonin balance in many of those affected. Serotonin is a messenger substance (transmitter) in the body that acts both in the brain and in the gastrointestinal tract and in many other areas of the body.

Hypersensitivity to light and noise: During an acute migraine attack, many sufferers are extremely sensitive to bright lights and loud noises. The reason for this has not yet been clarified with certainty. In any case, those affected should withdraw to a quiet and darkened room during an acute attack.

Activity aggravates : Migraine symptoms can be aggravated by physical activity, which is not the case with tension headaches , the most common type of headache. Even moderate exercise, such as climbing stairs or carrying grocery bags, can make migraine headaches and discomfort worse.

Migraine symptoms in the recovery phase

In the recovery phase, the migraine symptoms gradually subside. Many sufferers feel tired, exhausted and irritable. Difficulty concentrating, weakness and loss of appetite can persist for hours after the migraine attack. In rare cases, patients experience a kind of euphoria after a migraine attack. It may take another 12 to 24 hours for full recovery.

This is how you recognize migraines
Headaches associated with migraines usually occur on one side

Take migraine symptoms seriously

Basically, if you have frequent migraine symptoms, you should see a doctor. This can recommend effective measures for the treatment and prevention of migraines.

In some cases it turns out that the symptoms are not due to a migraine at all, but to another disease – such as a vascular malformation (aneurysm) or a tumor in the brain. It is imperative that you treat them early!

Migraines: causes

The exact causes of migraines and the underlying disease mechanisms have not yet been fully elucidated. Experts suspect that those affected have a genetic predisposition (disposition) – migraines often run in families. Based on this genetic tendency, migraine attacks are said to occur in interaction with various internal or external factors ( triggers ).

genetic predisposition

According to experts, migraine is generally based on a polygenetic predisposition : changes (mutations) in several genes increase the risk of migraine. Some of these genes are involved in regulating the neurological circuits in the brain.

Others are associated with the development of oxidative stress (increased concentration of aggressive, cell-damaging oxygen compounds). However, it has not yet been clarified exactly which biological mechanisms these gene mutations promote migraine.

Exception: Familial hemiplegic migraine

Familial hemiplegic migraine (FHM) is not based on genetic changes in several genes, but only in a single gene – it is therefore a monogenetic disease . Depending on the affected gene, four sub-types of FHM are distinguished:

  • FHM1 : The CACNA1A gene on chromosome 19 is affected by mutations.
  • FHM2 : Here the gene ATP1A2 on chromosome 1 is mutated.
  • FHM3 : It is based on mutations in the SCN1A gene on chromosome 2.
  • Then there are cases in which an FHM is obvious, but no mutations in the genes mentioned can be detected. Experts believe that they are probably based on mutations in gene loci that have not yet been identified.

The genes mentioned contain the instructions for components of various ion channels. These are large proteins in cell membranes that allow electrically charged particles (ions) to pass through the membrane.

Migraine triggers

Various migraine triggers can trigger a migraine attack with the appropriate genetic predisposition. The factors that “trigger” an attack in individual cases vary from person to person. Some examples:

Stress : A frequent migraine trigger is stress in the private or professional environment, eg conflicts in the family, at work or at school, changing jobs, high deadline pressure, being overwhelmed at work or at school.

Changes in the sleep-wake cycle : They can trigger a stress response in the body and thus become a migraine trigger. Affected are, for example, people with shift work or long-distance travelers. Even after a very restless night, the risk of a migraine attack is increased.

Sensory overload : If, for example, a mother works in the home office and at the same time looks after her child while the television is on and lunch is simmering on the stove, it can happen that her brain can no longer clearly separate these many impressions – it is stressed and overwhelmed, which can result in a migraine attack.

Weather/Changing Weather : There is no specific “migraine weather” that causes attacks in all patients. However, many migraine sufferers are sensitive to muggy, warm thunderstorm air, strong storms, hair dryers or very bright light on a cloudless day. For some, the cold triggers migraine attacks. Or climate change through travel (and related exertion) can cause migraines.

Certain foods and stimulants : Some people react to certain foods and stimulants (such as citrus fruits, bananas, cheese, chocolate, red wine, nicotine) with a migraine attack. Why is not yet clear. Tyramine is suspected in some products such as bananas or certain types of cheese. This is a breakdown product of protein building blocks ( amino acids ) which, among other things, stimulates the release of the messenger substance norepinephrine. This has a strong vasoconstrictive effect – also locally in the brain. This could be the reason for a migraine attack after eating foods containing tyramine.

Often, migraine attacks also set in when you have eaten too little (due to low blood sugar).

hormonal changes : Sex hormones have a strong influence on migraine attacks. In childhood, girls and boys are more or less equally affected by migraines. With puberty, however, the relationship shifts: women suffer from it much more often than men – often in connection with menstruation. For example, the drop in estrogen levels before menstruation begins triggers a migraine attack in some women. In addition, hormonal contraceptives (” the pill “) can also trigger migraines.

Migraine diary exposes trigger factors

To find out your personal trigger factors, you should keep a migraine diary. You should document the following things there:

  • Time of day, duration and strength of migraine attacks
  • any aura symptoms
  • any other side effects
  • drinks and food consumed before the onset of a migraine attack
  • physical exertion or stress before a migraine attack
  • other special events before a migraine attack (e.g. long flight, visit to the sauna)
  • timing and duration of menstruation
  • hormone intake
  • medication used to treat migraine attacks (active ingredient, dose, helpful or not)

These recordings can often be used to identify a pattern and personal migraine triggers – for example, if you get a migraine attack after a long, tiring day at work or after drinking alcohol.

There are also ready-made headache calendars for one month each, in which the information mentioned can be noted – available as a download from NetDoktor and from migraine/headache societies:

  • German Migraine and Headache Society: https://www.dmkg.de/patient/dmkg-headachecalendar
  • Swiss Headache Society: https://www.headache.ch/kopfwehkalender2
  • Austrian Headache Society: https://www.oeksg.at/index.php/infos/praxismaterial-kalender

Migraines: what’s going on in your head?

As mentioned, not only the causes of migraines, but also the underlying disease mechanisms are not yet known in detail. However, there are hypotheses or theories about what happens in your head when you have a migraine.

How does a migraine headache develop?

The currently leading theory for the development of a migraine assumes that the attack-like headache is the result of an activation of the so-called trigeminal vascular system. This is a network of nerves that connect to the blood vessels in the brain and are involved in pain processing. This is how you imagine the process:

  • Nociceptive nerve fibers (specialized in pain stimuli) in the meninges are activated – possibly by signals from the hypothalamus .
  • The activated nerve fibers release neuropeptides (= small proteins released by nerve cells as messenger substances). As a result, minor inflammations develop and the blood vessels in the meninges dilate. According to current knowledge, the messenger substance CGRP ( calcitonin gene-related peptide) plays a key role.
  • The pain signals are conducted along the branches of the trigeminal nerve (5th cranial nerve) from the meninges and large cerebral arteries to the so-called trigeminal ganglion (ganglion trigeminale). This “nerve node” is the division point of the trigeminal nerve – that is, the point where it splits into its three main branches (orbital, maxillary and mandibular nerves), which then branch out in turn.
  • From the trigeminal ganglion, signals travel to the brainstem and from there to the thalamus .
  • The signals then travel further to the cerebral cortex, among other things, through which the pain is then perceived.

How is the migraine aura formed?

With regard to the development of the migraine aura, many experts today assume a so-called “spreading depression” or “cortical spreading depression”:

It begins with a sustained excitation (depolarization) of nerve cells in one area of ​​the brain, which then spreads like a wave to other areas. There the nerve activity decreases – aura symptoms arise.

Migraines: investigations and diagnosis

If you suspect that you are suffering from migraines, your family doctor is the right person to talk to. They may refer you to a neurologist or a doctor who specializes in headaches.

It is particularly important to differentiate migraines from other types of headaches and other diseases, as these have to be treated differently. Symptoms similar to those of a migraine can occur with tension headaches and cluster headaches, for example . The doctor must also rule out other diseases as the cause of the pain attacks, such as tumors, inflammation or injuries in the head area.

Collection of medical history (anamnesis)

The doctor will first ask you about your symptoms and any previous illnesses in order to create your medical history (anamnesis). It is important that you describe your symptoms and their course as precisely as possible. Frequently asked questions by the doctor in the anamnesis interview are, for example:

  • How often do you have the pain attacks?
  • Where exactly do you feel the pain?
  • How does the pain feel (e.g. throbbing, throbbing, stabbing)?
  • Does physical exertion make the headache worse?
  • Does the pain occur in connection with certain events (lack of sleep, alcohol consumption, menstruation, etc.)?
  • Did other members of your family suffer or suffer from headaches regularly or more frequently?
  • Do you take medication, for example for headaches or for other reasons? If yes, which?

If you keep a migraine diary or a migraine calendar (see above) for a while before you go to the doctor, you can answer such questions particularly well. The doctor may also look at your notes himself.

You should answer the question about taking medication in particular precisely. Sometimes headaches are the result of taking medication (eg headache medicine) too often or for a long time. Doctors speak of a drug-induced headache .

Physical and neurological examination

Basically, the clarification of headache requires a physical examination. Among other things, the doctor will measure your blood pressure , check the mobility of your cervical spine and test whether pressing and tapping on the skullcap is painful.

It is also important to check the function of your nervous system. For this purpose, the doctor will test the sensitivity of your skin and your muscle strength and check whether your sense of balance is functioning normally. He also pays attention to any abnormalities in the eyes, for example a changed pupil reaction or a movement disorder of the eye muscles .

In the case of a migraine, such examinations are usually unremarkable outside of an acute attack. If not, there may be another cause of the headache.

Further investigations

The anamnesis and the physical-neurological examination are often sufficient to diagnose a migraine. Additional examinations are only necessary in certain cases – for example imaging of the head using magnetic resonance imaging (magnetic resonance imaging, MRI). For example, it may be indicated when:

  • a migraine occurs for the first time after the age of 40,
  • a previously effective therapy no longer works,
  • the headache character changes or
  • unusual symptoms appear.

Another imaging test that may be helpful in certain situations is computed tomography (CT) of the skull. For example, in the case of a suddenly occurring, severe headache with nausea, vomiting and photophobia, not only migraine can be considered as the cause, but possibly also a fresh subarachnoid hemorrhage (SAH). This form of cerebral hemorrhage can almost always be detected in a skull CT within the first few hours.

There are other tests that can be helpful in ambiguous cases, such as x-rays to visualize the cerebral vessels.

Migraines: treatment

Even if a migraine cannot be cured, the right treatment can significantly reduce the frequency and intensity of the pain attacks. In addition to measures in acute cases, it also includes preventive measures so that migraine attacks occur less frequently.

Measures in an emergency

A migraine attack can often be controlled with painkillers (analgesics), such as non-steroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (ASA) or ibuprofen . Patients should always discuss with their doctor which remedy is most suitable in which dosage in each individual case – especially when it comes to treating migraines during pregnancy or in children.

The treating physician may also recommend alternatives if a patient does not respond to the analgesics. In such cases, as in the case of (moderately) severe migraine attacks, other medications are chosen for acute therapy – so-called triptans (e.g. sumatriptan, zolmitriptan). If these alone do not work sufficiently, they may be combined with painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) such as ASA.

If the headache attack is accompanied by nausea and/or vomiting, so-called antiemetics (metoclopramide or domperidone) can help .

Apart from this acute drug therapy, retreating to a quiet, darkened room is also recommended in the event of a migraine attack.

preventive measures

Various preventive measures can – if used consistently – significantly reduce the number of migraine attacks and often also reduce their intensity. These include, for example:

  • Avoidance of personal trigger factors (e.g. stress)
  • endurance sports
  • relaxation procedures
  • biofeedback
  • Psychological pain therapy (e.g. pain management, stress management)
  • Possibly cognitive behavioral therapy
  • if necessary, medicinal migraine prophylaxis (e.g. beta blockers, valproic acid, topiramate)

If you suddenly have an unusual, very severe headache, if the symptoms persist despite standard measures, or if they keep coming back, you should definitely consult a doctor!

You can find out how to prevent migraines and how to treat them in acute cases in the text: What helps against migraines? .

Migraine: disease course and prognosis

Migraine is a chronic disease that can severely burden and limit those affected in their everyday lives. Some migraineurs are completely incapacitated for a few days during an acute attack.

With adequate treatment and the right lifestyle, however, the frequency and intensity of migraine attacks can be positively influenced. When taking painkillers or triptans, however, those affected should follow the doctor’s instructions exactly: If taken in excess, these drugs can themselves trigger headaches (drug-induced headaches).

A glimmer of hope for patients is the fact that the frequency of migraine attacks often decreases with age. In women, migraines can also improve with menopause. Basically, the course of a migraine is individually very different and not predictable.

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