Migraine: new approaches to treatment and long -term remission

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Migraine: new approaches to treatment and long -term remission

I. Understanding of migraines: deep review

Migraine is a complex neurological disease characterized by recurrent headaches, often pulsating, intense and one -sided. However, this is only a superficial description. A true understanding of migraines requires the consideration of its multifaceted aspects, including neurobiological mechanisms, a genetic predisposition, environmental factors and individual triggers.

A. Classification of migraines:

The International Headache Society (IHS) has developed a clear classification of migraines, which allows the clinicians to accurately diagnose various subtypes and develop individualized treatment plans.

  1. Migraine without aura: This is the most common type of migraine, characterized by a headache, which lasts from 4 to 72 hours and is accompanied by at least one of the following symptoms:

    • Pulsating nature of the headache
    • Unilateral localization of headache
    • Moderate or severe headache intensity
    • Deterioration in ordinary physical activity
    • Nausea and/or vomiting
    • Photophobia (sensitivity to light)
    • Phonophobia (sensitivity to sound)

  2. Migraine with aura: This type of migraine is characterized by transient neurological symptoms that precede or accompany headache. The aura usually lasts from 5 to 60 minutes and may include:

    • Visual symptoms (for example, flickering lights, zigzag lines, field fields)
    • Sensory symptoms (for example, tingling, numbness)
    • Speech disorders
    • Motor disorders (rarely)

    Migraine subtypes with aura:

    • A typical aura with a headache of migraine: The classic combination of aura and headache.
    • A typical aura without a headache of migraine (quiet migraine): The aura is present, but the headache is absent or weak.
    • Family hemiplegic migraine (FHM): A rare genetic subtype, characterized by an aura with motor weakness. Mutations in genes CACNA1A, ATP1A2 And SCN1A associated with FHM.
    • Sporadic hemiplegic migraine (ShM): Similar to FHM, but it arises sporadically, and is not inherited.
    • Basial type migraine (migraine with an aura of brain stem): The aura includes symptoms associated with the brain barrel, such as dizziness, double -gathering, dysarthria, ataxia and changes in the level of consciousness.
    • Migraine of the retina: The aura includes visual symptoms that occur in one eye.

  3. Chronic migraine: It is defined as headaches that occur 15 or more days a month for more than 3 months, while at least 8 days a month correspond to migraine criteria. The transformation of episodic migraine into chronic migraine is often associated with the excessive use of painkillers.

  4. Episodic migraine: Headaches that occur less than 15 days a month.

B. Pathophysiology of migraines: neurobiological chaos

Migraine pathophysiology is a complex and not fully studied process in which various brain structures and neurotransmitters are involved. Key mechanisms include:

  1. Trigemins system: This system, consisting of a trigeminal nerve and blood vessels of a durable brain shell, plays a central role in the occurrence of migraine. Activation of the trigeminal nerve leads to the release of neuropeptides, such as peptide associated with the calcitonin genome (CGRP), which causes the expansion of blood vessels of the durable cerebral membrane and neurogenic inflammation.

  2. Crimely spreading depression (CSD): This is a wave of neurons depolarization, which spreads through the cerebral cortex and can be a trigger of aura. CSD also activates the trigeminal nervous system and releases inflammatory mediators.

  3. CGRP role: CGRP is considered a key mediator of migraine. The increased CGRP levels are detected during migraine attacks, and CGRP blockade effectively reduces headache.

  4. The involvement of the thalamus and hypothalamus: Talamus plays a role in the transmission of pain signals, and the hypothalamus regulates various functions, such as sleep, appetite and hormonal balance. Dysfunction in these areas can contribute to migraine.

  5. Neurotransmitter: Various neurotransmitters, such as serotonin, dopamine and glutamate, play a role in migraine pathophysiology. For example, a decrease in serotonin levels can contribute to the development of migraine.

C. Genetics of migraines:

Migraine has a strong genetic predisposition. People who have relatives with migraine have a higher risk of developing this disease.

  1. Family hemiplegic migraine (FHM): As mentioned earlier, FHM is a genetic subtype of migraines with an aura associated with mutations in genes CACNA1A, ATP1A2 And SCN1A.

  2. Polygenic predisposition: Most migraines are probably the result of a complex interaction of many genes and environmental factors. Studies based on the genomic search for associations (GWAS) have revealed many genetic options associated with migraine, but none of them explains most of the risk.

D. Environmental factors and triggers:

Many environmental and lifestyle factors can provoke migraine attacks. Identification and avoidance of these triggers is an important part of migraine management.

  1. Food triggers: Some products and drinks are often associated with migraine, although individual susceptibility varies. Common food triggers include:

    • Sustained cheeses
    • Processed meat
    • Chocolate
    • Alcohol (especially red wine)
    • Sodium glutamate (MSG)
    • Artificial sweeteners

  2. Ecological triggers:

    • Weather changes (for example, atmospheric pressure changes, storm)
    • Bright or flickering light
    • Strong smells (for example, perfumes, chemicals)
    • High height

  3. Triggers lifestyle:

    • Stress
    • Lack of sleep or excess sleep
    • Irregular nutrition
    • Dehydration
    • Excessive physical activity
    • Passing for eating

  4. Hormonal changes: Hormonal vibrations associated with the menstrual cycle, pregnancy and menopause can be migraine triggers in women.

II. Migraine diagnosis: accuracy and differential diagnosis

The exact diagnosis of migraine is crucial for the development of an effective treatment plan. The diagnosis is based on the patient’s history, physical and neurological examination.

A. History:

A detailed history of the patient is the most important part of the diagnosis of migraine. The doctor must collect information about:

  1. Characteristics of the headache: The frequency, duration, intensity, localization and nature of the headache.
  2. Concomitant symptoms: Nausea, vomiting, photophobia, phonophobia, aura.
  3. Triggers: Factors that provoke migraine attacks.
  4. Family history: The presence of migraine in relatives.
  5. Medical history: Other diseases that can contribute to headaches.
  6. Drugs used: Including over -the -counter and prescription drugs.

B. Physical and neurological examination:

Physical and neurological examination is usually normal for migraine. However, they are necessary to exclude other causes of headache. A neurological examination should include an assessment:

  1. Visual function: Visual acuity, vision fields, eye movements.
  2. Cranial nerves: Smell, vision, eye movements, face sensitivity, hearing, swallowing, voice.
  3. Motor function: Strength, coordination, reflexes.
  4. Sensitive function: Touching, pain, temperature, vibration.
  5. Coordination and balance.
  6. Mental status.

C. Diagnostic criteria IHS:

The use of IHS diagnostic criteria helps to provide a standardized and accurate diagnosis of migraine. Criteria for migraine without aura and migraine with aura are described above.

D. The differential diagnosis:

It is important to exclude other causes of headache, especially in cases where headache has unusual characteristics or is accompanied by anxious symptoms. The differential diagnosis of migraine includes:

  1. Headache of tension: Typically, a dumb, pressing headache is characterized, which does not intensify with physical activity and is not accompanied by nausea or vomiting.
  2. Closter headache: It is characterized by intensive, unilateral headache, which occurs in clusters of periods separated by periods of remission. It is usually accompanied by symptoms from one eye, such as lacrimation and nasal congestion.
  3. Sinus headache: Headache associated with sinus infection.
  4. Intracranial lesions: Tumors, aneurysms, arteriovenous malformations.
  5. Meningitis and encephalitis: Infections of the brain and brain membranes.
  6. Idiopathic intracranial hypertension (brain pseudo -pouchol): Increased pressure of the spinal fluid in the absence of a tumor.
  7. Temporal arteritis: Inflammation of the temporal artery, which can cause headache, skin soreness and visual impairment.
  8. Medicinal Abusus headache: Headache caused by excessive use of painkillers.

E. Instrumental research methods:

In most cases, migraines are not required instrumental research methods. However, they can be necessary to exclude other causes of headache, especially in the presence of alarming symptoms, such as:

  1. Sudden beginning of headache
  2. Progressive deterioration of headache
  3. Headache, accompanied by fever, the rigidity of the occipital muscles or neurological deficits
  4. Headache arising after head injury
  5. Headache in a patient with cancer or HIV infection

Instrumental research methods may include:

  1. Computed tomography (CT) of the brain: To exclude hemorrhage, tumor or other structural anomalies.
  2. Magnetic resonance tomography (MRI) of the brain: For more detailed visualization of the brain and exclusion of a tumor, aneurysm, arteriovenous malformation or a demyelinizing disease.
  3. Lumbal puncture (spinal puncture): To exclude meningitis or subarachnoid hemorrhage.

III. Acute to stop the treatment of migraines: pain relief

Acute stopping treatment is aimed at facilitating headaches and related symptoms during migraine attacks.

A. Overcomplex painkillers:

  1. Nonsteroidal anti -inflammatory drugs (NSAIDs): Ibuprofen, steady, diclofenac. NSAIDs are effective for the treatment of light and moderate migraine attacks. It is important to observe the recommended dose and duration of admission in order to avoid side effects.
  2. Acetaminophen (paracetamol): It can be effective for the treatment of light migraine attacks, especially in combination with other drugs.
  3. Combined drugs: Aspirin, acetaminophene and caffeine (for example, Excedrin Migraine) can be effective for the treatment of moderate migraine attacks.

B. Destructured drugs:

  1. TRIPTA: Selective agonists of serotonin 5-HT1B/1D receptors. Triptans are one of the most effective drugs for the treatment of migraine attacks. They narrow the blood vessels of the brain and reduce the release of neuropeptides, such as CGRP. Examples of triptans include collapse, risatriciptan, intrigriptan, gyripriptan, ethletriptan and froverypantan. Triptans are available in various forms, including tablets, nasal sprays and injections.
  2. Dihydroergotamin (DGE): Ergotamine alkaloid, which also narrows the blood vessels of the brain. DGE can be effective for the treatment of migraine attacks, especially those that do not respond to tripatans. DGE is available in the form of injections, nasal sprays and tablets.
  3. Lazmiditan: Selective agonist of serotonin 5-HT1F receptors. Lazmiditan does not cause narrowing of blood vessels and may be a safe option for patients with cardiovascular diseases.
  4. Hypers (CGRP Antagonists): Rimegepant and Kurigorgepant are drugs that block CGRP receptors. They can be effective for treating migraine attacks and have less side effects than triptans. Both drugs are also approved for the preventive treatment of migraine.
  5. Opioids and barbiturates: These drugs are not recommended for routine treatment of migraines due to the risk of dependence and drug abusus headaches. They can be used in rare cases when other drugs are ineffective, and only under the strict supervision of a doctor.
  6. Anti -rate funds: Metoclopramide and coolroperazin can be used to treat nausea and vomiting associated with migraine. They can also improve the absorption of other drugs.

C. Strategies of acute buying treatment:

  1. Early treatment: Treatment should begin as early as possible during an attack of migraine, when headache is not yet very severe.
  2. Stratification of treatment: The choice of the drug should be based on the severity of a migraine attack and the presence of concomitant diseases.
  3. Individualized approach: Different drugs can be effective for different patients. It is necessary to find the most effective drug and the optimal dose for each patient.
  4. Prevention of drug abusus headache: Limit the use of painkillers up to 10 days a month.
  5. Using combined therapy: The combination of various drugs can be more effective than using one drug.

IV. Preventive treatment of migraines: reduction of frequency and intensity

Preventive treatment is aimed at reducing the frequency, intensity and duration of migraine attacks. It is recommended for patients in whom migraine occurs often or significantly affects the quality of life.

A. Drugs for preventive treatment:

  1. Beta blockers: Propranolol, metoprolol, Atenolol. Beta blockers reduce the frequency of migraines, but the mechanism of their action during migraine is not completely understandable. They can reduce blood pressure and reduce the reaction to stress.
  2. Antidepressants: Amititriptylin, NORTRIPTILIN, WENLAFAXIN. Tricyclic antidepressants (amitriptylin, Nectriptylin) are effective for the prevention of migraine, probably by increasing the level of serotonin and norepinephrine in the brain. Venlafaxin is an inhibitor of the reverse capture of serotonin and norepinephrine (SioZSN), which can also be effective for the prevention of migraine.
  3. Anticonvulsants: Valproic acid, topiramate. Valproic acid and topiramate reduce the frequency of migraines, probably by stabilizing neuronal excitability. Topiramate can also block glutamate receptors.
  4. Calcium channel blockers: Flunarizin. Flunarizine reduces the migraine frequency, blocking calcium channels in neurons.
  5. Shebotulinumoxin (Botox): Botox is approved for the preventive treatment of chronic migraine. It is introduced into the muscles of the head and neck and blocks the release of neurotransmitters that can cause migraine.
  6. Monoclonal antibodies to CGRP or its receptor: Erenumab, Freanzumab, Galkanzumab and Eptinezumab. These drugs block CGRP or its receptor and effectively reduce the migraine frequency. They are introduced subcutaneously or intravenously.
  7. Hypers (CGRP Antagonists): Rimegepant and atrogepant are also approved for the preventive treatment of episodic migraine.

B. The choice of the drug for prevention:

The choice of the drug for preventive treatment should be based on:

  1. Frequency and severity of migraines
  2. Concomitant diseases
  3. Potential side effects
  4. Patient preferences

For example, beta-blockers can be a good option for patients with migraine and hypertension or anxiety. Amitriptyline can be a good option for patients with migraine and depression or insomnia. Topiramate can be a good option for patients with migraine and epilepsy or obesity.

C. Preventive treatment strategies:

  1. Start with a low dose and gradually increase it to an effective dose.
  2. Give the drug enough time to act (several weeks or months).
  3. Be patient and persistent. It may be necessary to try several different drugs to find the most effective.
  4. Combine medicines with lifestyle changes.
  5. Regularly visit a doctor to control the effectiveness and side effects.

V. Neuracious methods of treatment of migraines: integrated approach

Neracular methods of treatment can play an important role in managing migraine, especially in combination with drug therapy.

A. Changes in lifestyle:

  1. Identification and avoidance of triggers: Keep a headache diary to identify factors that provoke migraine attacks. Avoid famous triggers.
  2. Regular sleep: Try to go to bed and wake up at the same time every day, even on weekends.
  3. Regular nutrition: Do not skip food meals and eat a healthy, balanced diet.
  4. Sufficient fluid consumption: Drink enough water during the day to avoid dehydration.
  5. Regular physical exercises: Regular moderate physical exercises can reduce the frequency of migraines.
  6. Stress management: Practice stress management methods such as meditation, yoga or tai-chi.

B. Biological feedback (biofidBek):

BiofidBek is a method that allows patients to learn how to control their physiological functions, such as heart rhythm, arterial pressure and muscle voltage. BiofidBek can be effective for reducing the frequency and intensity of migraine.

C. Cognitive-behavioral therapy (KPT):

KPT is a type of psychotherapy that helps patients change negative thoughts and behavior that can contribute to migraine. KPT can be effective for managing stress, anxiety and depression, which are often associated with migraine.

D. Acupuncture:

Acupuncture is a method of traditional Chinese medicine, which includes the introduction of thin needles into certain points on the body. Some studies show that acupuncture can be effective for reducing the migraine frequency.

E. Massage:

Massage can help reduce muscle tension and stress that can contribute to migraine.

F. additives:

Some additives can be useful for migraine prevention:

  1. Riboflavin (vitamin B2): High doses of riboflavin can reduce the frequency of migraine.
  2. Magnesium: Magnesium additives can be useful for patients with magnesium deficiency.
  3. Coenzim q10: Coenzyme Q10 can reduce the migraine frequency.
  4. Melatonin: Melatonin can improve sleep and reduce the migraine frequency.
  5. Beetroot (FEVERFEW): Some studies show that the drill can reduce the migraine frequency, but additional studies are needed.

VI. Migraine in special groups of the population:

A. Migraine in women:

Migraine is more common in women than in men, and hormonal changes play an important role in the occurrence of migraine in women.

  1. Menstrual migraine: Migraine that occurs in connection with the menstrual cycle. There are two forms of menstrual migraines:

    • Pure menstrual migraine: Migraine occurs only during menstruation.
    • Migraine associated with menstruation: Migraine more often occurs during menstruation, but can occur in other periods of the cycle.

  2. Migraine during pregnancy: Migraine can improve during pregnancy, especially in the second and third trimesters. However, in some women, migraine may worsen. It is important to consult a doctor about safe treatment for migraine during pregnancy.

  3. Migraine during menopause: Migraine can worsen or improve during menopause. Hormonal replacement therapy can affect migraine.

B. Migraine in children and adolescents:

Migraine is also found in children and adolescents. Symptoms of migraines in children may differ from the symptoms of migraine in adults. For example, in children there is often a bilateral headache and abdominal migraine (headache, accompanied by abdominal pain).

C. Migraine in the elderly:

Migraine can persist or arise for the first time in the elderly. It is important to exclude other causes of headaches in older people, such as temporal arteritis and intracranial lesions.

VII. Future directions in the treatment of migraines:

Migraine studies are constantly developing, and new approaches to treatment appear.

A. New drugs:

  1. CGRP new generation antagonists: New CGRP antagonists with an improved safety and efficiency profile are being developed.
  2. PACAP inhibitors (peptide that activates the pituitary adenilatcyclase): Pacap is a neuropeptide that also plays a role in the pathophysiology of migraine. Drugs that block PACAP are developed.
  3. Preparations affecting glutamate receptors: Glutamate is an exciting neurotransmitter that plays a role in the pathophysiology of migraine. Drugs that affect glutamate receptors are developed.

B. non -invasive neuromodulation:

  1. Transcranial magnetic stimulation (TMS): TMS is a method that uses magnetic impulses to stimulate or suppress the activity of certain areas of the brain. TMS can be effective for the treatment of migraine attacks and for the prevention of migraine.
  2. Transcranial stimulation direct current (TSPT): TSPT is a method that uses a weak electric current to stimulate or suppress the activity of certain areas of the brain. TSPT can be effective for treating migraine attacks.

C. Gene therapy:

General therapy may be a promising approach to the treatment of migraine in the future.

VIII. Life with migraine: management and support

Life with migraine can be difficult, but there are strategies that will help patients manage their condition and improve the quality of life.

A. Self -help:

  1. Keep a headache diary: Write down the characteristics of the headache, triggers, the drugs used and their effectiveness.
  2. Follow the daily routine: Regular sleep, nutrition and physical exercises.
  3. Manage stress: Practice relaxation methods.
  4. Join the support group: Communicate with other people living with migraine.

B. Support for family and friends:

Explain to your loved ones what migraine is and how it affects your life. Ask them about support and understanding.

C. Work and migraine:

Discuss your migraine with the employer. Try to create conditions at the workplace that will help you manage your condition.

D. Resources:

  1. National Headache Foundation: Provides information and resources for people with headaches.
  2. American Migraine Foundation. Provides information and resources for people with migraine.
  3. International Society of the Headache (International Headache Society): Provides information for healthcare professionals.

IX. Alternative methods for treating migraines: what works and what is not

In recent years, many alternative methods for the treatment of migraines have appeared, which are often advanced as “natural” or “non -lemonal” solutions. It is important to understand which of these methods have scientific support and which are not.

A. Methods with some scientific support:

  1. Iglowerie (acupuncture): As already mentioned, several studies have shown that acupuncture can be effective for reducing the migraine frequency. The mechanism of its action is not completely clear, but it is assumed that it can affect the release of neurotransmitters and the modulation of the pain routes. It is important to contact a qualified acupuncture specialist.

  2. Biological feedback (biofidBEC): BiofidBek allows patients to learn how to control physiological reactions, such as muscle voltage and heart rate, which can contribute to the development of migraines. Several studies have shown that biofidback can be effective for reducing the frequency and intensity of migraine.

  3. Meditation of awareness: Meditation of awareness includes concentration at the present moment without judgment. It can help reduce stress, which is a famous migraine trigger. Some studies have shown that awareness meditation can be useful for reducing the frequency and intensity of headaches.

  4. Yoga: Yoga combines physical poses, breathing exercises and meditation. It can help reduce stress, improve flexibility and reduce muscle tension, which can be useful for people with migraine.

  5. Massage: Regular massage can help relieve muscle tension in the neck and shoulders, which can contribute to the development of headaches.

  6. Plant preparations and additives (with caution and consultation of a doctor): Some plant drugs and additives, such as drill, riboflavin, magnesium and coenzyme Q10, received some support in research. However, it is important to remember that these drugs can have side effects and interact with other drugs. Never start taking any new additives without prior consultation with a doctor. It is important to choose high -quality products from reliable manufacturers.

B. Methods with insufficient or conflicting scientific support:

  1. Hiropractic: Hiropractic involves manipulation with the spine. Although some patients report the relief of headaches after chiropractical procedures, scientific data confirming its effectiveness for the treatment of migraine are limited. In addition, manipulations with the cervical spine can be associated with the risk of serious complications, such as stroke.

  2. Homeopathy: Homeopathy is an alternative medicine system based on the principle of “like this.” Homeopathic agents are greatly diluted and contain minimal concentrations of the source. There is no convincing scientific evidence confirming the effectiveness of homeopathy for the treatment of any diseases, including migraine.

  3. Craniosacral therapy: Craniosacral therapy involves soft manipulations with the bones of the skull and sacrum. It is claimed that it helps to improve the flow of cerebrospinal fluid and relieve voltage. However, there is no convincing scientific evidence confirming the effectiveness of craniosacral therapy for the treatment of migraine.

  4. Special diets (for example, gluten, adhesive): Although food triggers can play a role in the development of migraines, there are no general recommendations for the use of special diets for all patients with migraine. The exclusion of certain products from the diet should be carried out only under the guidance of a doctor or nutritionist, especially if you have other diseases or allergies.

  5. Detoxes and enemas: There is no scientific evidence confirming that detox diets and enemas are effective for the treatment of migraine. Moreover, they can be dangerous to health.

Important warnings:

  • Always consult your doctor before any new treatment, even an alternative. It is important to make sure that treatment is safe for you and does not interact with other drugs that you take.
  • Do not rely solely on alternative methods of treatment and neglect traditional medicine. Alternative methods can be useful as an addition to traditional treatment, but they should not replace it.
  • ** Be careful with the promises of “miraculous healing.”

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