More than 23 million people suffer from migraine headache in the United States—more than have diabetes, epilepsy or asthma. Migraines are considered to be a vascular headache, and their signs and symptoms have been found and well-documented on papyrus as far back as ancient Egypt. About one in eight adults suffers from migraine; women are two to three times more likely to experience migraine headache than men. Migraine headache is most commonly found in the 25 to 34 year-old age group.
Migraine pain is usually described as a moderate to severe “throbbing” or “hammering” headache, typically on one side of the head. The pain will prevent activities of daily living and will increase with exertion. While the individual experiencing a tension headache is able to go up and down stairs, or perform household or office activities, the migraine sufferer will find the pain too debilitating to do so.
Patients experiencing a migraine attack, as it is often referred to, may complain of photophobia and sensitivity to sound. This is a typical complaint that may be used to differentiate it from a tension-type headache. Associated nausea and vomiting are also very common for the migraine sufferer.
Migraines may be classified as either “common” or “classic.” Common migraines do not have any warning signs or symptoms, while classic migraines do have a warning in the form of an aura. Patients may have migraines regularly on a weekly or monthly basis. For women, this may occur relative to their monthly menses cycle, triggered by fluctuating hormone levels. Ovulation, birth control pills and the birth control patch may also be contributing factors. Some victims, on the other hand, may go months or even years between attacks.
In general, a migraine headache may last from four to 72 hours. Most individuals with diagnosed migraine headaches understand their condition better than EMS providers do. It is important for us to question why this patient called 9-1-1 when they already know what the problem is. It is key to ask what is different about this headache. If the duration of the headache is longer than 72 hours, consider what is known as a complicated migraine. It would also be appropriate to ask the patient if there is anything else unusual about this particular headache, such as an aura.
The aura, which is caused by cerebral vasospasm and spreading cortical depression, is often described as visual disturbances or changes. It may come on over a period of 10 to 30 minutes. Patients may describe spots before their eyes, loss of peripheral vision or even complete loss of vision, as well as numbness or tingling of the limbs. Slurred speech or changes in speech patterns may also present as an aura. It is also common for patients to experience protracted vomiting, diarrhea and hypovolemia. It is easy to understand why a patient or family member would be alarmed, as these symptoms certainly say stroke until proven otherwise.
Patients who experience some neurological dysfunction with their headache are classified as having a complicated migraine. The area of the body affected by the dysfunction is related to the area of the brain where the headache is occurring. A vertebrobasilar migraine would be associated with symptoms affecting the brain stem. These patients would report vertigo or double vision and may be reported by a bystander or family member to have passed out or fainted. The symptoms from a complicated migraine may last only a few hours or up to several days.
Patients with a history of migraine headache are often prescribed triptans, or serotonin receptor agonists. The most commonly prescribed are sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), and zolmitriptan (Zomig). These are usually found in tablet form or as a nasal spray; however, they may also be prescribed as a self-administered injection.
Ergotamine derivatives and Midrin, which is a combination of the drugs isometheptene, acetaminophen and dichloralphenazone, are other medications used by migraine sufferers. Nonsteroidal anti-inflammatory drugs (NSAIDS), which are over-the-counter medications, may also help arrest a migraine in some individuals.
Patients who experience migraine headaches as frequently as three or more times per month are often prescribed medications to help reduce the number and intensity of the attacks. Most commonly prescribed are beta-blockers, such as propranolol (Inderal); antidepressants, including tricyclics like amitriptyline (Elavil) or fluoxetine (Prozac, Sarafem), paroxetine (Paxil), or sertraline (Zoloft); anticonvulsants like valproic acid (Depacon, Depakene) or divalproex sodium (Depakote), and calcium channel blockers such as verapamil.
The exact cause of migraine headache is not fully known; however, it is believed that blood flow in the brain is the key component. At the start of a migraine, blood vessels in certain parts of the brain constrict and reduce blood flow, at which time the symptoms described as an aura occur, along with visual disturbances, numbness, tingling and slurred speech. Minutes to hours later, the blood vessels dilate, blood flow increases, and the onset of migraine occurs. While the changes in blood vessels and blood flow are not completely understood, it is believed that certain triggers make it more likely for the migraine sufferer to experience an attack.
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