Migraines

Introduction

Migraine is a chronic neurological disease characterized by recurrent, often disabling headache attacks, accompanied by digestive symptoms and increased sensitivity to light and noise. It affects about 15 to 20% of women and 6 to 8% of men, peaking in frequency between ages 25 and 55. A migraine is not just a "headache": it is a complex disorder of neurovascular origin, with a major impact on quality of life. Fortunately, effective treatments exist to relieve attacks and reduce their frequency.

If you experience severe or unusual headaches, first contact your primary care physician. If they are unavailable, Docadom offers an emergency consultation by a home visit doctor: call 021 845 45 45 or use our app available on the App Store and Google Play.

Who is at risk?

Migraines mostly affect women (due to hormones), with a very common genetic predisposition (family history). The main triggers are: stress, lack or excess of sleep, hormonal fluctuations (menstruation, contraception, menopause), fasting, dehydration, certain foods (chocolate, cheeses, red wines, glutamate), alcohol, caffeine (excess or withdrawal), weather changes, bright or flashing lights, loud noises, strong odors, and intense physical exertion.

Migraine Symptoms

A migraine attack typically progresses through several phases: prodromes, sometimes aura, headache, and postdrome.

Key Symptoms

• Headaches typically throbbing, unilateral (though they can affect both sides), of moderate to severe intensity.

• Worsening with physical exertion and head movements.

• Nausea, vomiting.

• Photophobia (sensitivity to light) and phonophobia (sensitivity to noise).

• Duration: 4 to 72 hours without treatment.

• Migraine with aura (in 15-30% of patients): visual disturbances (scintillating scotomas, zigzag lines), sometimes numbness, speech difficulties, more rarely motor deficits. Precedes the headache by 10 to 60 minutes.

• Prodromes: fatigue, irritability, food cravings, yawning, neck stiffness, in the hours or days preceding the attack.

• Postdrome: fatigue, concentration difficulties, feeling drained after the attack.

When to seek emergency care?

An emergency consultation is necessary in the case of an atypical headache or warning signs:

• Sudden headache, "thunderclap," reaching peak intensity within seconds — call 144 (suspected subarachnoid hemorrhage).

• Headache associated with fever, a stiff neck, or altered consciousness (suspected meningitis or encephalitis).

• Persistent neurological deficit after the attack (paralysis, aphasia).

• First ever very intense attack or a noticeable change in the usual migraine pattern.

• Headache in a pregnant woman, following a head injury, or in a patient taking anticoagulants.

• Recent onset headaches in a patient over 50 years old (suspected Giant Cell Arteritis/Horton's disease, tumor).

• Migraine resistant to habitual treatments, status migrainosus (> 72 hours).

What to do before calling Docadom? Rest quietly in a dark room, take your rescue treatment if you have one, and contact your primary care physician first. If they are unreachable or if you need a home doctor outside of opening hours, call Docadom at 021 845 45 45 or place your request directly from our smartphone app (App Store and Google Play). In case of warning signs (sudden headache, neurological deficit, high fever), dial 144 without delay.

Causes and Pathophysiology

Migraine results from neuronal hyperexcitability with cortical spreading depression, followed by inflammation of the meningeal blood vessels and the release of peptides such as CGRP. This pathophysiology explains the effectiveness of modern treatments targeting CGRP.

Triggers to Identify

• Stress and sudden relaxation phases ("weekend migraine").

• Insufficient or excessive sleep.

• Menstruation and hormonal changes.

• Alcohol (especially red wine), caffeine.

• Fasting, hypoglycemia, dehydration.

• Foods: chocolate, aged cheeses, glutamate, certain additives.

• Sensory stimuli: flashing lights, strong smells, noise.

• Weather changes, altitude.

Diagnosing Migraine

The diagnosis is clinical, based on the IHS (International Headache Society) criteria. Imaging is only helpful in atypical cases.

Diagnostic Methods

• Detailed anamnesis: characteristics of the attacks, frequency, duration, associated signs, history, triggers.

• Normal neurological examination between attacks.

• Migraine diary: a key tool to objectively track frequency and triggers.

• Brain MRI: indicated only in case of atypical signs, changes in the usual pattern, or abnormal neurological exam.

• No specific biological marker for migraine.

Alternative Diagnostics

• Tension headaches: bilateral, band-like, non-throbbing pain, without associated signs.

• Cluster headaches: ultra-short, highly painful, peri-orbital attacks, with tearing of the eye.

• Acute sinusitis with frontal headache.

• Subarachnoid hemorrhage: sudden thunderclap headache.

• Meningitis, encephalitis.

• Intracranial hypertension, brain tumor.

• Horton's disease (Giant Cell Arteritis) in elderly subjects.

• Medication overuse headaches.

Migraine Treatment

Acute Treatment

• Simple painkillers: paracetamol, NSAIDs (ibuprofen, naproxen, ketoprofen) — to be taken at the very onset of the attack.

• Triptans (sumatriptan, zolmitriptan, rizatriptan, eletriptan, almotriptan, frovatriptan): highly effective for migraines, to be taken at the start of the headache phase. Contraindicated in cases of cardiovascular disease.

• Anti-nausea medication (metoclopramide, domperidone) in case of significant nausea.

• Gepants (rimegepant, ubrogepant): a new class, alternative to triptans.

• Avoid opioids (risk of drug overuse and chronic headache development).

Preventative Treatment

Indicated in cases of frequent attacks (≥ 8 days per month) or highly disabling ones:

• Beta-blockers (propranolol, metoprolol): first-line choice.

• Topiramate, amitriptyline, candesartan, flunarizine.

• Anti-CGRP (erenumab, fremanezumab, galcanezumab, eptinezumab): a new generation of injectable treatments, highly effective in severe cases.

• Botulinum toxin for chronic migraines.

• Duration of preventative treatment: at least 6 months, to be reassessed thereafter.

Associated Measures

• Rest in a quiet, dark place.

• Identification and avoidance of triggers.

• Healthy lifestyle: regular sleep, balanced diet, hydration, moderate physical activity.

• Relaxation techniques, stress management, meditation, biofeedback.

• Cognitive behavioral therapies for chronic migraine.

Migraine Prevention

• Consistent healthy lifestyle: stable sleep and meal times.

• Sufficient hydration.

• Regular, moderate physical activity.

• Stress management.

• Limiting stimulants (alcohol, caffeine, tobacco).

• Identification of personal trigger foods or stimuli.

• Keeping a migraine diary.

• Adapting contraception in case of hormonal triggers (to be discussed with the doctor).

• Avoiding medication overuse (no more than 10-15 acute treatment intakes per month).

Possible Complications

Migraines can evolve into chronic migraine (≥ 15 headache days per month for 3 months). Medication overuse headaches are a common complication: overusing painkillers sustains and worsens attacks. Status migrainosus (attack > 72 hours) requires specialized medical care. More rarely, a migraine-induced stroke can occur in cases of migraine with prolonged aura. On a psychosocial level, migraines are responsible for a major decline in quality of life, absenteeism, anxiety, and depression.

When to Contact a Doctor for a Migraine

Any disabling or treatment-resistant migraine warrants medical advice:

• First step: contact your primary care physician, who can adjust the acute treatment or prescribe preventative medication.

• If your doctor is unavailable (evenings, weekends, holidays), Docadom offers an emergency consultation with a home visit doctor. Call 021 845 45 45 or make a request via our mobile app, available for free on the App Store and Google Play.

• In case of warning signs (sudden lightning-strike headache, neurological deficit, high fever, stiff neck, recent head trauma), dial 144 immediately.

Conclusion: A Chronic Illness that Can Be Treated

Migraine is a common and disabling neurological condition that should not be overlooked. It is characterized by throbbing, often unilateral headache attacks, accompanied by nausea, photophobia, and phonophobia, which can lead to complications like chronic migraine, medication overuse, or an altered quality of life. Modern treatments — triptans, gepants, anti-CGRP inhibitors, botulinum toxin — have profoundly improved patient care. Identifying triggers and maintaining a consistent, healthy lifestyle are essential.

In case of a severe attack or if in doubt, contact your primary care physician first. If they are unavailable, Docadom provides an emergency doctor at home 7 days a week: call 021 845 45 45 or use our mobile app (App Store, Google Play) to request an emergency consultation.