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What we must know about Migraine


What we must know about Migraine

Definition: A migraine headache is a form of vascular headache. It is caused by enlargement of blood vessels (vasodilatation) of the brain. This enlargement stretches the nerves that coil around the vessels and causes the nerves to release chemicals.

The chemicals cause inflammation, pain, and further enlargement of the vessel (artery). The increasing enlargement of the arteries magnifies the pain.


Migraine attacks commonly activate the sympathetic nervous system in the body, and this activation causes many of the symptoms associated with migraine attacks, for example, the increased sympathetic nervous activity in the intestine causes nausea, vomiting, and   diarrhea.


Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed. The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.


The increased sympathetic activity  also decreases the circulation of blood and this leads to pallor of the skin as well as cold hands and feet. The increased sympathetic activity also contributes to the sensitivity to light and sound as well as blurred vision.


Diagnosis:

A diagnosis of migraine headache may be determined if a patient has at least five attacks that meet the following criteria:


1- Headache attacks that last four to 72 hours (untreated or unsuccessfully treated)

2- Headache that has two of the following characteristics:

  • Unilateral site.
  • Pulsating quality.
  • Moderate to severe intensity.
  • Aggravation by walking stairs or similar routine physical activity.

3- During headache, at least one of the following symptoms:

  • Nausea or vomiting (or both).
  • Photophobia and phonophobia.
  • No evidence of another related disease.


Treatment:

 

Medicines are used to:

1- Reduce the number of attacks:

  1. Antidepressants: Amitriptyline.
  2. Antihypertensives: Beta blockers (Propanolol) or calcium channel blockers (verapamil).
  3. Anticonvulsants: Valproic acid, phenobarbital, gabapentin, and topiramate.
  4. SSRIs: Venlafaxine.
  5. SNRIs: Duloxetine


2- Stopping an attack:

  1. O.T.C. Pain Medications: Aspirin, Ibuprofen, Acetaminophen.
  2. Triptans: Almotriptan, Frovatriptan, Sumatriptan, Zolmitriptan.
  3. Ergots: Dihydroergotamine.
  4. Isometheptene: Midrin.


3- Treating symptoms:

  1. Nausea: Prochlorperazine.
  2. Sedatives: such as Butalbital.
  3. Narcotic pain relievers: Meperidine.
  4. NSAIDs


Some Variants of Migraine Headaches:

 

  1. Vertebrobasilar Migraines: Are characterized by dysfunctions of the brainstem. The symptoms are fainting, vertigo, and double vision.
  2. Hemiplegic Migraines: Are characterized by paralysis or weakness of one side of the body or they are mimicking a stroke.
  3. Retinal or Ocular Migraines: Are rare attacks characterized by repeated instances of scotomata (blind spots) or blindness on one side, lasting less than an hour.


Promising New Medicines and Treatments for Migraine:

 

1- Almotriptan (axert, almogran): Has been approved recently by FDA to treat episodic migraine in adolescents, ages 12 to 17- years old . It is a selective serotonin receptor agonist and it helps in stopping the migrainous process by slowing the pain process, reducing the vascular changes that may come with a migraine attack and reducing inflammation.


2- Botox (onabotulinumtoxin): has now been approved for the treatment of chronic migraine (more than 14 days per month with headache lasting 4 hours a day or longer). It is given approximately every 12 weeks as multiple injections around the head and neck. The recommended dose is 155 units administered I.M, and injections should be divided across 7 specific head \ neck muscle areas.


3- Needle-free Sumatriptan Injection for Migraines:
In 2009, FDA, approved the first needle-free sumatriptan  injection. It is named sumavel and it provides migraine relief within 10 minutes for some patients, and it will be a welcomed treatment option, because it combines key benefits– the rapid efficacy of subcutaneous sumatriptan and a simple to use needle-free delivery system.


4- Migraine Abortive Telcagepant Performs Well in Trials:
In a study published in The Lancet, November 2008, telcagepant, a new oral antagonist of calcitonin gene-related peptide receptor, showed great promise as a new migraine abortive. In the latest phase III study, telcagepant proved safe and effective in treating migraines and caused fewer side effects than zomig. 1380 patients suffered from moderate to severe migraine were involved in this study at 81 sites in U.S and Europe. They were divided to groups and each one was  given 150 or 300 mg of telcagepant, 5mg of zomig, or placebo. Final results showed that telcagepant 300 mg was effective as an acute treatment for migraine with efficacy comparable to that of zolmitriptan 5 mg, but with fewer associated adverse effects. One potential benefit of this new drug is the absence of vasoconstriction, a liability of the triptans, which may allow for the safe administration of telcagepant in patients with migraine with cardiovascular disease.


5- A New Option for Aborting Migraine Attacks Without Medications:
Transcranial Magnetic Stimulation (TMS) was, and still is, showing great promise as a new abortive treatment for migraine with aura in clinical trials.


TMS is a non-invasive technique that applies a brief magnetic pulse to the scalp and  underlying cortex, changing the pattern of neuronal firing.


In a study that involved 200 patients in 18 migraine centers in U.S, about 40% of these patients were pain-free at two hours after treatment  with TMS, and absence of pain was sustained 24 to 48 hours after treatment without serious adverse events. These results could make TMS a promising acute treatment for some patients with migraine with aura. This study was published in The Lancet Neurology 2010.


Some news related to the subject:

 

1- Aspirin and antiemetic is a reasonable option for migraine headache and associated symptoms:
A single dose of 900 - 1000 mg aspirin can substantially reduce migraine headache pain within two hours for more than half of people who take it. It also reduces any associated nausea, vomiting and sensitivity to light or sound. Formulations of aspirin 900 mg together with 10 mg of metoclopramide are better than placebo at reducing symptoms of nausea and vomiting.
These were the finding of a Cochrane Systematic Review using data from 13 studies with 4222 participants and published in April, 2010.


2- First genetic link to common migraine is exposed:
A world-wide collaboration of researchers has identified the first ever genetic risk factor associated with common types of migraine. The researchers who looked at the genetic data of more than 50000 people found that patients with a particular DNA variant on chromosome 8 between two genes– PGCP and MTDH\AEG -1 have a significantly greater risk for developing migraine. The team also discovered a  potential explanation for this link. It appears that the associated DNA variant regulates levels of glutamate which transports messages between nerve cells in the brain. The results suggest that an accumulation of glutamate in nerve cells junctions in the brain may play a key role in the initiation of migraine attacks. Prevention of the build up of glutamate at the synapse may provide a promising target for novel therapeutics to ease the burden of the disease.


This study is published in the Aug. 29, 2010  issue of Nature Genetics.


3- I.V treatment of refractory migraines:
Doctors in Chicago Hospital have been working toward more effective treatments for refractory migraines (not responding to treatment) and have found several I.V     treatments that are extremely successful.


About 1100 patients were treated and doctors utilized these medications (either alone or in combinations):

  • Magnesium sulfate
  • Dexamethasone
  • Valproate
  • Droperidol
  • Metochlopramide
  • Dihydroergotamine
  • Promethazine
  • Lidocaine
  • Popofol
  • Tramadol
  • Levetiracetam
  • Ketamine


Results were measured by successful resolution of symptoms, defined by at least a 50% decrease in severity of the presenting migraine, or by return to regular activity. The results showed that the rate of success for this kind of treatment was 98%.


These information were presented at the 49th Annual Scientific Meeting of the American Headache Society in June 2007.


اضغط هنا للقراءة باللغة العربية

Prepared by: Scientific Section


Source :

mayo clinic
drugs.com
medicinenet.com
sciencedaily.com






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