Dr. Risa Ravitz | December 7, 2018

Let’s talk about the M-word

The surge of research on migraines in recent years is certainly making headway, yet there’s still a long way to get to the bottom of what causes the condition. If you or anyone you know has ever had a migraine, you’ll be well aware that it’s not “just a headache.” It’s a debilitating condition that often sends people to the ER.

Migraines are a significant cause of disability, missed work, and emergency room visits, and are much more common in the active working years (ages 15-55). In fact, they have led to an estimated lost productivity of $5.6 billion because of missed work and restricted activity. One third of patients require bed rest during a headache, and astonishingly, women are two to three times more likely to experience a migraine (with hormones likely playing a key role in this).

Doctors diagnose migraines clinically. They listen to a patient and base the diagnosis almost solely on their symptoms. There are no imaging or blood tests that can confirm the diagnosis of a migraine, though we do often get pictures of the brain and run other tests to make sure we’re not missing something more serious, like an aneurysm or a tumor.

The clinical criteria for a migraine includes:

A person having at least five painful attacks, lasting from four hours to three days. Symptoms can include any two out of these four qualities:

  1. Pulsing or throbbing in the head
  2. One-sided pain (unilateral headache)
  3. Moderate to severe pain in the head
  4. Pain is worsened by regular physical activity (e.g. walking up stairs, bending over)
  5. Nausea or vomiting and light or sound sensitivity

The person may also experience nausea or vomiting, and sensitivity to light or noise. Other factors, such as bleeding in the brain, doesn’t usually explain these migraines.

So, what does cause migraines?

There is, unfortunately, a lot of mystery around what causes migraines. What is clear is that migraines are often hereditary, and have a genetic component. There are also some theories that explain the pain pathways that occur during a migraine:

  • Activation of the peripheral trigeminal nerve branches. These branches directly innervate and affect the brain blood vessels and the dura mater (a membrane that envelops the arachnoid mater). Both the dura mater and the blood vessels can “feel” pain and cause it to be registered as a symptom in the brain. These nerve branches also send pain signals into the bloodstream, which make the head more sensitive to pain, and it takes time to clear out these particles that are involved in inflammation and excitation. An inflamed and excited brain is primed to feel pain and “wired” to set off a cascade of patterned events: a migraine.
  • Plasma extravasation. This process describes how the nerve receptors in the brain release more painful substances into the blood and circulation, thereby furthering the pain process.
  • Sensitization. This is the process by which nerves become more reactive and can feel pain from something that usually doesn’t cause pain. For example, a gentle touch of the scalp may be painful to a patient that has a migraine.
  • Imbalances in cerebral neurotransmitters such as Serotonin have been observed in brain pathophysiology experiments. This is the target of some of the medications for migraines. A brain experiencing a migraine is more excitable and affects a variety of functions in the body, including balance, wakefulness, sleep, reactions to normal stimuli, thinking speed, mood, and appetite.

Understandably, many patients that experience symptoms of migraines go to an emergency room or see their primary care doctor. Often they’ll get treatment that puts them to sleep, or are told to see a specialist — which can mean months-long wait times. However, consulting an online specialist like those at Modern Migraine MD is a much faster way for a specialized doctor to assess your symptoms, schedule follow ups, and get you on the right track for migraine care.

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