Table of Contents
Migraine is one of the most common forms of headache. Despite the fact that migraine does not belong to fatal diseases and it rarely has serious complications, it largely reduces the quality of life of patients. It has great economic and medical-social significance. Striking people of young working age, migraine headaches lead to a considerably decrease in efficiency and worse work in connection with severe attacks. It limits social activity and violates the joy of family communication and total satisfaction of life.
Different diseases and disorders that largely interfere with social adaptation and quality of life in general can develop migraine. This fact explains the growing interest in the problem of migraine comorbidity. The study of multipurpose approach to the treatment, which can affect concomitant diseases linked together by a single pathogenetic mechanism of migraine, is very urgent in modern conditions. Thus, due to the fact that migraine has a problem of comorbidity, this disease needs an integrated multipurpose approach to study and treatment.
Diagnosis and Treatment
Migraine refers to the most frequent forms of primary headache. WHO included migraine in the list of 19 diseases that hinder the social adaptation of patients to the grates extent. The prevalence of women’s migraine varies from 11 to 25%, men’s - from 4 to 10%. It usually appears at the age of 10 to 20 years. At the age of 35-45 years, the frequency and the intensity of migraine attacks reach a maximum, after 55-60 years in most patients migraine ceases. Migraine has a hereditary character in 60-70% cases. Since the problem of migraine has significant relevance, the current information including the diagnosis and the treatment of the migraine headaches should be synthesized.
Similarly to other primary headaches, the diagnosis of migraine is based entirely on the patient's complaints and the history and does not require the use of additional research methods. Careful anamnesis is the basis of the correct diagnosis of migraine. Making a diagnosis, a doctor should rely on the diagnostic criteria of the International Classification of Headache. In 10-15% of cases, the attack of headaches is preceded by migraine aura, which is a complex of neurological symptoms that occur immediately before the onset of migraine headache or in its debut (Malone, Bhowmick, &Wachholtz, 2015). Thus, migraine with and without aura are identified in the medical practice. The aura develops within 5-20 minutes, remains no more than 60 minutes, and completely disappears with the onset of the painful phase (Malone, et al., 2015). Most patients have migraine attacks without an aura and never, or very rarely, experience this symptom. At the same time, patients suffering migraine with aura can experience attacks not preceded by this condition. In rare cases, a migraine attack does not occur after aura (aura without a headache).
The visual, or classical, aura is the most common (Malone, et al., 2015). It is manifested by numerous visual phenomena: photopsy, flies, a shimmering scotoma, or a zigzag-like glowing line fortification spectrum (Malone, et al., 2015). Weakness or paresthesia in the limbs (hemiparesthetic aura), transient speech disorders, distortion of the perception of the size and shape of objects can disturb the patient less often (Penas, Chaitow & Schoenen, 2013). If it occurs more than 15 times a month during more than 3 months, it becomes chronic (Scher, Bigal & Lipton, 2005). Two main factors play a role in the transformation of episodic migraine into a chronic form. They are the abuse of anesthetics and depression, which usually occurs in the condition of a chronic psychotraumatic situation (Malone, et al., 2015).
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In most cases, objective examination does not reveal organic neurologic symptoms (they are noted in no more than 3% of cases). Besides, almost all patients with migraine have high tension and soreness in one or more pericranial muscles, which is so-called Myofascial syndrome. Often, an objective examination of the patient with migraine reveals signs of autonomic dysfunction, namely palmar hyperhidrosis, discoloration of the fingers, and increased neuromuscular excitability. As already mentioned, additional methods of examination of migraines are not informative. They might be applied only with atypical flow and suspicion of the symptomatic nature of migraine.
Traditional treatment of migraine headaches includes relief of an already developed attack and treatment aimed at preventing attacks (Scher, et al., 2005). The key to successful cure of migraine is also the anticipation and treatment of comorbid disorders (Lal & Singla, 2010). It can prevent the progression of (chronic) migraine and improve the quality of patients’ life (Scher, et al., 2005).
Drug therapy for ceasing an attack should be prescribed depending on the intensity of the migraine attack. If the patient has mild or moderate attacks of duration not more than one day, simple or combined analgesics, including non-steroidal anti-inflammatory drugs (orally or in the form of suppositories) such as paracetamol, naproxen, ibuprofen, acetylsalicylic acid, ketorolac, as well as codeine-containing drugs (solpadein, sedalgin) have to be used. Prescribing drug therapy, a doctor should warn patients about the possible risk of strong headache (with excessive use of pain medication) and addiction (with the use of codeine-containing drugs). This risk is especially high for patients with frequent attacks (10 or more per month) (Lal & Singla, 2010).
It is important to note that during the attack of migraine many patients experience atony of the stomach and intestines simultaneously. It means that the absorption of drugs taken inside is violated (Lal & Singla, 2010). In this regard, especially in the presence of nausea and vomiting, a doctor should prescribe antiemetic such as metoclopramide or domperidone, which can stimulate peristalsis and improve absorption concurrently. A patient should take such drugs 30 minutes before analgesics (Malone, et al., 2015).
With a high intensity of pain and a considerable duration of attacks (24-48 hours or more), specific therapy is indicated (Malone, et al., 2015). The most effective means that are able to relieve the migraine pain after 20-30 minutes are tryptans - agonists of serotonin receptors: sumatriptan (sumamigren, amigrenin), zolmitriptan (Zomig), and eletriptan (Relpax) (Malone, et al., 2015). Interacting with receptors located both in the central nervous system and at the periphery, these drugs block the release of painful neuropeptides, selectively narrowing the dilated vessels of the dura mater and terminate the migraine attack. The early effectiveness of therapy with triptans is much higher (within an hour after the onset of a migraine attack). The early administration of triptans helps to avoid further development of the attack, reduce the duration of headache up to two hours, prevent the return of headache and, most importantly, quickly restore the quality of life of patients (Villalоn, Centuriоn, Valdivia, Vries & Saxena, 2003).
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It should be mentioned that triptans has to be used only for relief of migraine headache. They are ineffective in other varieties of cephalgia (Villalоn, et al., 2003). Therefore, it is extremely important to distinguish a migraine attack from other types of cephalgia. In general, the triptans are well-tolerated by patients, and contraindications to their prescription (eg, coronary heart disease, malignant hypertension, etc.) are almost not found in patients with migraine. Nevertheless, due to the presence of certain contraindications and side effects, before starting the administration of tryptanes, the patient should carefully read the instructions for using the drug.
However, migraine has a serious problem of comorbidity, which is the presence of several chronic diseases linked together by a single pathogenetic mechanism. Patients with migraine have polymorphism of the angiotensin converting enzyme (ACE) deletion gene (Villalоn, et al., 2003). It is closely associated with hypercoagulable conditions, thrombophilia, vasomotor disorders, decreased bradykinin functional activity, and increased vascular smooth muscle tone. Migraine is an integral component in the structure of some genetically determined syndromes, such as Melas, Cadasil (Villalоn, et al., 2003). Since the late 1980s, a large number of studies proved the high comorbidity of migraine and stroke. In a large population study, the Oxfordshire Community Srtoke Project found that, in general, the incidence of migraine infarction is 3.36 cases per 100 thousand people every year (Villalоn, et al., 2003). Importantly, the elimination of modifiable risk factors for patients with migraine does not reduce the relative risks of trauma in this group of stroke. In addition to the above, migraine has comorbidity with a number of other diseases such as epilepsy, restless legs syndrome, bronchial asthma, etc. Therefore, it requires an integrated approach to study and treatment.
Current Literature Review
Most of the researches studying the quality of life of migraine sufferers are aimed at assessing the degree of violation of individual aspects of the patients' lives (social, professional, family). Malone, et al. (2015) investigated treatment patterns, stress experience, and impact of migraine on working and social activity. Scher et al. (2005) researched comorbidity more deeply than coincidental association of separate conditions. They investigated comorbidity in wider directions connected with fundamental mechanisms of migraine such as congenital heart defects, coronary heart disease, etc (Scher, et al., 2005). At the same time, Vivek Lal and Monika Singla systematized comorbid factors within 4 groups involving psychiatric, neurologic, cardiovascular, and miscellaneous disorders (Lal & Singla, 2010). Still, insufficient attention was created by the identification of comorbid factors that affect the quality of life of migraine patients, in particular, the correlation of clinical and mental characteristics. Comprehensive approaches to the problem of improving the life quality have not been widely considered.
Villalon, et al. (2003) widely researched pharmacology, pathophysiology, treatment, and future trends of migraine. They showed big steps in understanding new approaches to treatment and action of antimigraine drugs (Villalоn, et al., 2003). Penas, et al. (2013) also concentrated on broader therapeutic approach to treatment. They show that complex therapy and precautionary seizures not only affect the treatment of migraine in the area of prevention but also improve comorbid factors. However, this issue was not studied sufficiently. The currently accepted list of migraine-associated diseases, which by virtue of their hypothetically common pathogenetic nature of migraine can be referred to as comorbid, is certainly incomplete. In addition, only epidemiological aspects of migraine comorbidity were mainly studied. At the same time, the importance of comorbid disorders for the severity of migraine flow as well as their impact on the quality of life and regular preventive measures in the inter-attack period have been discussed superficially. Meanwhile, it seems obvious that the quality of life is determined not only by the severity of migraine attacks but also by the condition of the patient outside the seizures.
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Pharmacological and Nonpharmacological Treatment of Migraine
Treatment of migraine includes both the traditional pharmacological and non-pharmacological approaches. The both types are effective in combining. The pharmacology of migraine implies a group of non-narcotic analgesics and narcotic analgesics. Paracetamol, metamizole, aspirin, ketoprofen, naproxen, diclofenac and ibuprofen are effective as non-narcotic analgesics, while codeine and butorphanol are narcotic. Their use is justified by their analgesic effects they have (Villalоn, et al., 2003). Moreover, selective antagonists, such as scataptan, zolmitriptan and naratriptan, and nonselective antagonists, like ergotamine and dihydroergotymine, have significant advantages in using to narrow excessively dilated vessels of the brain and the meninges and prevent neurogenic and aseptic inflammation. The pharmacology of antiemetics metoclopramide and domperidone can suppress nausea and vomiting, and combined drugs (migrenol, solpadine, sedalgin) have an analgesic and sedative effects simultaneously along with narrowing the vessels (Lal & Singla, 2010).
Though pharmacology can be sufficient and active during the attack, the non-pharmacological approach impacts on the life of the patient between seizures. Such tools of this approach as diet, identification and elimination of triggers, physical exercises and relaxation in an experienced psychotherapist as well as lesser methods like biological feedback and acupuncture can improve the quality of treatment. Consequently, combining these approaches is most effective.
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Methodical Approaches to the Treatment of a Migraine Attack
The correct choice of the treatment method is a difficult task, the solution of which depends on the nature of the migraine attack, concomitant diseases, and past experience with the use of drugs. There are two main methodical approaches for the treatment of migraine attack: staggered and stratified (Malone, et al., 2015). Staggered approach assumes that it is impossible to establish the features of the disease during the primary examination of the patient that determine the differences in treatment (Lal & Singla, 2010). Therefore, a doctor begins treatment with the first stage of the therapeutic pyramid, which includes the cheapest medication for migraine, usually a non-narcotic analgesic (paracetamol, aspirin). If the trial treatment was ineffective, the patient rises to the next step of the pyramid until an effective treatment will be found (Malone, et al., 2015). In accordance with one of the variants of the staggered approach, treatment begins at the level that corresponds to the results of therapy in the past. For example, if simple analgesics did not help the patient previously, it is possible to start treatment with a combination of drugs. The second variant of the staggered approach assumes that the patient can climb from one level of the pyramid to another during an attack. For example, if at the beginning of an attack simple analgesics were ineffective and the admission occurs again, combined drugs should be used.
However, a patient with severe seizures accompanied by vomiting and the state of stunning cannot be treated with simple analgesics or drug combination. For such patients, it seems acceptable to use stratified approach, which proposes to select the treatment of an attack. In essence, it suggests that the best criterion for the successful selection of migraine treatment is the intensity of pain and the degree of disability. It is very likely that a patient with mild migraine attacks can be satisfied with the treatment corresponding to the first stage of the therapeutic pyramid. Patients with severe migraine attacks should begin treatment with drugs of a higher level. It is clear that highly effective treatment of a migraine attack requires individual selection of a drug based on well-known principles about the comparative clinical effectiveness of the drugs, their side effects, concomitant diseases, the severity of the migraine attack, and the previous experience of using drugs.
The Choice of Treatment and Its Defense
There are several approaches to choosing the type of treatment and determining the drug as described above. However, in the treatment of migraines, it is important not only to choose in favor of a particular approach or method but to use a combination of methods. Thus, the most relevant choice of the treatment option is the combination of the both methods. It can be defended clearly. Effective treatment includes an integrated approach because it will help to influence comorbid factors. Migraine has comorbid complications. If migraine is accompanied with different disorders, the approach to their treatment must not be narrow. Only combinations of pharmacological treatment, diet, identification and control over the triggers, physical actions, and exercises in an united integrated system can bring result and improve the quality of life. Combined efforts at each stage of treatment should include all the components: prevention of seizures, treatment of seizures, and prevention of comorbid factors (Malone, et al., 2015). Vivek Lal and Monika Singla also confirm the idea of combined treatment. They even distinguish each comorbid factor treatment simultaneously with the treatment of migraine (Lal, & Singla, 2010). Furthermore, preventing migraine attacks involves training the patient to identify precursors, determine migraine triggers, and avoid situations that cause migraines. Lipton, et al. (2005) also support the idea of united combined approach as they connect mechanisms of migraine with comorbid disorders directly (Scher, et al., 2005). In this way, patient can achieve prevention or a significant reduction in the number of seizures without the use of drugs. Treatment of seizures should include both the pharmacological and non-pharmacological approaches described above. Moreover, the fear associated with waiting for an attack disadapts many patients suffering from migraine (Scher, et al., 2005). In this regard, it is very important to work with the patient on treatment tactics in various combined scenarios of migraine development. Due to this combined option of migraine treatment, the information provided by the authors can be considered credible as all the described parts of treatment are suitable for cases of migraine. Migraine has comorbid nature; it rarely acts alone because different disorders are connected with it. Therefore, such an option is the best solution due to its consistency.
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Preventive treatment of migraine and comorbid factors should be used if migraine attacks are frequent (more than 2 times per week) and/or if behavioral and pharmacological interventions are ineffective. Indications for such prevention are also specific forms of migraine or comorbid factors, namely hemiplegic migraine or migraine with aura with a stable neurologic deficit (Malone, et al., 2015). Pharmacological agents used to prevent migraine include several groups. They are ß-adrenoblockers (propranolol, metoprolol) and agents having an α-adrenoceptor blocking effect (dihydroergocryptin). Calcium channel blockers (verapamil, nimodipine, flunarizine) can be effectively used in prevention as well as tricyclic antidepressants, selective serotonin reuptake inhibitors, selective serotonin and noradrenaline reuptake inhibitors, anticonvulsants or botulinum toxin preparations (Malone, et al., 2015). This complex will help to reduce the frequency, duration and severity of migraine attacks and prevent excessive intake of medications to stop seizures. This will make possible to reduce the impact of migraine attacks on daily activity to treat comorbid disorders (Scher, et al., 2005). In turn, such an integrated approach will be helpful in avoiding chronic diseases and improving the quality of life of the patient.
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The study discusses migraine problems, its diagnosis and treatment. Traditional migraine therapy includes treatment of an already developed attack and preventive measures aimed at anticipation of attacks. It is emphasized that in cases of the presence of comorbid disorders in a migraine patient, which significantly disturb the condition in the interictal period, treatment should also be directed at combating these undesirable conditions. Only a comprehensive campaign including early arrest of migraine attacks, prevention of attacks and treatment of comorbid disorders will help to ease the condition of patients during the interictal period, improve their quality of life and prevent the progression (chronic) of migraine.