Symptoms of migraine

Symptoms of migraine are characterized by a typical migraine pain, which is more often pulsating and pressing, usually captures half of the head and is localized in the forehead and temple area, around the eye. Sometimes a headache can begin in the occipital region and spread anteriorly into the forehead region. In most patients, the side of pain may change from an attack to an attack.

Migraine is not characterized by a strictly unilateral character of pain, it is considered an indication for an additional examination, the purpose of which is to eliminate the organic damage of the brain!

The duration of the attack in adults usually ranges from 3-4 hours to 3 days and an average of 20 hours. With episodic migraines, the frequency of attacks varies from one attack in 2-3 months to 15 per month, the most typical frequency of attacks is 2-4 per month .

In some patients, for a few hours or even a day before symptoms of migraine develop, there may be a prolongation (harbingers of headache), which includes various combinations of symptoms such as weakness, mood deterioration, difficulty concentrating, sometimes, on the contrary, increased activity and appetite, tension in the neck muscles, increased sensitivity to light, sound and olfactory stimuli. After an attack, part of the patients for some time remain drowsy, general weakness and pallor of the skin, often there is yawning (post-drift).

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Concomitant migraine symptoms

Migraine attack, as a rule, is accompanied by nausea, increased sensitivity to bright light (photophobia), sounds (phonophobia) and smells, a decrease in appetite. Somewhat less often, vomiting, dizziness, and fainting may occur . Because of pronounced photo and phonophobia, most patients during an attack prefer to stay in a darkened room, in a calm, quiet environment. Pain with migraines is aggravated from normal physical activity, for example, when walking or climbing a ladder. For children and young patients, the appearance of drowsiness is typical, and after a dream, the headache often disappears without a trace.

The main symptoms of migraine are as follows:

• severe pain on one side of the head (temple, forehead, eye area, occiput), alternation of sides of headache;
• typical accompanying migraine symptoms: nausea, vomiting, light and phobia;
• increased pain from normal physical activity;
• the pulsating nature of pain;
• typical provoking factors;
• a significant limitation of daily activity;
• migraine aura (15% of cases);
• Headache attacks are poorly cured by conventional analgesics;
• hereditary migraine (60% of cases).

In 10-15% of cases, the attack is preceded by migraine aura - a complex of neurological symptoms that occur immediately before the migraine headache or in its beginning. This feature distinguishes migraine without an aura (previously "simple migraine") and migraine with aura (previously "associated migraines"). Do not confuse the aura and prodromal migraine symptoms. The aura develops within 5-20 minutes, remains no more than 60 minutes and with the onset of the painful phase completely disappears. For most patients, migraine attacks without an aura are common, a migraine aura does not develop or is very rare. At the same time, patients with migraine with aura can often develop seizures without an aura. In rare cases, after the aura, a migraine attack does not occur (the so-called aura without a headache).

The most common is the visual, or "classical" aura, manifested by various visual phenomena: photopsy, flies, a one-sided drop-out of the field of vision, a flickering scotoma, or a zigzag-like glowing line ("fortification spectrum"). Less often, one-sided weakness or paresthesia in the limbs (hemiparestetic aura), transient speech disorders, distortion of perception of the size and shape of objects (the "Alice in Wonderland" syndrome) is possible.

Migraine has a close relationship with female sex hormones. Thus, menstruation becomes a provocateur of an attack in more than 35% of women, and menstrual migraines, in which attacks occur within 48 hours after the onset of menstruation, occur in 5-10% of patients. In two thirds of women, after a certain increase in episodes in the first trimester of pregnancy in the II and III trimesters, there is a significant relief of the headache, up to the complete disappearance of migraine attacks. Against the background of taking hormonal contraceptives and hormone replacement therapy, 60-80% of patients report a more severe course of migraine.

[10], [11], [12], [13], [14], [15], [16], [17], [18]

Frequency and course of migraine attacks

All described forms of migraine (with the exception of bundles) proceed, as a rule, with different frequency - from 1-2 times a week or a month to 1-2 times a year. The course of a migraine attack consists of three phases.

The first phase - prodromal (expressed in 70% of patients) - clinically manifests itself depending on the form of migraine: for a simple - in a few minutes, less than hours, mood and performance decrease, lethargy, apathy, drowsiness, and then an increasing headache; when migraine with aura begins - depending on the type of aura that may precede the onset of pain or develop at its height.

The second phase is characterized by an intense, predominantly pulsating, rarely bursting, bursting headache in the frontal, periorbital, temporal, less often parietal areas, as a rule, one-sided, but sometimes captures both halves of the head or alternates - left or right.

At the same time, some features are noted depending on the lateralization of pains: the left-sided are more intense, often occur at night or pre-day, right-sided - 2 times more often accompanied by vegetative crises, edema on the face and occur at any time of the day. During this phase, paleness of the skin of the face, congestion of the conjunctiva, especially on the side of pain, desires for nausea (in 80%), sometimes vomiting are noted.

The third phase is characterized by a reduction in pain, general lethargy, frustration, drowsiness. Sometimes the course of an attack has a so-called migraine status (1-2% of cases), when pain attacks within a day or several days can follow one after another. When accompanied by repeated vomiting, dehydration of the body occurs, hypoxia of the brain. Often there are focal neurological symptoms of migraine, seizures. All this requires urgent therapeutic correction, hospitalization of the patient.

The most significant clinical differences of migraine from a tension headache

Symptoms	Migraine	Headache of tension
The nature of pain	Pulsating	Compressive, compressive
Intensity	High	Weak or medium
Localization	Gemikraniya (frontal-temporal zone with periorbital area), less often bilateral	Two-sided diffuse pain
Time of appearance	At any time, often after waking; often a seizure occurs during relaxation (weekends, holidays, after resolving a stressful situation)	At the end of the working day, often after the emotional load
Duration of headache	From a few hours to a day	Many hours, sometimes days
Behavior during an attack	The patient avoids movements, if possible prefers to lie with closed eyes, activity increases pain	The patient continues normal activities
Factors that ease the headache	Sleep, vomiting at the height of pain	Mental relaxation, relaxation of pericranial muscles

Clinical migraine varieties

Some patients may have vegetative migraine symptoms during an attack: increased heart rate, facial swelling, chills, hyperventilation manifestations (lack of air, a feeling of suffocation), lacrimation, pre-stupor, hyperhidrosis. In 3-5% of patients, the vegetative manifestations are so numerous and bright that they achieve the degree of a typical panic attack with a sense of anxiety and fear. This is the so-called vegetative, or panic, migraine.

In most patients (60%), seizures occur exclusively in the daytime, i.e. During wakefulness, 25% of patients are concerned about both wakefulness attacks and seizures that awaken them at night. Not more than 15% of patients suffer exclusively from sleep migraine, i.e. Painful attacks occur during a night's sleep or on waking in the morning. Studies have shown that the main prerequisite for the transformation of migraine wakefulness into a migraine sleep is the presence of severe depression and anxiety.

In 50% of women with migraine, there is a close relationship of seizures with the menstrual cycle. Most of the seizures associated with menstruation - migraine attacks without an aura. The division of such seizures into a true menstrual (catagenaly) migraine (when the seizures occur only in the "near-menstrual" period) and migraine associated with menstruation (when the seizures can be caused not only by menstruation, but also by other migraine triggers: weather change, stress, alcohol, etc.). True menstrual migraine is found in no more than 10% of women. The main mechanism for the development of an attack of catamenial migraine is the decrease in the content of estrogens in the late luteal phase of the normal menstrual cycle (more often in ovulation).

The diagnostic criteria for menstrual migraines are as follows.

• True menstrual migraine.
• Headache attacks in a menstruating woman who meet the criteria for migraine without an aura.
• Seizures occur exclusively in the 1-2 days (ranging from -2 to +3 days) in at least two of the three menstrual cycles and do not occur during other periods of the cycle.
• Migraine associated with menstruation.
• Headache attacks in a menstruating woman who meet the criteria for migraine without an aura.
• Attacks occur on the 1-2 day (ranging from -2 to +3 days) in at least two of the three menstrual cycles, and in addition, in other periods of the cycle.

Chronic migraine. In 15-20% of patients with a typical episodic migraine at the beginning of the disease, the frequency of seizures increases with the years until the appearance of daily headaches, the nature of which gradually changes: the pains become less strong, acquire a permanent character, may lose some typical migraine symptoms. This type, which meets the criteria of migraine without an aura, but occurs more often 15 days a month for 3 months and longer, was called chronic migraine (previously used the term "transformed migraine"). Along with some other disorders (migraine status, migraine infarction, seizure caused by migraine, etc.), chronic migraines were included for the first time in section MKGB-2 "Migraine complications".

Chronic tension headache and chronic migraine are the main clinical varieties of chronic daily headache. It is shown that two main factors play a role in the transformation of episodic migraine into a chronic form: abuse of analgesics (the so-called drug abusus) and depression, which usually occurs against a background of chronic psychotraumatic situation.

The following criteria are most important when establishing the diagnosis of chronic migraine:

• daily or almost daily headache (usually 15 days per month) for more than 3 months for more than 4 hours / day (without treatment);
• typical migraine attacks in history, beginning before the age of 20;
• the growth of the frequency of cephalgia at a certain stage of the disease (the period of transformation);
• decrease in the intensity and severity of migraine features (nausea, photo and phonophobia) as the headaches become more frequent;
• the likelihood of maintaining typical migraine triggers and unilateral character of pain.

It is shown that migraine is often combined with other disorders that have a close pathogenetic (comorbid) connection with it. Such comorbid disorders significantly increase the severity of the attack, worsen the condition of patients in the interictal period and, on the whole, lead to a marked deterioration in the quality of life. Such disorders include depression and anxiety, vegetative disorders (hyperventilation manifestations, panic attacks), disturbance of night sleep, tension and soreness of pericranial muscles, gastrointestinal disorders (dyskinesia of biliary tract in women and stomach ulcer in men). To comorbid migraines, disturbances can also be attributed to the accompanying tension headaches, often worrisome patients in the period between migraine attacks. Treatment of comorbid disorders, disturbing the condition of patients in the interictal period, is one of the goals of preventive therapy of migraine. In addition, there is supposedly a comorbid connection between migraine and such neurological disorders as epilepsy, stroke, Raynaud's syndrome and essential tremor.

With a separate "basilar artery migraine" there are pulsating pain in the nape, visual impairment, dysarthria, imbalance, nausea, and consciousness disorders.

At the ophthalmologic form the migraine proceeds with lateral pain, a diplopia, a nausea and a vomiting.

A condition called the equivalent of migraine is described when there are painful neurologic or symptomatic seizures without the most headache.

Symptoms of migraine with an aura depend on the fact in the zone of which vascular pool the pathological process develops:

1. ophthalmic (i.e., what was formerly called a classic migraine), starting with bright photopsies in the left or right fields of vision ("flickering cattle" in the expression of J. Charcot) followed by a short-term fallout of the visual fields or simply a decrease in it - "veil" with the development of acute hemicrania. The cause of visual auras, apparently, is the discirculation in the basin of the posterior cerebral artery;
2. retinal, which manifests itself as a central or paracentral scotoma and transient blindness to one or both eyes. It is assumed that visual disorders are caused by discirculation in the system of branches of the central artery of the retina. In an isolated form, retinal migraine is very rare, it can be combined or alternated with bouts of ophthalmic migraine or migraine without an aura;
3. ophthalmoplegic, when at the height of the headache or simultaneously with it there are various oculomotor disorders: unilateral ptosis, diplopia as a result of partial external ophthalmoplegia, which may be due to:
   1. compression of the oculomotor nerve with dilated and edematous carotid artery and cavernous sinus (it is known that this nerve is the most susceptible to such compression due to its topography) or
   2. spasm and subsequent edema of the artery, supplying it with blood, which leads to ischemia of the oculomotor nerve and also manifests itself with the symptoms described above;
4. paresthesia, which usually begins with the fingers of one hand, then the entire upper limb, face and tongue are captured, while paresthesia in the language is considered by most authors as migraine [Olsen, 1997]. By frequency of occurrence, sensitive disorders (paresthesia) usually stand in second place after ophthalmic migraine. With hemiplegic migraine, a part of the aura is hemiparesis. Approximately half of families with familial hemiplegic migraine had a connection with the chromosome 19 [Joutel et al., 1993]. There may be combined forms (hemiparesis, sometimes with hemianesthesia, paresthesias on the side, opposite headache, or extremely rarely on the same side);
5. aphatic - transient speech disorders of various types: motor, sensory aphasia, less often dysarthria;
6. vestibular (vertigo of varying severity);
7. cerebellar (various coordination disorders);
8. quite rare - basilar form of migraine; often develops in girls aged 10-15 years. It begins with a visual impairment: there is a sensation of bright light in the eyes, bilateral blindness for several minutes, then dizziness, ataxia, dysarthria, tinnitus. In the middle of the attack, paresthesia develops in the hands, feet for several minutes; then - the sharpest throbbing headache; in 30% of cases, loss of consciousness is described.

The basis of these symptoms is the narrowing of the basilar artery and / or its branches (posterior or posterior cerebellar, internal auditory, etc.); the disorder of consciousness is caused by the spread of the ischemic process in the region of the reticular formation of the brainstem. Diagnosis is usually helped by the presence of a hereditary anamnesis, paroxysmal character of a typical headache, complete regression of the described symptomatology, absence of any pathology in additional studies. Later, when puberty is reached, these attacks are usually replaced by a migraine without an aura. Often, patients describe the aura, after which there should not be a headache. This type of "migraine without a headache" is more common in men.

In recent decades, another special form of unilateral vascular headaches has been described: cluster headache, or cluster syndrome (synonyms: Harris' migraine neuralgia, Horton's histamine headache). Unlike usual migraine, this form is more common in men (the ratio of men and women is 4: 1), people of young or middle age (30-40 years) become ill. The attack is manifested with the sharpest pain in the eye area with the periorbital and temporal region, accompanied by lachrymation and rhinorrhea (or nasal congestion) on the side of the headache, often on the left; pain can irradiate to the neck, ear, arm, sometimes accompanied by Horner's syndrome (ptosis, miosis). If, during a normal migraine, patients try to lie down and prefer peace, silence and a darkened room, then with a headache they are in a state of psychomotor anxiety. Attacks last from several minutes (10-15) to 3 hours (mean duration of pain attack 45 minutes). Seizures go in series - from 1 to 4, but not more than 5 per day. Often occur at night, usually at the same time. They last 2-4-6 weeks, then disappear for several months or even years. Hence the name "bundle" (cluster) headache. Nausea and vomiting occur only in 20-30% of cases. The aggravation occurs more often in the autumn or in the winter. Attention is drawn to the appearance of patients: high growth, athletic build, transverse folds on the forehead, face "lion". By nature they are more ambitious, inclined to argue, outwardly aggressive, but internally helpless, timid, hesitant ("the appearance of a lion, and the heart of a mouse"). Hereditary factors with this form of migraine are noted only in a small number of cases.

There are two forms of cluster headache: episodic (the period of remission is several months or even years, occurs in 80% of cases) and chronic (the duration of the "light" interval between painful attacks is less than 2 weeks).

The so-called "chronic paroxysmal hemicrania" (CPG) is quite similar in clinical manifestations [Sjaastad, 1974]: daily attacks of intense burning, drilling, less often - pulsating pain, always one-sided, localized in the orbital-frontotemporal region "Duration of one paroxysm 10-40 min, but their frequency can reach up to 10-20 per day. Attacks are accompanied by lacrimation, redness of the eye and rhinorrhea or nasal congestion on the side of the pain. Unlike the cluster syndrome, women predominate (8: 1), there are no long "light" gaps, there are no "bundles". "Dramatic" effect is observed with the use of indomethacin: perennial attacks go through a few days after treatment.

[19], [20], [21], [22]

Migraine Complications

Early clinical observations and especially recent advances in the development of modern research methods (computed tomography, evoked potentials, nuclear magnetic resonance) suggest that in a number of cases frequent, prolonged attacks of migraine attacks can serve as a prerequisite for severe vascular lesions of the brain, more often as a type ischemic strokes. According to the computed tomography (CT) scan, we found foci of reduced density in the corresponding zones. It should be noted that vascular accidents often occur in the basin of the posterior cerebral artery. The presence in such patients of frequent migraine attacks with an acutely developing headache and subsequent ischemic process is considered by the authors as a "catastrophic" form of migraine. The basis for the assumption of the general pathogenesis of these conditions (migraine, transient ischemic attacks) is the similarity of discirculation in various cerebral vascular basins (according to angiography and CT) in these processes.

In addition, a catamnesis, tracked in 260 patients who had migraine attacks in the past, revealed in 30% of them in the subsequent hypertensive disease. There are indications of a combination of migraine with the phenomenon of Reynaud (up to 25-30%), which reflects the disturbance of diffuse neuro-regulatory vascular mechanisms.

The literature also describes patients with migraine attacks, who then developed rare epileptic seizures. In the following, these paroxysmal states alternated. EEG showed epileptic activity. A definite value is attached to the caused by frequent severe migraine attacks of brain hypoxia, although the genesis of these conditions is not entirely clear. There are indications when mitral valve prolapse and migraine symptoms (20-25%) are combined. The question of the possible risk of cerebrovascular disorders in a combination of these processes is discussed. Observations are made on the combination of migraine with Tourette's disease (in 26% of the latter), which is explained by the presence of a disturbance in the metabolism of serotonin in both diseases.