In an interview with InFo NEUROLOGIE & PSYCHIATRIE, Dr. med. Andreas R. Gantenbein, Head Physician of Neurology at the RehaClinic Bad Zurzach, provides information on the possible causes and trigger factors of migraine and discusses the most important symptoms that enable a differential diagnosis and thus differentiation from strokes and epileptic seizures. In addition, he addresses cluster headaches, which require different drug therapy than migraine.
Dr. Gantenbein, the prevalence of migraine has increased in industrialized countries in recent years. According to the latest findings, are genetic predispositions or lifestyle factors decisive for the development of the disease?
Dr. Gantenbein:
It’s probably an interplay of both areas. We now know that certain genes are responsible for migraine. We sometimes see this in the fact that the disease is clustered in some families. Environmental factors and lifestyle in terms of diet, exercise or food also play a crucial role.
Triggers vary by gender, age and life situation. What trigger factors should patients be individually warned about?
There are numerous suspected trigger factors, some well established, others less so. Very many of those affected cite stress when asked what triggers it. However, stress does not always have to be negative, but can also be positive, so one should not make a blanket judgment here. In addition, many patients suffer from migraines only when the stressful time is over and they could actually relax.
Furthermore, the hormonal balance has a decisive influence; in certain women, migraine attacks accumulate during or before menstruation. Here, stabilization measures, such as constant use of the pill without interruption for three months, can sometimes already improve the migraine. Basically, if the headache changes when you take a newly prescribed pill, you should certainly reconsider the choice and, if necessary, take further clarifications. The combined pill is also contraindicated in women with migraine with aura.
Diet is also a factor: it’s not necessarily what you eat, but that you eat at all and at regular intervals. As a precursor to migraine, sufferers often experience so-called “food craving,” with increased desire for food. Later, they link the migraine to the specific food, such as chocolate, that they ate at the time. They overlook the fact that the urge to eat was itself already a partial symptom of the migraine, and at another time, when they eat chocolate, they do not get a migraine.
One interesting new approach I find is that there is an increasing attempt to teach patients how to deal with triggers rather than strict avoidance. This is done, for example, with behavioral therapy approaches. The aim is to achieve a kind of desensitization by repeatedly exposing oneself to the triggers in a targeted manner. However, scientific studies in this area are still lacking.
What is recommended to migraine patients is a balanced, regular, “boring” lifestyle: always get up at the same time, eat meals and go to bed. In addition, drink enough and exercise. However, this is precisely what is not always easy to comply with in certain life situations, e.g. in the middle of professional life.
Excessive use of painkillers (more than ten times a month) may in turn lead to more frequent headaches. This induces a vicious cycle: headache, drug, headache. How can the patient be released from it?
This problem is not so rare: It is estimated that about 100,000-200,000 Swiss suffer from it. If the migraine becomes more frequent due to difficult lifestyle factors, and you as a sufferer know that a certain medication works, you then use it again and again. A critical threshold is reached when the drug is taken on more than ten days per month. Then the headache can suddenly be constant and not go away. Although the attacks are no longer as severe and the symptoms may no longer correspond to typical migraines, a constant, diffuse pain similar to tension-type headaches is experienced. These are then so-called MÜKS (medication overuse headaches).
First of all, it is necessary to recognize FMD as a physician, then possibly optimize prophylaxis, but above all to inform. Education alone can help the patient. In some cases, a medication break from the acute medications becomes necessary. Thus, improvement can usually be expected after three to four weeks, provided that medication overuse was indeed the chronicity factor. If this does not work, or if someone has a particularly high number of comorbidities, they may need to be admitted as an inpatient with withdrawal and rehabilitation where they learn to abstain from acute drug use.
The clinical picture of migraine is multifaceted. What are the major main forms that can be distinguished in diagnosis, and what is the risk of overlooking a differential diagnosis?
There are the two major subdivisions: Migraine with and without aura. In the first form, the headache is typically preceded by neurological dysfunction, usually visual, as the visual cortex is largest. However, sensory, motor or speech disorders may also occur. The distinction from a stroke or epileptic seizure, which often occur with tumors, can be made on the basis of a typical symptomatology: In migraine, the discharge wave, the so-called “cortical spreading depression,” moves very slowly – at a few millimeters per minute across the brain surface. Accordingly, the aura phenomena in the visual field also spread slowly. If, on the other hand, the phenomena occur abruptly, one must rather think of a hemorrhage, a cerebral stroke or epileptic seizure. One of the most important accompanying symptoms of migraine is also hypersensitivity to sensory stimuli – light, noise, smells, movement.
Most of the diagnosis is therefore based on the patient’s medical history; headache diaries, for example, are helpful here. If the typical symptoms occur periodically, but everything is fine in between, this indicates a migraine. If there are peculiarities or abnormalities in the neurological status, if the symptoms increase or change, feel different or if they come very suddenly, this is certainly a reason for further clarification.
Migraine remains incurable. Have there been any decisive drug therapy advances in treatment in recent years?
For a good 20 years we have had the triptans, which have brought a decisive improvement in acute treatment. Compared to other substances, they are certainly the most effective, if you can tolerate them. They are contraindicated in cases of previous stroke or myocardial infarction, as they constrict the vessels. Therefore, alternatives for acute treatment are currently being sought which do not involve this contraindication. Here, various studies on the so-called CGRP receptor antagonists are ongoing.
Prophylactic effects have been found mostly by accident, with drugs that were not actually developed for migraine. Such are also being investigated in studies. In this area, topiramate in particular has recently provided good data and has therefore also received approval for the prophylactic treatment of migraine.
If migraine, but especially cluster headaches, can no longer be treated with medication, there are now initial approaches that test neuromodulative procedures: surgical or transcutaneous.
To what extent is it important to treat comorbidities such as depression that occur in connection with the disease?
It is essential to treat them as well. I often observe the unholy triangle of sleep disorders, affective disorders, and pain. In many patients, these three points are related, so if one is affected, so are the other two. Often, however, the others improve as well, if one starts therapeutically at one point.
But even if someone has high blood pressure or sleeps poorly, this should be taken into account and co-therapy, use the “side effects”.
Infantile migraine is a special form: what are the principles to consider for the practice when dealing with very young patients?
I’m not a neuropediatrician, but I do know that with children, you work as little as possible with medication, but rather with sleep. Sleep is a very good medicine that would also work for many adults if they could take the time.
Otherwise, one tries to trace the reasons, e.g. a visual impairment can lead to overexertion and headaches.
Cluster headaches surpass even migraine attacks in severity. Do we now know more about the etiology of these extremely painful attacks?
Systems similar to those involved in migraine are probably involved in its development. Basically, it is also a dysfunction of central pain processing. However, details are not yet known. Cluster seizures often occur in groups throughout the year, seasonally and temporally, including at night. The “inner clock” probably plays a role here.
Due to the faulty pain processing, the pain, often in the eye, then appears particularly strong.
Which therapeutic measures are useful here acutely, which prophylactically?
Here, the focus is primarily on drugs that act as quickly as possible. Since such an attack lasts on average 45 minutes to an hour, it is impossible for sufferers to wait an hour for the painkiller to take effect. Triptans, as a nasal spray or injection can help, they get into the system quickly.
In addition, high-dose oxygen is also an established therapy in many patients, not so much to suppress the attack as to reduce and postpone it, usually requiring triptans after all. In the episodic form, which affects about 90% of sufferers, there is often an accumulation of seizures once a year for a few weeks, which can then be treated with cortisone or an injection in the area of the occipital nerve.
In the prolonged, as well as the chronic form, the best drug is verapamil in a sufficiently high dosage. Alternatively, topiramate or valproate may be used. In any case, drug therapy should be planned with the involvement of a specialist.
The worst thing that can happen to a cluster patient is the misdiagnosis of a migraine and the corresponding treatment (beta blockers, antidepressants).
Interview: Andreas Grossmann
InFo Neurology & Psychiatry 2014; 12(1): 33-35.
