Migraine: seizure-like, often pulsating, usually unilateral headache, often initiated or accompanied by vegetative symptoms, sensitivity to light and noise, and neurological deficits such as z. B. A visual impairment.
Migraine is a common disease: about 15% of women and 5% of men in adulthood suffer from it. The onset of the disease is usually in adolescence or early adulthood; rarely, children are also affected. After the age of 45. Migraine often improves by itself in the second half of life – in women, the transition to menopause usually has a positive effect.
Half of the sufferers have about one attack per month, but one in ten have 4 or more attacks per month.
Symptoms and leading complaints
– Repeated headache attacks, mostly pulsating and unilateral (a change of sides is possible)
– Duration a few hours up to 3 days, onset is typically in the morning
– increase during physical activity
– everyday activities are substantially impaired or impossible during the migraine attack
– Initial or concomitant noise or light aversion, nausea, frequent vomiting, visual disturbances and other sensory disturbances.
When to see a doctor
In the next 2 weeks, if
– a headache that "fits" a migraine occurs for the first time.
– the character of a known migraine changes or a previously successful self-treatment no longer works.
In the next days when
– the headache attacks always begin in the morning.
– between the "attacks there is no absence of symptoms. Headache is very severe. On "nothing respond.
Call the doctor immediately if
– the sufferer has cramps, becomes unconscious or shows signs of paralysis.
Overview. Migraine is not, as previously assumed, psychologically caused and certainly not a migraine attack is faked ("she has her migraine again"), but psychological factors influence the course of the disease. Migraine is probably hereditary; in a rare special form, genetic defects have been identified as a direct cause. If there is a tendency to migraine, a wide variety of influences, such as certain foods and stimulants like red wine, chocolate or cheese, changes in the sleep-wake rhythm, heat, noise, flickering light, stress (or relaxation after previous tension), staying at high altitudes, but also "coming up", trigger migraine attacks infections or, in women, the "pill as well as menstrual migraine attacks from.
Forms. If the attack starts immediately with headache, it is called a
Migraine without aura. This is the most common. However, in about 10-15% of those affected, neurological deficits (often visual disturbances such as z. B. Light flashes and visual field defects) a migraine attack a. This form is called Migraine with aura (or classic migraine).
Causes. How exactly a migraine attack occurs is still not entirely clear. According to current knowledge, a functional disorder of the nerve cells is the cause of migraine. Not the blood vessels at the beginning of the event. By means of SPECT and PET, increased blood flow in parts of the brain stem could be detected. This probably leads to a change in the release of neurotransmitters, whereby the neurotransmitter serotonin plays a decisive role. This is then to the fibers of the trigeminal nerve ("responsible" for the sensations of the meninges and face) and the body's own pain-regulating systems act back and dilate the meningeal vessels, leading to the migraine-typical headache.
Probably responsible for the aura is a reduced nerve cell activity, which moves over parts of the cerebral surface and reduces the blood flow in phases. End of attack: Pain subsides with exhaustion. Increased need for sleep.
The predisposition to migraine cannot be changed, but with a combination of the treatment options mentioned below, most sufferers succeed in keeping it within tolerable limits.
Special forms. Migraine attacks that are associated with menstrual bleeding are considered menstrual migraine migraine attacks with long-lasting neurological symptoms, e.G., a headache. B. Paralytic attacks as migraine accompagnée.
Complications. Migraine attacks that do not stop within 72 hours are referred to as Status migraenosus. They require special therapy measures. Often a hospitalization.
Confirmation of diagnosis
If the complaints are typical and the doctor can find no other abnormalities "stands" the diagnosis.
If the picture does not quite fit, however, z. B. First time failures occur, the disease does not begin until after 40. If a patient has a migraine on his or her 60th birthday or if a known migraine changes, the doctor must rule out other underlying diseases, which usually requires a CT scan and/or an MRI of the skull.
The therapy of migraine is difficult – there are no miracle cures, and no drug eliminates all symptoms. Modern approaches include, in addition to drug treatment, psychotherapeutic. Physiotherapeutic remedies as well as lifestyle changes and self-help measures.
Pharmacotherapy in the migraine attack
Many migraine attacks are so severe that self-help measures (see below) are not sufficient. Against nausea. Vomiting an antiemetic such as z. B. Metoclopramide 10-20 mg as a tablet.
– Fifteen minutes later for the pain:
As first-line agent, 900-1000 mg acetylsalicylic acid, 1000 mg acetaminophen, or 400 mg ibuprofen, preferably as an effervescent or chewable tablet. There are also combination preparations – for example with 250-265 mg acetylsalicylic acid, 200-265 mg paracetamol and 50-65 mg caffeine – for many they are more effective than the individual substances. The single intake dose is 2 tablets. For children and adolescents under 16, paracetamol or ibuprofen are best, and for pregnant women, paracetamol is best. Paracetamol can also be administered as a suppository.
Metamizol (up to 1000 mg as a tablet) is considered a second-choice drug.
Triptans, such as sumatriptan, zolmitriptan or naratriptan, have a stronger effect. They interfere with the neurotransmitter structure (more precisely, the serotonin balance) in the brain. Triptans are available as melting tablets, suppositories, nasal sprays and subcutaneous injections. Triptans may be taken only in the migraine attack – and not already during the aura, since Triptans otherwise lead even to the (drug-induced) headache and even to more frequent migraine attacks. A follow-up dose after at least 6 hours is allowed.
If a triptan is not sufficient, the doctor recommends combining the triptan with a non-steroidal anti-inflammatory drug (NSAID such as z. B. Acetylsalicylic acid, naproxen or ibuprofen).
Other medications: Ergot alkaloids or ergotamines, which were frequently prescribed in the past, have now been displaced by the triptans. However, some sufferers do well with these medications and can then continue to take them.
Medication for seizure prophylaxis
In the case of frequent migraine attacks, continuous administration of preventive medication is advisable because of the risk of side effects from the attack medication.
– The beta-blockers metoprolol and propranolol, known from the treatment of hypertension, the calcium antagonist flunarizine and the antiepileptic drugs topiramate and valproic acid are used preferentially. Their effectiveness can only really be assessed after 2 months: the number of migraine days should have decreased by 30-50. To determine this, keeping a headache diary is indicated. If therapy is effective, discontinuation or dose reduction should be attempted after 6-12 months. If the migraine worsens again, a new treatment cycle is then initiated.
– If these standard medications are not sufficient, the antidepressant amitryptillin, the analgesic naproxen, botulinum toxin, the phytopharmaceutical butterbur and many other medications are used (partly "off label"), d. H. Without being approved for migraine prophylaxis).
– For children, pregnant women as well as patients with menstrual migraine there are special recommendations.
Non-drug seizure prophylaxis
The Acupuncture is now firmly established in non-drug seizure prophylaxis, and its efficacy has been proven in numerous studies (in some cases it is even effective in the onset of a migraine attack and can possibly reduce the risk of migraine). Prevent a pronounced attack).
The Progressive muscle relaxation according to Jacobson and Biofeedback-assisted behavioral therapies are comparably effective methods to prevent migraine attacks. In biofeedback-assisted behavioral therapies, the patient learns to influence pain at will through concentration. A sensor above the temporal artery measures its blood flow, which is displayed on a screen. From this feedback, the patient learns to increase the diameter of the artery at will, thereby controlling blood flow.
Further exercising procedures like Stress management classes or Behavioral therapies are also helpful in individual cases. At Autogenic training, which studies have also found to be effective, the forehead cooling exercise is the crucial part of the exercise program and aims at comprehensive relaxation. Autogenic training should be taught in appropriate courses z. B. Learned in adult education centers and practiced regularly for a longer period of time – ideally years. Once the basic exercises have been learned in a course, it is possible to perform the exercise on one's own.
Regular endurance sports can reduce the number of migraine attacks. Jogging three times a week for 30-40 minutes causes the brain to release endorphins three times a week. This raises the individual pain threshold, and migraine attacks occur less frequently and are weaker. The need for medication also decreases, as several studies have found.
Note: However, intense exercise is a migraine attack trigger for some patients. These sufferers are then recommended moderate(er) endurance sports such as fast walking or dosed training on the exercise bike or bicycle ergometer.
Your pharmacist recommends
Avoid triggers. Known attack triggers should be avoided, though it is often not easy to figure out what provokes an attack and what is the best prescription against it. Then, for a limited time, keeping a headache diary is useful.
For a long time, chocolate and sweets were considered to be migraine triggers, as sufferers often reported ravenous appetite attacks before the attack. However, a recent study shows that chocolate does not cause the attack, but rather that the increased desire for sweets heralds it. The reason behind this: The brain needs energy for the impending migraine attack. This means: To prevent an attack, it is of no use to give up chocolate. On the contrary, according to the study, this abandonment actually increases the symptoms.
Physical applications. During the attack, rest in a dark, quiet room and cold applications help best, z. B. By cold compresses as well as cold packs applied to the neck or in the form of migraine goggles.
Some patients benefit from a hot shower or a full bath lasting 10-20 minutes. Bath additives made from spruce needles and rosemary promote circulation, valerian and hops soothe, arnica and hay flower relieve pain.
Acupuncture. In a large acupuncture study (GERAC, 2005), acupuncture was shown to be equal to standard medical treatment.
Phytotherapy. A classic remedy for migraines is butterbur rootstock (Petasites hybridus). It is recommended for prophylaxis and relief of migraine attacks, several neurological societies in Europe consider the medicinal plant effective and its use beneficial. However, it does not work for every patient and there is a (very small) risk of liver damage, so it should only be used under medical supervision.
In individual cases, natural remedies for chronic headaches such as chocolate and sweets should also be considered. B. Extracts from willow bark.
Homeopathy. Recommended are for example Belladonna, Cimicifuga, Gelsemium and Sanguinaria as acute (D6 or D12) or combination therapy (from C30) – clear evidence of efficacy is missing, however, despite many studies. As a complex means z. B. Cyclamen oligoplax proposed.