How to recognize and manage acute migraine, one article

Migraine is a common clinical chronic neurovascular disease.
The annual prevalence reported in various countries is 3.
3%-32.
6% for women and 0.
7%-16.
1% for men
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Migraine can occur at any age, and the first onset is more common in adolescence
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Migraine has a great impact on the quality of life.
More than half of patients have headaches that affect work or study, and nearly one-third of patients will be absent from work or school due to headaches
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 There are many triggers for migraine.
For clinicians, to better understand how potential triggers cause migraine, the most important thing is to understand: (1) the heterogeneity of triggers; (2) perceptual triggers The frequency and intensity of the factors; (3) the patient’s effort to control the triggers, and (4) the subtle difference between the true triggers of migraine and the aura symptoms
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Only by recognizing how these four issues affect the patient’s experience can clinicians best manage migraine patients
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 Heterogeneity of trigger factors Because there are many reasons for headaches in migraine patients, and the trigger factors are heterogeneous, it is extremely challenging to understand the trigger factors and perceive the various potential stimuli in the trigger factors
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A meta-analysis of 85 studies (involving more than 27,000 participants) conducted over a 60-year period showed that (1) most people who experience frequent headaches—including migraine sufferers—have at least one trigger; (2) ) Stress is the most frequently mentioned triggering factor of patients, followed by sleep and environmental factors
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 Perceived differences in trigger frequency and intensity Heterogeneity extends beyond triggers and perceptual triggers; frequency and intensity may also vary widely
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In a cross-sectional observational study, 300 headache patients were asked to rate 33 triggers according to frequency and intensity
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It turns out that the most common triggers encountered each month are air conditioning and caffeine (both 30 days); secondly, red wine is considered to be the least common trigger (0 days); in addition, the heterogeneity between people Sex is significant-most of the range of each trigger spans 15 days or more
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 It is widely believed that the triggers that increase the frequency of headaches are stress (75%), skipping meals, and dehydration (both 60%)
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Nuts and salty foods are the least likely to increase headaches (both 0%)
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Similar to the perception of trigger frequency, people's perception of trigger intensity also varies greatly, and the range of each trigger exceeds 50%
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 Even though there are two patients in the study who have the same understanding of the importance of triggers that induce headaches, the heterogeneity observed in the frequency of encountering triggers still exists
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In addition, most headache patients don't think that the triggering factor is just present or non-existent
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On the contrary, they have different views on the strength of perceptual triggers
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These wide differences between patients make it difficult for clinicians to predict how individual headache patients will evaluate these triggers
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 The patient's trigger belief system Many migraine sufferers use the so-called trigger belief system to create a safe and controlled environment to avoid headache attacks
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Indeed, perception can often determine how to trigger headaches, but it also adds to the complexity of managing headache patients
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A study involving more than 200 patients showed that the perceived control and impact of headaches are related to the severity of headaches
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Another trial involving more than 300 patients seeking headache treatment showed that those who are confident in better management of headaches also believe that they can control the factors that affect headaches
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Although avoiding triggers is an active coping strategy, it also causes more anxiety
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 Triggering avoidance can also lead to a decline in the quality of life
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For example, patients are advised to prevent and manage migraines through physical exercise, but 80% of migraine patients choose to avoid physical exercise because they are afraid of triggering a headache attack
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A recent study found that higher anxiety scores are associated with more frequent avoidance of physical activity
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Participants with physical concerns were about 8 times more likely to avoid strenuous exercise than others, and those who mentioned cognitive problems were more than 5 times more likely to avoid moderate-intensity physical exercise
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 From this point of view, although patients are usually advised to avoid triggers, in some cases, increased patient anxiety may lead to more migraine attacks
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Therefore, although avoidance may be the best choice for certain triggers with real biological mechanisms, it is best to deal with triggers caused by anticipatory anxiety or fear through gradual exposure and desensitization
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 How to distinguish true triggers and aura symptoms If clinicians can distinguish migraine aura symptoms from actual triggers, they can provide the best treatment for patients
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However, it is not always easy to make a distinction
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Aura symptoms usually appear 2-48 hours (or longer) before the onset of migraine
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Symptoms include changes in mood and activity, irritability, fatigue, craving for food, repeated yawns, stiff neck, and photophobia
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Since these symptoms can last even after the migraine aura stage, they are often misunderstood as the real migraine trigger
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It has been found that 30%-80% of migraine attacks are accompanied by aura symptoms
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Neck pain, photophobia, and food cravings are often confused with the true cause of migraine
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 Timing of migraine symptoms It is important to understand the time between symptoms and migraine attacks, as this can help determine whether it is an actual trigger, aura symptom, or other manifestations
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The 4 stages of migraine attack can be divided into prodromal period, aura period, headache period and recovery period
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These 4 stages are characterized by specific symptoms, which usually (but not always) occur along a timetable (as shown in the figure below)
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Although this symptom schedule can help guide clinicians and migraine sufferers, it is important to understand that these stages do not always occur individually, but often have significant overlaps, which may mislead clinicians and patients
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 Common triggers ➤Stress: Stress is the most common self-reported trigger for migraine patients.
Many studies have shown that there is a link between stress and migraine
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However, retrospective and prospective diary studies have not yet confirmed the connection between stress and acute migraine attacks
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In addition, studies have shown that migraines are less likely to occur during holidays or rest days, but relaxation does not work
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Fatigue is more common than mental exhaustion or insomnia, which has led researchers to speculate that fatigue is a symptom of aura rather than the cause of migraine
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Even more confusing is that the study found that the reduction in stress from the first day to the second day is related to the migraine attack on the second day.
Due to the so-called disappointment effect, it may become a predictor of the migraine attack
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 ➤Menstruation: Menstruation seems to be the most common migraine trigger for women
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A large 3-month study showed that the prevalence and persistence of migraine increased as high as 96%
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In addition, diary studies have shown that menstruation is a trigger.
In a population-based trial, more than half of women with migraines reported an increased incidence of migraine
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However, only 4% of people actually suffer from migraine during menstruation
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 ➤Diet: Food seems to be one of the several contributing factors of migraine, not the only factor
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In most patients, fasting is one of the most studied and persistent causes of migraine, and it seems to be more common in longer fastings
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Dehydration is not believed to be the cause; instead, it may be caused by low blood sugar
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A trial involving more than 3,000 women showed that the quality of the diet of women with migraines was lower than that of women without migraines
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Other smaller studies have shown that low-fat vegetarian diets and ketogenic diets are good for health
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In addition, patients with irritable bowel syndrome and migraine may benefit from not eating these stimulating foods, thereby improving the frequency of migraines and intestinal symptoms
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 ➤Weather: Some small studies have assessed the link between weather and migraine
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A study involving 77 migraine patients showed that slightly more than half of them are sensitive to at least one weather factor (namely, changes in air pressure, lightning, temperature, and precipitation)
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Another study involving 238 participants showed that there was no statistically significant increase in the frequency of migraine attacks on days of high pressure, low wind speed, and increased sunlight, but they thought this correlation was questionable
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A study of 90 people found that lightning is an independent risk factor for migraine
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 ➤Sensory stimulation: Although visual, auditory, smell and other sensory stimuli have been shown to cause migraines in susceptible individuals and increase the intensity of migraines, it is difficult to determine whether these are the real trigger or the aura symptoms
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In fact, migraine sufferers have a low discomfort threshold for various sensory stimuli
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Of all sensory stimuli, smell is the most common trigger
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Studies have shown that 7 out of 10 migraine sufferers are triggered by the smell of migraine
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Common odor irritants include perfume, paint, gasoline, bleach, and rancid odors
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At the same time, problems with smoke and exhaust gas were also found
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 How to manage migraine patients-recommended strategies ➤ Ask patients to keep a headache diary, which can eliminate false memories and have a clearer understanding of the frequency and severity of migraines
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Symptoms include records and other important factors - missed work time, family activities canceled, nausea and vomiting
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Recording logs can discover specific triggers, which can be eliminated or adapted to these triggers by changing certain behaviors
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It can also reveal to patients that certain triggers may not be as useful as initially thought in predicting migraine
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 ➤It is recommended that patients pay attention to healthy life>
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Some studies have shown that a healthy life>
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Although behavioral changes, such as adapting to certain noises, are considered not a healthy life>
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 ➤If it is observed that the patient is afraid of experiencing migraines between episodes, active treatment is required
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If left unchecked, this condition may lead to chronic migraine and drug overuse
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Although the correct acute medication may be sufficient, sometimes cognitive behavioral therapy and biofeedback technology may be necessary because it can solve behavioral problems that may interfere with successful treatment
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 ➤If the patient has frequent migraine attacks and it is difficult to identify the unique cause, preventive treatment is required to reduce the excitability of the brain, so that the patient is not prone to migraine
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 Literature Index: Identifying Acute Migraine Triggers.
AAN 2021.