Headaches are counted among the most common types of pain, but there’s a variant of headaches with very particular characteristics, and it is called migraines. This disorder is very complex, and it can be further subdivided into various types according to the signs and symptoms and whether or not there’s an associated aura, which is a sensory disturbance that will be covered later in this chapter.
This type of headache is more common in females, and it has a strong genetic predisposition to it. The diagnosis of a migraine type of headache is always based on the symptoms and the patient’s history. It is usually suspected in patients with 5 or more headaches lasting for more than 4 hours, and with at least two characteristics we will cover in this article. Thus, the diagnosis should be done by a qualified doctor, and if you suspect your case is a classic migraine, it is essential to talk to your physician in order to handle the symptoms and receive proper guidance.
The most common signs and symptoms in migraines are as follows:
1. Headache
Migraines are a type of headache with particular characteristics. It is thought to be caused by a dilatation of arteries in the brain. This change in the vascular plexus directly stimulates the outer layers of the brain, called meninges, and they have many nerve terminals transmitting the sensation of pain. In the process, the fifth cranial nerve is also involved in sending the sensation of pain.
Headache in migraines usually lasts 4 to 72 hours with or without treatment, it is often felt as unilateral pain that involves one side of the brain only, and it has a pulsating quality with a moderate to severe intensity. It is often aggravated by physical activity and may be triggered by certain visual stimuli.
Migraine headaches are different from headache caused by high blood pressure because this type of pain often involves both sides of the brain at the same time, and it is rather oppressive instead of pulsatile. It may last for 30 minutes to a few hours, and it does not change after performing physical activity. However, pain in migraines is never isolated and should be evaluated along with other signs and symptoms that will be further described in this article.
2. Nausea and vomiting
To diagnose migraines, patients should display at least one episode of nausea with or without vomiting or high sensitivity to sound or light, which will be described in the following paragraph. Nausea and vomiting are gastrointestinal symptoms, but they are associated with the central nervous system because in the brain, there is a control center for the gag reflex that triggers nausea and vomiting under certain circumstances. Pain triggers a series of chemical reactions leading to the activation of such brain centers and the occurrence of nausea with or without vomiting, especially in cases of a headache with high intensity.
3. High sensitivity to light and sound
There are a series of neurologic findings associated with migraine pain, and the most common is high sensitivity to light and/or sound. They are clinically named photophobia and phonophobia, and usually appear when there’s an insult to the meningeal linings of the brain, which is why they are listed as symptoms of meningism or meningeal involvement.
This symptom is very important in the diagnosis of migraines, and patients must either have nausea and vomiting, high sensitivity to light and/or sound, or both symptoms at the same time. Other less common neurologic findings that some patients may report in cases of migraines are paralysis or weakness in one side of the body, vertigo, difficulty to speak or coordinate speech, and other symptoms we will describe when talking about migraine auras.
4. Red eyes
It is also known as conjunctival hyperemia, and it is common in patients with migraines and cluster headaches. The headache is located on one side of the brain, and the eye on the same side is taken and looks red. In most cases, patients may report pain in the area surrounding the eye, located in the eyeball or dull pain in a deeper structure near the eyes.
This is because the eyes are innervated by a cranial nerve called trigeminal nerve, which is very important in the development of migraines. This cranial nerve affects the blood flow to the eyes, and it results in a strange sensation in the ocular area. However, the trigeminal nerve does not cause a vascular hemorrhage. Red eyes typically result from the constant rubbing of the affected eye or might result from vomiting and other types of physical strain a patient with migraine constantly has.
5. Excessive tearing
Another function of the trigeminal nerve is associated with the production of tears. Since migraine patients usually have an alteration in the trigeminal nerve, it becomes overactive and triggers excessive tearing, even if there’s no foreign object to clear in the eyes. Excessive tearing is unilateral, which means only one eye is affected by this condition, and it usually has conjunctival hyperemia and associated ocular pain in the same side of the head.
6. Nasal discharge and nasal congestion
The eyes and the nasal cavities are connected through a series of tubules that drain tears into the nose, which is why crying is always followed by nasal discharge. Similarly, excessive tearing leads to nasal discharge in the side affected by the headache symptoms. Such a discharge is usually crystal clear because it is formed mainly by tears.
Moreover, certain types of migraines trigger an inflammatory reaction mediated by histamines, a substance that is commonly involved in allergies and respiratory infections. Histamines in the blood vessels of the nasal cavity mediates vasodilation of the blood vessels, leads to fluid loss by osmosis and activates the cells that produce mucus. Thus, many patients do not only experience an annoying nasal discharge but nasal congestion as well.
7. Swelling in the eyelids
Another symptom mediated by histamines is an abnormal and temporary swelling or edema in the eyelids. Similar to what we have already described in the nasal cavity, in a very specific type of migraine headaches, we have an abnormal discharge of histamines that affects the blood vessels in the eyes and eyelids. This leads to the dilation of the blood vessels, filtration of liquids out of the blood vessels in the eyelids and collection of water in the interstitial tissue.
This symptom is called palpebral edema, and it is an alarm sign in cases of food allergies and other types of allergic reactions. Thus, it is very important to talk to your doctor if you have this and any other concerning symptoms to be able to differentiate one medical condition with other life-threatening problems that may arise in the same patient.
8. Excessive sweating
An additional side effect of histamines in patients with migraines is that it activates brain centers associated with anxiety, triggers the sympathetic nervous system, and interacts with the neurotransmitter acetylcholine. That is how migraines trigger excessive sweating, which may be seen only in the area of the face and neck, and this symptom may be found in the affected side only.
9. Pupil alterations
In many patients with migraines, you will find an asymmetric pupil, one that either dilates more than the other or does not dilate properly. This is usually seen in cluster headaches, ocular migraines, and migraines associated with ocular pain and similar signs and symptom. Pupil asymmetry is an essential sign to diagnose this type of migraine and is usually encountered by the doctor, who has the equipment and skill to evaluate the correct pupilar function of the eye.
10. Nervousness or agitation
There are many reasons why patients with migraines feel anxious or agitated. The prolonged headache symptoms are major contributors because the typical migraine headache lasts for 4 hours or more, and may even extend for more than one day. Moreover, pain triggers the sympathetic nervous system, which is specialized in the fight-or-flight response. This may also trigger the release of adrenaline to the bloodstream and lead to nervousness and agitation as a consequence.
11. Visual alterations
Patients with migraine may report various types of ocular symptoms before and during the attacks. There’s a subtype of migraines called retinal migraine, which features a series of visual alterations in only one eye that may be mild as in twinkling lights or severe as in total blindness. These symptoms should be differentiated from aura symptoms, which are very similar but not as intrusive as retinal migraine symptoms. It is very difficult to differentiate whether you’re suffering from a retinal migraine or a migraine with an aura, so if you have visual symptoms associated with a recurrent headache, it would be a good idea to talk to your doctor about your symptoms before starting with any treatment.
12. Migraine visual aura
Many patients with migraines experience auras, which is a series of sensory disturbances or sensations that signal or precede migraine attacks. There are many types of aura, but each patient usually experiences the same before an upcoming migraine, and this may even become useful to start medications early and prevent more severe symptoms.
Auras are divided into three types: sensory aura, which is either visual, auditive, a change in smell perception, and others; language aura, which is an impairment in the speech, difficulty to use language, find the right words or articulate properly; and finally motor aura, which is associated with weakness or paralysis, which commonly appears in one side of the body, and it is the least common type of aura.
The most common aura symptoms in migraines are visual disturbances that include zig zag lines, blind or colored spots, stars, sparkles or flashing lights, tunnel vision, a distortion in shape or size in the visual field, or just an increased sensitivity to light.
Other patients describe symptoms such as abdominal discomfort or sudden sensation of nausea and bloating, an unexpected sensation of fear and anxiety, confusion, cognitive problems, forgetfulness, and even psychiatric symptoms such as feeling that one is separated from one’s own body.
13. Postdromal symptoms
Even after the headache has ceased, patients are left with remaining symptoms that are clinically referred to as postdromal symptoms. Patients after a long migraine attack often feel irritable and tired. The opposite might be true as well, and they may also experience a euphoric and refreshed feeling. It is common to have muscle soreness and weakness as a result of the prolonged stress caused by migraine pain. These symptoms may be persistent for up to 24 hours after headache has ceased.
Treating migraines is often a challenge among doctors, and there are medications to alleviate the symptoms and other preventive medications patients can use as prophylactic to reduce the recurrence of migraine attacks. Treatment of this type of headache with nonsteroidal anti-inflammatory drugs is often not enough to improve the symptoms, and patients often need a combination of analgesics with compounds called ergot alkaloids and antiemetic drugs when there is nausea or vomiting involved.
Another part of the treatment of migraines should be achieved by the patient because there are various triggers you can identify and avoid to prevent the onset of migraines. One of the most common triggers is stress, but certain foods, sleeping habits, altitude changes, and medications may also start a migraine. Since there are so many variants in the treatment of migraines, it is important to be properly guided by a physician before trying to treat recurrent headaches affecting one side of the brain, associated with either nausea/vomiting of light sensitivity and at least two of the symptoms we have described in this article.
References
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Cutrer, F. M., & Charles, A. (2008). The neurogenic basis of migraine. Headache: The Journal of Head and Face Pain, 48(9), 1411-1414.
Perciaccante, A. (2008). Migraine is characterized by a cardiac autonomic dysfunction. Headache, 48(6), 973-973.
May, A., & Goadsby, P. J. (1999). The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation. Journal of Cerebral Blood Flow & Metabolism, 19(2), 115-127.