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Migraine occurs at five trigger zones:
Medials border of the supraciliar arch, close to the insertion. Medial part of the proximal/anterior fibres of temporal muscle, close to its insertion surrounding the saggital suture. Sub occipital area at the level of insertion of thick muscles of neck. Occipital area surrounding the emergence of the Arnold’s nerve, medial area of the superior trapezius in the neck. With the above number of trigger points and location of these points along with the accompanied characteristics features of unilateral location, photophobia and phonophobia (Calandre et al, 2006).
Migraine occurs with many triggers like:

a. Stress (relief of stress)
b. Lack of Food or Infrequent Meals (missing meals)
c. Certain Foods (including of products like caffeine, tyramine, alcohol, monosodium glutamate)
d. Changing Sleep Patterns (weekend lie-ins or shift work)
e. Hormonal Factors (menstrual cycles, oral contraceptives)
f. Over tiredness /Over-exertion (both physical or mental)
g. Extreme Emotions (anger and grief)
h. Environmental Factors (loud noise, bright lights, strong smells, hot stuffy atmosphere)
i. Climatic conditions (strong winds, extreme cold or hot)
j. Obesity is a risk for migraine(progress from episodic to chronic migraine) (Scher et al 2003)

Stages of Migraine Attack:
In human beings, migraine is different, which includes five stages that distinguish migraine from another headache.

Premonitory or warning phase:
It is also known as prodrome phase were certain physical and mental changes such as tiredness, mood changes, feeling thirsty and a stiff neck. This symptom lasts about 1 to 24 hrs.

Aura phase:
This stage includes a wide range of neurological symptoms lasting for 5 to 60 minutes, where migraine without aura does not include. Symptoms include dark or colored spots, numbness, vertigo, speech and hearing disturbance, confusion, partial paralysis. Around 20% children and young people experience “aura”.

Main attack:
In this phase, you will have cephalgia or abdominal pain, nausea, vomiting decrease in concentration and sensitive to light or sound.

Resolution /Postdrome stage:
This phase is the final stage of attack; symptoms mimic first stage and lasting about hours or days to disappear the feeling of hangover or tiredness (migrainetrust.org).

Diagnosis of Migraine:
Migraine can be diagnosed on the basis of frequency and number of attacks and associated with typical warning signs and symptoms. It is typically manifest by episodic headache though it is more than just head pain

Differential Diagnosis:
Migraine is typically diagnosed from Tension Type Headache (TTH) as it lasts about hours or days as TTH is chronic present more often. Migraine varies from cluster headache with unilateral headache with autonomic dysfunction and other type is medication overuse headache (MOH) which is transformed into chronic daily headache similar to that of chronic TTH with some migrainous features.
According to International Headache Society Criteria, migraine is of two types: Migraine with Aura (Table No.: 1) and Migraine without Aura (Table No.: 2). Note that trigger factors, family history, treatment response have no additional diagnostic value.

Migraine without Aura (MO) is often known as common migraine characterized with episodic diabling headache lasting about few hours to few days accompanied with gastrointestinal symptoms or by heightened special senses it displays the criteria of IHS with generalized or mild pain and does not have to be severe or unilateral. This is common within patients referred with “intractable migraine” or “status migrainosus”.

Migraine with Aura (MA) is often called as focal or classical migraine. Aura affecting movement, sensation, cognition, vestibular function or consciousness may difficult to distinguish with thromboembolism or epilepsy patient presenting recent onset of MA gives longer history of MO mistakenly diagnosed as “bilious attacks”,” sinusitis” or normal headache.MA often without headache triggers fearing transient ischemic attacks(TIA).

Table No. 1: Diagnostic Criteria for Migraine with Aura (i-h-s.org /2004)

Table No. 2: diagnostic criteria for Migraine without aura (www.i-h-s.org /2004)

Examination and Investigations:
The main goal of examination and investigation is to consider brain disease and to screen out hypertension and depression along with exclusion of causes of migraine like symptoms but no tests to confirm migraine. Investigations include brain scan which is referral to find the early diagnosing of neurological disorders which provides impossible workload of 18% women, 6% men have migraine, 3% have chronic daily headache.
Other tests include erythrocyte sedimentation rate (ESR) in early headache of geriatrics which address temporal arteritis and chest X-ray in smokers to consider metastatic cancer.

Pain Management of Migraine:
Pain is generally cured both non-pharmacologically and pharmacologically with the help to treat acute episodes and prophylaxis. Pharmacological treatment of migraine affects primarily to alleviate head pain, avoiding headache recurrence and immense use of rescue medications (Landy 2004, Stewart et al 1992).

Non-pharmacologic treatment of migraine includes cognitive behavior therapy.
Cognitive Behavioral Therapy (CBT): It is based on principle that anxiety and distress are aggravators of an evolving migraine headache.it is designed to help patient identify and modify maladaptive response that may trigger or aggrevate a migraine headache (Selby,1960). Stress management training is often part of treatment. CBT is usually combined with other behavioural therapies but it is more effective as its own (Bakal et al. 1981, Richardson 1989).These technique are combined with biofeedback therapy (a technique where people learn to sense changes in the body activity and to use relaxation and other methods to control body responses (hartp.neurology.ucla.edu), although uncontrolled studies have shown their efficacy in reducing efficacy, duration and frequency of headache when used alone (Sorbi 1984, Warner 1975).

Complementary Treatments: These includes acupuncture or acupressure (19%), massage (42%), exercise (30%) and chiropractice (15%), herbs (15%) etc. In acupressure with the help of fine metal needles or mechanical pressure the acupuncturist manipulates energy called Chi or Qi. In massage, relaxation of the body releases stress buildup in muscle tissue and teaches body awareness (hartp.neurology.ucla.edu).

Yoga therapy: Yoga, coupling physical exercise and breathing, meditation are the alternative form of mind body therapy and used to lower the symptoms of chronic pain, emotional stress, anxiety and depression (Kim et al. 2005, Kakigi et al., 2005). It has potential effect as therapeutic intervention in various chronic disease conditions. Yogic breathing is a unique method for balancing the autonomic nervous system and influencing psychologic and stress-related disorders (Mel, 2002). These practice of yoga is carried in prodromal stage and not in resolution and postdromal stage (John et al 2007).

Other Supplement Treatments:
Some of the vitamins as well as mineral supplements are responsible in treatment of migraine which is observed in scientific studies that potentiates the treatment.
Riboflavin: It is vitamin B2, which is important for energy metabolism. The rationale for using riboflavin is that it helps in boost brain metabolism. It is taken about 400 mg per day.

Melatonin: It is used as homeopathic sleep aid and to help with jet lag, but no significant studies in treating migraine or other headache, useful in treating sleep disturbances. It is taken 3-6 mg at bedtime.

Magnesium: Magnesium has wide function in our body, fluctuations in levels of magnesium results in triggers of migraine. It is given about 300-500 mg per day.

Co-Enzyme Q10: It is very essential constituent of cells that involves metabolism. In migraine triggers it is used to increase Q10 levels that increase brain metabolism. It is given about 300-600 mg per day (hartp.neurology.ucla.edu).

Feverfew: 1 CAPSULE 3-4 times per day for 1 month if effective the dosage may slowly have reduced. Avoid during pregnancy and with NSAIDS (hartp.neurology.ucla.edu).

Lifestyle Modifications: Lifestyle impacts the severity and frequency of migraine can be understand and useful for successful prevention of migraine.

Sleep: Maintain consistent sleep patterns, including weekend and holidays

Exercise: A routine of 20-40 minutes of aerobic exercise can relieve stress and maintain balance internal physiology.

Eating: Maintain regular meals and take good diet.
Reduce stress and increase posture: Reduce stress with yoga, meditation and maintain posture that imparts migraine triggers


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