The fight against migraine
Symptoms, treatment, causes – pain specialist explains
According to the German Medical Journal, migraine is the most common neurological disorder. Six to eight percent of all men and even more women—12 to 17 percent—suffer from migraine. There is no special migraine diet. However, there are some triggers that can promote this type of headache. Dr. Wolfgang Welke, chief of Special Pain Medicine at the Sportklinik Hellersen, explains the most important facts about migraine in an interview.
Video: The fight against migraine
What is migraine, in fact?
Dr. Wolfgang Welke: Migraine is a very debilitating type of headache that affects many people and significantly reduces their quality of life. There are different types of migraine. These vary, for example, in the frequency of attacks—some patients experience migraine attacks only twice a year, while others have them daily or several times in a row. The latter usually require long-term preventive medication. There are migraines with neurological deficits, such as paralysis, numbness, or visual disturbances. Another form is perimenstrual migraine, which is associated with hormonal changes during a woman's menstrual cycle. These are often patients who are bedridden for several days and suffer greatly from the symptoms.
The major risk associated with migraines is that patients take non-steroidal painkillers such as ibuprofen, naproxen, or diclofenac relatively freely to relieve the pain. However, this uncontrolled use can damage organs and even lead to drug dependence. There is a type of medication-induced headache in which frequent use of painkillers itself leads to headaches.
What are the typical signs of a migraine?
Dr. Wolfgang Welke: The pain is described as moderate to very severe, usually requiring acute medication. Attacks of throbbing headaches, often on one side of the head, irregular, sometimes daily, accompanied by nausea and vomiting as well as sensitivity to light. Often, one side of the forehead, temples, or eye area is affected. Changes in the sense of smell and taste or other neurological deficits may occur.
Patients may say beforehand: “Here it comes!” They have preliminary symptoms such as visual field defects, flickering eyes, or nausea. This is why we refer to migraine with aura (with preliminary symptoms) or without aura. We ask about all of this in order to obtain a reasonable headache history from the patient, as there are over 100 different types of headaches. And migraine is just one of them. For successful treatment, the type of headache must be correctly diagnosed.
“We are clearly trying to get to the bottom of the cause.”
Dr. Wolfgang Welke
Chief of Special Pain Medicine
When should a migraine be treated by a doctor?
Dr. Wolfgang Welke: It is always important to get to the root cause. Comorbidities, i.e., additional health problems that can occur alongside the primary condition, should be taken into account. One example of this is problems with the cervical spine, such as herniated discs, disc protrusions, or narrowing of the spinal nerves, which can lead to cervicogenic headaches. Cervicogenic headaches arise from problems in the cervical spine or neck area, can extend to the head, and can therefore also be associated with migraine.
In such cases, it may be necessary to provide orthopedic pain therapy as part of the treatment or as a preventive measure. This may reduce the frequency of attacks, both in terms of number and intensity.
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Das heißt, es werden nicht nur die Symptome behandelt?
Dr. Wolfgang Welke: Zuerst sollte bei einem Migränepatienten geschaut werden, welche Symptome auftreten, um die Migräne zu klassifizieren. Ist es wirklich ein einseitiger Kopfschmerz? Bei einem Fünftel der Fälle sind allerdings auch beide Seiten betroffen. Und in 80 Prozent der Fälle ist der Migränekopfschmerz auch – anders als man es klassisch in den Büchern liest – mit einem Spannungskopfschmerz vergesellschaftet. Das heißt, es ist oft eine Mischform von Kopfschmerzen.
Die Patienten erhalten bei uns ein Kopfschmerztagebuch. Darin notieren sie genau, bei welcher Gelegenheit der Kopfschmerz auftritt, wie lange er dauert und wie oft er pro Woche und Monat vorkommt. Anhand dieser Erkenntnisse kann man schon ziemlich klar sagen, an welcher Kopfschmerzform der Betroffene leidet.
Was können mögliche Ursachen für Migräne sein?
Dr. Wolfgang Welke: Die Ursache der Migräne ist umstritten. Man geht davon aus, dass das mit einer Durchblutungsstörung, speziell einer Erweiterung im Rahmen der Meningealgefäße, also der Hirnhautgefäße zusammenhängt. Das wiederum hat höchstwahrscheinlich mit einem bestimmten Neurotransmitter zu tun, nämlich Serotonin, dessen Vorläufer die Aminosäure Tryptophan ist. Bei diversen Mangelzuständen kommt es zum Serotoninmangelsyndrom und einer Gefäßdysregulation. Die Migränepatienten sprechen häufig von einem pulsierenden, pulssynchronen Kopfschmerz – auch ein kleiner Hinweis darauf, dass die Gefäße irgendwo involviert sind.
So it's not just the symptoms that are treated?
Dr. Wolfgang Welke: The first step in treating a migraine patient is to identify the symptoms in order to classify the migraine. Is it really a headache on one side of the head? In one-fifth of cases, however, both sides are affected. And in 80 percent of cases, migraine headaches are also associated with tension headaches, contrary to what is typically described in textbooks. This means that it is often a mixed form of headache.
We give patients a headache diary. In it, they note exactly when the headache occurs, how long it lasts, and how often it occurs per week and per month. Based on this information, it is possible to say quite clearly what type of headache the patient is suffering from.
“We give patients a headache diary. In it, they note exactly when the headache occurs, how long it lasts, and how often it occurs per week and month.”
Dr. Wolfgang Welke
Chief of Special Pain Medicine
What are the possible causes of migraine?
Dr. Wolfgang Welke: The cause of migraine is controversial. It is assumed that it is related to a circulatory disorder, specifically a dilation of the meningeal vessels, i.e., the vessels of the meninges. This, in turn, is most likely related to a specific neurotransmitter, namely serotonin, whose precursor is the amino acid tryptophan. Various deficiencies can lead to serotonin deficiency syndrome and vascular dysregulation. Migraine patients often describe a pulsating headache that is synchronized with their pulse—another small indication that the blood vessels are involved somewhere.
What might treatment look like once the symptoms have been identified?
Dr. Wolfgang Welke: First, a distinction is made between acute and chronic migraine. Chronic migraine—defined as more than three attacks per week lasting more than three or four days—may be an indication for migraine prophylaxis.
Many patients take nonsteroidal medications for acute migraine attacks. Naproxen, on the other hand, is very often helpful for menstrual migraine.
As I said, duration and frequency are important, and it may well be that with sensible prophylaxis, for example with a beta blocker, the frequency of attacks can be drastically reduced, making the whole thing bearable.
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What about other cases?
Dr. Wolfgang Welke: In a migraine emergency, the patient cannot get out of the attack, has extreme headaches, and is admitted to the hospital for acute treatment. Here, Aspisol—an aspirin infusion, a Novalgin infusion, a paracetamol infusion, or intravenous cortisone—can be administered to get this severe condition under control as quickly as possible. A subcutaneous injection or nasal spray of a triptan can also help very quickly. These are a class of drugs that have been specifically developed for the treatment of migraine attacks and have revolutionized migraine therapy. They are well tolerated and highly effective in migraine attacks.
“That's always the goal: as few migraine attacks as possible.”
Dr. Wolfgang Welke
Chief of Special Pain Medicine
In most cases, patients do not come to the pain clinic first. What is the typical journey for a migraine patient?
Dr. Wolfgang Welke: That's right, patients often come to us pain specialists at the end of the chain. The normal route is usually for the patient to see their family doctor first. They should also definitely see a neurologist, as headaches can have other causes, including meningitis or a brain tumor. An EEG and a cranial MRI are therefore usually necessary. An MRI of the cervical spine is also necessary to clarify the orthopedic history. If the symptoms and the evaluated pain questionnaire confirm that it is migraine, it can be treated with medication and behavioral therapy. Diet also plays a major role, as do the patient's behavior and occupation or posture at work. Stress and psychological strain are common triggers for migraine attacks. If a few factors are changed, the number of attacks will already decrease. And that is always the goal: as few migraine attacks as possible.
Can migraine be completely cured?
Dr. Wolfgang Welke: There are cases where migraine disappears – in women, this usually happens during menopause. There are patients who only develop migraines after menopause. This is difficult to predict. What is definitely possible is to pay attention to the triggers. These include, for example, magnesium deficiency, dehydration (you should drink at least two liters a day), lack of sleep, electrolyte imbalance, and a deficiency in vitamin D or B6 vitamins.
