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Integrated Pain Management



A migraine…

can be described as a neurological disease characterized by recurrent headaches which are either moderate or severe. The disease is often associated with some autonomic nervous system symptoms.

In most cases, the headache will affect one side of the head and the pain will come in a pulsating nature and will last anywhere from 2 to 72 hours.


Migraines are believed to emanate from a combination of genetic and environmental factors. About 66% of migraines run in the family. Hormonal level changes are also thought to be connected to migraines as studies show that during puberty, more boys are affected but in adulthood, 2-3 more women than men are affected.

During pregnancy, the risk of migraine is known to greatly decrease. Though the exact causes and mechanism of migraine are not known, medical experts believe it is a neurovascular disorder.

This theory is based on the abnormal control of the pain neurons located in the brainstem’s trigeminal nucleus and the excitability of the cerebral cortex.

Phases of a Migraine

In most cases, Migraines will occur with headaches that are recurrent and connected to autonomic symptoms. 15%-30% of individuals with migraines will experience them with an aura and will also have headaches without an aura.

The duration of the headache, the pain severity and the attack frequency are always varying. Migraines that last for a duration of over 72 hours are referred to as status migrainosus.

A migraine comes in four phases but it is not always that an individual will experience all the four.

Prodrome Phase

Premonitory or prodromal symptoms are experienced by about 60% of people with migraines. This happens with an onset ranging from 2 hours to 2 days before they start experiencing the aura or the pain.

Symptoms in this phase can include mood alteration, fatigue, euphoria or depression, certain food craving, stiff neck muscles, diarrhea or constipation, and sensitivity to noise and odors. This will occur in people with an aura and those without.


Aurae are transient focal neurological phenomena that happen before the headaches and sometimes during the headache. 30-40% of people who experience aurae will also get a sensory aura.

This is usually a pins and needles feeling that starts from one arm and spreads to the mouth-nose area on the same side as the arm.

Other symptoms include language or speech disturbance, word spinning and sometimes though rarely, a motor problem.


Typically, the headache or the pain is throbbing, unilateral and can range from moderate to severe. The headache comes gradually and is mostly escalated by physical activity.

In over 40% of migraine cases, the pain experienced is bilateral and neck pain is a common occurrence. In adults, the pain lasts between 4 and 72 hours and in children, it has been found to occur for a period less than an hour.

The pain frequency varies from a number of cases in a lifetime to several in a week with the most common frequency being once in a month.



The effect of a migraine can be felt a few days after the main pain or the headache is over. This is what is referred to as the migraine postdrome.

Most people who have experienced migraines report experiencing a sore feeling where the pain was and there are reports of impaired thinking during this period.

The symptoms of this phase are fatigue or a ‘hang over’ feeling, cognitive difficulties, mood altering, weakness and gastrointestinal symptoms. The feeling after a pain attack can be refreshing and euphoric, or malaise and depression.

Causes of a Migraine

Migraine causes are not known. Though this is the case, they are believed to be a result of a mix of genetic and environmental factors.

Most migraines run in the family and will rarely occur as a result of single gene defects. Initially, it was believed that migraines occur in people with a high intelligence but this has been disapproved.

There are many biological events associated with migraines as are psychological conditions such as bipolar disorder, anxiety and depression.


It is believed that migraines are neurovascular disorders. Some medical researchers have placed neuronal mechanisms as playing the greater role while others believe that blood vessels are at the center of migraines and the other group believes that both the neuronal mechanisms and blood vessels are involved.

5-hydroxytryptamine or neurotransmitter serotonin in high levels is believed to be another element involved in the occurrence of migraines.


The signs and symptoms of a migraine are what its diagnosis is based on. There is no need for neuroimaging tests when diagnosing migraines but this test might be used in other headache cases that are not migraines.

Studies have shown that a good number of people with migraines have not been diagnosed. If an individual experiences 2 of the following: inability to work or study in a day, nausea, or photophobia it is possible that they have a migraine.

If they experience 4 of the following: pain occurring on one side of the head, pulsating head ache for a duration of between 4 and 72 hours, nausea, and other symptoms that affect their personal life, then the chance of this being a migraine is 92%. For people with less than 4 of the above signs and symptoms, then the probability drops to 17%.



Preventive migraine treatment can include nutritional supplements, lifestyle changes, medications and surgery. Experts recommend prevention in people with headaches occurring more than 2 days in a week, have severe uncontrollable attacks or cannot tolerate acute attack medication.


The preventive medications for migraines are only considered effective if they decrease the severity and reduce the frequency of the attacks by 50% or more. Some of the medications that are used include propranolol, metoprolol, topiramate, divalproex/sodium valproate and timolol. Frovatriptan has been found to be effective in the prevention of menstrual migraine.

Tx360 is another solution, a migraine treatment device, it has help sufferers almost 90% of the time

Alternative therapy

Acupuncture has been found to be equally effective but with less side effects as compared to preventive medication. Stress reduction techniques such as biofeedback, relaxation and cognitive behavior therapy have been found to be effective. Of all the alternative medicines used in dealing with migraines, butterbur has the best evidence for use.


For people who do not show any improvement with medication surgery is recommended. This is the decompression of some nerves located around the neck and the head.


Management of migraine is through three aspects: pharmacological prevention, acute symptomatic control, and trigger avoidance. While medication is effective in early attack stages, an over use may cause ‘medication overuse headache’ leading to more severity and increased frequency. This is why it is recommended that any person with migraines or recurrent headaches seeks proper medical attention.