Dr Rajisha Ramachandran
Migraine is one of the most common neurological disorders. It is classified as a primary headache disorder characterized by recurrent headaches, typically unilateral which lasts for 4-72 hours, associated with nausea, vomiting and photophobia. It may or may not be associated with aura. Migraine without aura is also called common migraine. The incidence of migraine is increasing now days probably due to modern food habits and the stresses and strains of life. The world health organization has listed migraine as a significant public health concern and the major cause of years of life with a disability.
Migraine is a recurrent headache disorder affecting ˜15% of the population, during the formative and most productive periods of their lives between the ages of 22 and 55 years.1
Migraine is an inherited headache disorder that is typically unilateral, moderate to severe, worsened by routine physical activity, associated with nausea and vomiting and accompanied by photophobia and phonophobia, which lasts for 4 to 72 hours.2
Migraine is 3 times more common in women than men and is influenced by hormonal levels, such as oral contraceptives, pregnancy, postpartum and menopause. The frequency, intensity and duration of attack vary in the same individual at different times, brought on by triggering factor such as stress, lack of sleep, intake of caffeine, alcohol and menstruation.
Both during and between attacks, migraine sufferers may experience symptoms of depression, anxiety, exhaustion, increased levels of stress, frustration, and apprehension. It is also associated with the impairment of social, family, and work-related activities.
RISK FACTORS OF MIGRAINE:3
|Modifiable factors||Un-modifiable factors|
Snoring and sleep apnoea
Low education or
low socioeconomic status.
Medications such as opiates, barbiturates, anti-inflammatory, OCP ‘s, Anti-hypertensives, Antibiotics, histamine-2 blockers medications have been associated with higher risk of progression of migraine.
Alcohol, Tobacco, Beverages, Red wine have association with migraine attacks. But sudden withdrawal of caffeine in individuals with migraine is associated with rebound headaches which suggest caffeine to be a risk factor.
Stressful life events
Chronic migraine was also found to be more common in women with major depression disorders.
Individuals with BMI >30 have five times higher risk of having headaches, whereas individuals with BMI ranging from 25 to 29 have three times a higher risk.
Snoring and sleep apnoea
Snoring can be related any type of headache. This association is independent of weight, age, gender.
Alterations in membrane excitability can predispose to migraine.
- Sleep disturbances
- Bright light/ visual stimuli
- Weather changes
- Alcoholic beverages
- Ice cream
PATHOGENESIS OF MIGRAINE:
- Exact mechanism is unknown; it is the consensus that an attack of migraine consists or a neuromuscular disorder of the intracranial as well as extra cranial vessels. Sequential studies of cerebral blood flow show an initial reduction, which may be localized or generalized followed by increases in blood flow later. The basic cause of these circulatory disturbances is unknown. it is found those blood levels of serotonin, histamine and norepinephrine increases during the attacks. There is also an increase in platelet aggregability. This may account for strokes, which complicates migraine. The headache has been attributed to extreme pulsation of extracranial as well as. intracranial arteries.5
- There is now good evidence that in classical migraine there is extreme cerebral oligemia at the onset of the attack. This is often occipital in site but may spread to the parietal and temporal lobes. Oligemia may be secondary to some primary cortical dysfunction, since attack can be set off by neural stimuli like bright light or strong odours. Others believe that vasospasm is responsible for the initial dysfunction.
- During headache phase there is dilatation and oedema the extra cranial arteries and probably some alteration in pain sensitivity in their walls. These vascular changes may be due to fluctuation in blood 5 hydroxy tryptamine levels.6
CLASSIFICATION OF MIGRAINE:
International Classification of Headache Disorders III (ICHD- III) has classified migraine as follows:
- Migraine without aura
- Migraine with aura
- Migraine with typical aura
- Typical aura with headache
- Typical aura without headache
- Migraine with brainstem aura
iii. Hemiplegic migraine
- Familial hemiplegic migraine (FHM)
- Familial hemiplegic migraine type 1 (FHM1)
- Familial hemiplegic migraine type 2 (FHM2)
- Familial hemiplegic migraine type 3 (FHM3)
- Familial hemiplegic migraine, other loci
- Sporadic hemiplegic migraine (SHM)
- Retinal migraine
- Chronic migraine
- Complications of migraine
- Status migranious
- Persistent aura without infarction
iv. Migranious infarction
- Migraine aura-triggered seizure
MAJOR TYPES OF MIGRAINE:
Migraine has two major types:
- Migraine without aura:
- Migraine with aura:
Migraine without aura: Is a clinical syndrome characterized by headache with specific features and associated symptoms.
It is also known as ―Common migraine‖ or ―Hemicrania simplex‖. It is a recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia. The location of pain is usually in the frontotemporal region.
Migraine with aura: It is primarily characterized by the transient focal neurological symptoms that usually precede or sometimes accompany the headache.
It is also called ―Classical migraine‖ or ―Complicated migraine. It is characterized by repeated attacks of unilateral, completely reversible visual, auditory and other CNS symptoms that last minutes and are typically accompanied by headache and other migraine symptoms The aura is a complex of neurological symptoms that occurs usually before the headache, but it may begin after the headache phase has commenced or continued into the headache phase.7
CLINICAL FEATURES OF MIGRAINE:
Location of Headache – Frontal/ Temporal region, most common unilateral which is characteristic.
Characteristic- It is pulsatile or throbbing in nature and commonly has some precipitating or triggering factor producing the onset.
- Visual disturbances
- Altered consciousness
Here episode begins with prominent neurological symptom such as visual disturbances as zig zag fines, spreading scotoma homonymous hemianopia, field defects or rarely total blindness, sensory disturbances as affecting one half of body or paraesthesia, disturbances of speech or hemiparesis may be present. These symptoms are associated with focal cerebral oligemia. There is commonly a sensation of white or coloured lights, scintillating spots, wavy lines or defects in visual fields. Sometimes there may be numbness of both hands and around the mouth. These symptoms may last for up to half an hour and are followed by head ache which begins in one spot and subsequently involve the whole one side of head, this may be same side or side opposite to the visual or sensory disturbances.
Here there are no preceding neurological symptoms but there is unheralded onset of headache nausea and vomiting following the same sequence.
It is a vascular headache or a migranious variant. The name cluster headache refers to its occurrence 4n bouts. Disease is more common in males. Male: Female ratio is 4:1. The headache starts within 3 hours of falling asleep, it is non throbbing unilateral and orbital in location.
Along with pain there may be lachrymation, nasal obstruction, rhinorrtioea and sometimes miosis, ptosis. flushing and oedema of cheek all lasting approximately an hour or two. It tends to occur every night for weeks or months followed by complete freedom for years. Such dusters of headache may occur over years.8
COMPLICATIONS OF MIGRAINE:
Status migranious: Is a debilitating migraine attack lasting for more than 72 hours. It may be with or without aura. It can also be caused due to medication overuse.
Migraine Stroke: One or more migraine aura symptoms occurring in association with an ischaemic brain lesion in the appropriate territory demonstrated by neuroimaging, with onset during the course of a typical migraine with aura attack.
Persistent aura without infarction: An aura symptom persisting for a week or more without the evidence of infarction on neuroimaging. These are the symptoms that are often bilateral and may last for months or years.
Migraine aura-triggered seizure: A seizure triggered by an attack of migraine with aura, during or within an hour of the attack. This phenomenon, sometimes referred to as ―” migralepsy”, is a rare event.9
A detailed history of headache and other symptoms which includes the following has to be recorded:
- Type of headache.
- Age of onset.
- Frequency and duration of attack.
- Intensity of pain.
- Symptoms associated with pain.
- Effect of headache on everyday activities.
- Family history of headache.
- Changing patterns of headache if any.
- Triggers of headache.
- Treatment history.
- Examination is done to rule out neurological problem.
Negative history to be ruled out includes-
- H/o fever, head injury, trauma, infections and neck stiffness.
- Mental confusions, seizures.
- Loss of consciousness.
- Vertigo, tinnitus and numbness of parts.
- Other associated systemic illnesses like hypertension
MANAGEMENT OF MIGRAINE:
The management of migraine may include
- non-pharmacological approach (includes preventive measures)
- Pharmacological approach- It can be acute (abortive) or preventive, and patients with frequent severe headaches often require both approaches.
There is no cure at the moment for migraines; there are only ways to reduce the pain or avoid the triggering factor, which may reduce the frequency or severity.
Some of the measures that can be employed are:
- Avoidance of stress, noise, odour, bright and flickering lights, exertion.
- Behavioural changes — avoid sleep deprivation, excessive sleep.
- Medications — avoid oral contraceptives, hormone replacement therapy,histamine- 2 blockers.
- Proper diet – avoid fasting, skipping meals & food that are known to cause migraine.
- Relaxation therapy—breathing exercises and muscle relaxation.
- Cognitive-behavioural therapy—identification and avoidance of behaviours or responses to migraines that may exacerbate a migraine attack.
- Acupuncture which originates from Traditional Chinese Medicine (TCM), dating back 3000 years. In acupuncture, fine needles are inserted into the body at specific locations. The needles stimulate the chi (the flow of energy through the channels within the human body).
- Massage and Physical therapy- Massage involves a therapist pressing, stroking, rubbing, kneading and pressing on the body ‘s tissues and muscles. There has also been evidence that massage for migraine sufferers may help reduce the number of attacks.10
STUDIES DONE IN HOMOEOPATHY:
- Mohanty et.al., conducted a single blind placebo controlled randomised clinical trial to explore the efficacy of homoeopathic medicines in the treatment of migraine carried out on 60 participants, assigned to two groups; test group (n=30), control group (n=30). Result shows that Females were more commonly affected than males and the incidence was higher in the second and fourth decades of life and lower in elderly people. Paired t-test was applied to observe the difference in groups and found statistically significant (p<0.0001). Natrum mur was the most frequently prescribed homoeopathic medicine. Onosmodium and Prunus spinosa were also frequently prescribed in acute conditions. Study concluded that Homoeopathic medicines were effective in the treatment of migraine in this study.11
- Brigo et. al., conducted a double blinded randomised controlled trial to assess the efficacy of classical homeopathic treatment for migraine on 60 participants. Placebo or one or two of the following homeopathic remedies in potency C30: Belladonna, Ignatia, Lachesis, Silicea, Gelsemium, Cyclamen, Natrum muriaticum, Sulphur. Homeopathic remedies or matching placebos were applied in 4 single doses with 2-week intervals. Results shows that Homoeopathically treated patients had significant reductions in the periodicity, frequency, and duration of migraine attacks, while only frequency of attacks was diminished significantly among placebo patients. Overall assessments by patients concerning the efficacy of the treatment were significantly better (p< 0.001) in the Homoeopathically treated group. Study concluded that Homeopathic medicines were found to be effective in the treatment of migraine.12
- Danno et.al., conducted a prospective, multicentre observational study to evaluate the effectiveness of homeopathic medicines for the prevention and treatment of migraine in children on 168 subjects aged 5–15 years, with definite or probable migraine diagnosed using International Headache Society 2004 criteria.
Outcome measures: The frequency, intensity, and duration of migraine attacks in the 3 months prior to inclusion were compared with those during the 3-month follow-up period. The secondary outcome measure was the impact of homeopathic medicines on education, measured as absence from school. Result shows that the frequency, severity, and duration of migraine attacks decreased significantly during the 3-month follow-up period (all p < 0.001). Preventive treatment during this time consisted of homeopathic medicines in 98% of cases (mean = 2.6 medicines/patient). Children spent significantly less time off school during follow-up than before inclusion .13
REPRESENTATION OF MIGRAINE IN REPERTORIES:
Chapter-HEAD, Headache (cephalalgia), Type, Rubric -Migraine, megrim, nervous: Am.c.,Anac.,Anhal.,Arg.n.,Aspar.,Avena,Bell.,Bry.,Caff., Calc.ac.,Calc.c., Can.ind.,Carb.ac.,Ced.,Chionanth., Cim., Cocc., Coff., Crot.casc., Cycl., Epiph., Gels., Ign.,Indigo, Iris, Kali.bich., Kali.c., Lac.d., Lach., Meli., Menisp., Nat. m., Nux v., Onosm., Plat. mur., Puls., Sang., Saponin, Scutel., Sep., Sil., Spig., Stann., Sul., Tab., Thea, Ther., Verbasc., Xanth., Zinc. sul., Zinc. v.14
BOGER BOENNINGHAUSEN’S CHARACTERISTICS AND REPERTORY:
HEAD – Internal – half of, one (migraine etc.)
acon. AGAR. Agn. ALUM. am-c. Am-m. ANAC. ang. ant-c. Ant-t. ARG-MET. Arg-n. Arn. Ars. ASAF. Asar. aur. BAR-C. Bell. bism. borx. Bov. bry. CALC. calc-act. camph. CANTH. caps. carb-an. Carb-v. Caust. Cham. Chel. CHIN. chinin-s. Cic. cimic. CINA clem. COCC. Coff. colch. COLOC. con. Croc. cupr. CYCL. Dig. dros. DULC. eup-per. euph. euphr. ferr. Gels. Glon. Graph. GUAJ. Hell. Hep. hyos. Ign. iod. Ip. Kali-bi. KALI-C. kali-n. Kreos. lac-d. lach. Laur. Led. lil-t. Lyc. Mag-c. Mag-m. MANG. meli. Meny. Merc. MEZ. mosch. MUR-AC. Nat-c. NAT-M. Nit-ac. Nux-m. NUX-V. OLND. onos. PAR. petr. PH-AC. PHOS. pic-ac. PLAT. Plb. prun. PULS. ran-b. ran-s. rheum Rhod. rhus-t. ruta SABAD. SABIN. samb. SANG. SARS. sec. sel. seneg. SEP. Sil. SPIG. Spong. Squil. Stann. STAPH. STRONT-C. SUL-AC. sulph. tab. Tarax. ter. Teucr. Thuj. valer. verat. VERB. viol-o. viol-t. vip. ZINC.15
CONCISE REPERTORY – PHATAK
MIGRAINE- chio, gels, ipec, kalibi, lac defl, nat mur, nat sul, onos,psor. lob, sang, spig, sil, ther.16
Inner head- hemicrania (megrim, migraine)- calc, caps, clem, chin, cocc, cornus, gels, indigo, kali bi, kreos, lach, lac defl, syph, ver.17
INDICATIONS OF SOME HOMOEOPATHIC MEDICINES14, 18, 19,20
It is a deep-seated neurotic disease and by some it is supposed to be of epileptic in nature. It comes periodically. There is frequently boring pain in the head, which is worse in the left frontal eminence. The boring is relieved by tight bandaging. It is excited by any a mental emotion or by anything that depreciates the nervous system, as loss of fluids, loss of sleep or mental strain. Sometimes the pain becomes as severe that the patient loses his consciousness. The paroxysms frequently end in vomiting of bile or sour fluid.
Causes a throbbing, stupefying headache over the left eye. The arsenicum headache is temporarily relieved by the application of cold water.
Flickering before eyes, then blurring. The nausea is made worse by closing the eyes and also by noise.
Headache after any unwanted exertion. The pains excite nausea and fainting. The peculiarity is that there will be obscuration of vision after headache. Headache is decreased by urination.
Headache comes in the morning or at 10 a.m. lasting until 3 pm or evening. The headache is periodical. It is preceded by partial blindness (Iris, gels, Kali bic, psorinum, silic etc.) sensation as if there were little hammers beating in the skull similar to psorium. Headache during menses.
Violent hyperaemia with throbbing carotids red face, intolerance of least, noise or jar. Hemiopia, retinal blindness, slight paralysis of tongue even transitory hemiplegia.
<Afternoon or evening before or during menses
> in a dark room
Migraine which had existed for years with profuse leucorrhoea has been cured with sepia. It is usually left sided and pain extends backwards. Deep stitching pain seems to be in the membranes of the brain. It is so severe that it extorts cries and frequently ends in vomiting. It is < by motion light, noise or by thunderstorm
> sleep, rest in dark room.
It get worse during menstrual periods.
Nux vom is more suited to man than in sepia. The attack commences early in the morning and generally increase to a frantic degree. Headache can be caused by tobacco, coffee, alcohol intake, digestive troubles, constipation and hepatic insufficiency. It suits the gouty and haemorrhoidal subjects. Headache is usually left sided, and is associated with sour taste or perhaps nausea and violent retching. The dull, wooden, busting of head following a debauch is most characteristic of Nux vom. Headache of high livers, business men.
< stooping & coughing, Moving the eyes & motion is general.
A headache all over the head is also characteristic of Nux. vom.
Intense frontal headache preceded by hot flushed face <forenoon. Periodically recurring every few days > epistaxis &Menstrual flow
Hemicrania from excessive use of wine. Nausea Dimness before eyes like a cloud followed by most violent headache > by vomiting.
Headaches are neurasthenic in type, brought on by strenuous exertion. Such as going on a visit, doing a day’s shopping etc. Visions get a little blurred. It is worse on rising from supine position and in the open air. There is a decided relief offer a sound sleep pressive pain in the temples traveling inwards.
< from working in open air. Headache is caused by mental and physical exertion and they are preceded by hunger.
In nervous sick headache which is caused by excitement and over exertion with frequent scanty urination. Associated with restless sleep and night terrors. Worse over right eye, aching in eye balls. Explosive headache of school teachers
< Noise, odour, light
> Night, rest
Frontal migraine in anaemic women with nausea, vomiting and obstinate constipation. Hyperesthesia of sight and hearing. Icy coldness of body even near the stove. Deathly sickness of stomach. Sometimes vomiting < during menses.
Pain over left eye < noise and talking
>rest and cold water
Neuralgic pain in left side of head followed by a film over right eye. Intense darting. pain around left eye.
The patient is affected with blindness objects become obscured; the headache then begins. It is violent and is associated with aversion to light and noise and the sight returns as the headache grows worse. It can be compared with psorinum. In psorinum blindness, before headache and the sight returns before the pain begins.
Migraine with polyuria the urine being perfectly clear. Eyes heavy and blood shot can hardly lift the eyelids. Speech is thick unwieldy.
Migraine with vertigo and nausea, occipital pain is characteristic. Sick headache from riding in a carriage, boat train or cars. headache at each menstrual period with nausea and inclination to vomit. Headache from loss of sleep.
Juglans cinerea is one of the important remedies for occipital headache with hepatic complaints.
Headache commencing with blindness and especially it is also a remedy for headache due to eyestrain (onos). Pain commences in the occiput and comes up over head and settles over eyes. (Cocculus is another remedy for occipital pain). Headache get worse with sun begins at 2 or 3 am and reaches its height at afternoon. It is associated with stiff neck. The patient cannot think effectively or fix his attention. Copious urination relieves the headache and the headache is accompanying with visual troubles such as double vision, squinting and dim sight.
Right sided headache. Pain comes from the occiput. They increase and decreases with the course of the sun, reaching their height at midday. The paroxysms and with profuse urination (Sil, gels, Verat alb). They recover at every 9th day. Sanguinaria also has a menstrual headache, which attends a profuse flow in contrast to sepia, where the menses will be scanty.
When the attack begins with blurring of sight (gels, Kali bic, Nat mur, Psor, Lac.def) are attended with sour watery vomiting. Pain involves the infra orbital and dental nerves, with stupid stunning head ache. Mostly right sided. It is useful remedy for Sunday headache, which occurs in teachers, scholars, professors etc, in which a relief of the strain of the preceding six days; produces the head ache. In sick headache with continuous nausea, it is one of our most useful remedies, and when the headache is produced by eating sweet things, iris is probably the remedy.
<Towards evening, from cold air, coughing, violent motion
>from moderate motion, open air
Pulsatilla is very similar to sepia. Both are indicated by scanty menses, bursting, throbbing, boring or stitching pain on one side of the head obscuration of sight, white tongue, nausea & vomiting pulsatilla has more vomiting, and thickly furred tongue with clammy with mouth and relief from cold air. The pains are shifting in nature and associated with chilliness in the evening.
Right sided migraine shooting pain from right frontal bone through brain to occiput pain in right eye ball as if it would burst.
Sensation as if the temples were crushed together. neuralgic pain in the zygoma tempero maxillary joint and ear, particularly of left sided, with lachrymation, coryza and sensation as if parts were crushed with tongs. Talking, sneezing and change of temperature aggravate the pain also pressing teeth together. Pain seems to come in flashes, excited by least movement, occurring periodically at some hour in the morning and afternoon each day.
A remedy for migraine associated with restlessness and dreams. Pressure from within outward with stretching and yawning and pain down the back. Sick headache, pain in forehead and temples moving to occiput
For migraine in children – Tight feeling in head as if compressed by a rubber band headache. better by green tea, while smoking.
Migraine attack preceded by unusal excitement with loquacity.
Headache with flatulence. Feels as if top of head were opening and shutting and as if calvarium were being lifted.
Periodical headache that comes on in the afternoon and continues to increase till midnight every third attach being more violent than the two previous attacks. Gastric headache with nausea, vomiting and prostration.
Headache of females, brough on by sudden cessation of menses, and it is always better when the patient eats something
Used in migraine with neurological affections. Tearing pain in supra orbital nerve with beat and throbbing pain in head. Trembling in right upper lid. The symptoms are < by rest, when seated
> by movement & pressure
Migraine is accompanied by sparking before eyes. One sided headache. Vertigo things turn in a circle, better in a room worse open air. Frequent sneezing and itching of ears.
Headache from overstudy or overwork occipital pain. Relieved by bandaging tightly worse from slightest mental exertion.
- Migraine causes a significant disability to the sufferers and it is more prevalent among females than men. Homoeopathy was found effective in the treatment and prophylaxis of migraine. The Homoeopathic remedies help in reducing the intensity and frequency of the migraine attack.
- Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology. Journal of Neuroscience. 2015 Apr 29;35(17):6619-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412887/
- Goldman L, Ausiello DA, editors. Cecil medicine. Philadelphia: Saunders Elsevier; 2008.
- Fulkerson P, Miller A, Lizer S. Using WWW-based instruction modules and E-mail for a remote neurology course.
- Martin V, Behbehani M. TOWARD A RATIONAL UNDERSTANDING OF MIGRAINE TRIGGER FACTORS. Medical Clinics of North America
- V. Krishnadas – Textbook of medicine, 5th edition.
- Davidson’s Principles and practice of medicine,20th
- Charles A. The Evolution of a Migraine Attack – A Review of Recent Evidence. Headache: The Journal of Head and Face Pain [Internet]. 2012
- Migraine without aura – ICHD-3, The International Classification of Headache Disorders 3rd edition. 2019. https://www.ichd-3.org/1-migraine/1-1-migraine-without-aura/
- Papadakis M, McPhee S, Rabow M. Current medical diagnosis & treatment 2020. McGraw- Hill Education, New York.
- Farooq M, Gupta A, Goyal M, Walia R. Migraine: Diagnosis and Prophylactic Management. Indian Journal of Pharmacy and Pharmacology [Internet].
- Mohanty N, Sahoo AR, Choudhury S, Jena SK. Homoeopathy in the treatment of migraine: A randomized placebo-controlled clinical trial.
- Brigo SG. Homeopathic treatment of migraines. A randomized double blind controlled study of sixty cases. Berlin Journal of Research in Homeopathy.
- Danno K, Colas A, Masson JL, Bordet MF. Homeopathic treatment of migraine in children: results of a prospective, multicentre, observational study. The journal of alternative and complementary medicine.
- William Boericke’s Pocket Manual of Homoeopathic Materia Medica and Repertory and A Chapter on Rare and Uncommon Remedies: New Delhi, B. Jain publishers; 2002. 702.
- Boger C M. Boger Boenninghausen’s Characteristics and Repertory. Introduction, Head Internal #New Delhi. B Jain publishers; 2002; xxv-xxxii, 250-290.
- Concise Repertory of Homoeopathic Medicines – S.R. Phatak
17. Repertory of Hering’s Guiding symptoms of our Materia Medica- C.B. Knerr
- Clinical Materia Medica by Farrington.
- Clinical Materia Medica by N. M. Choudhari.
- Clark’s dictionary of Materia Medica.
Dr Rajisha Ramachandran
PG Scholar Department of Practice of medicine U/G/O Dr Praveen Kumar P. D (HOD of Dept of Medicine)
Government Homoeopathic Medical College and Hospital,
Dr. Siddhaiah Puranik Road, Basaveshwar Nagar, Bengaluru,560079