Migraine

Syndrome:
An
Analysis of Causes
and Treatments.
Carissa Webster-Marquis
Health Services/Sciences 2

Abstract
The purpose of this research is to compile and analyze all the information available on
migraine headaches, and Chronic Migraine Syndrome. Chronic Migraine is described as a person
experiencing or suffering from multiple headache days a month, usually totaling 15 days or more
of headaches in a month. These headaches can come with various symptoms that all have
seemingly permanent effects on the brain, ranging from intrinsic brain structure abnormalities, to
white matter lesions forming on the brain in patients who suffer migraine with aura (a disruption
in normal sight patterns during or before a headache). These headaches are largely
misunderstood, misdiagnosed, and often left untreated until theyve reached a state where theyre
incapacitating the person theyre afflicting. Because so little is known about migraine headaches
and how they begin in migraine patients, it is important that there exist a wide range of treatment
options, so no one patient is left in pain and suffering because they cant find a treatment to work
for them. Much more research needs to be done in the future to continue to advance these
treatments, and to further our understanding of the migraine headaches that effect hundreds of
thousands of people a day.

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Migraine headaches are, most simply described, a, a recurrent throbbing headache that
typically affects one side of the head and is often accompanied by nausea and disturbed vision,
(Mayo Clinic, 2014). These headaches regularly attack over 11 million people, adding one new
migraine sufferer to the list every day (MRF, 2015). These headaches strike at random times,
with over being entirely, seemingly, causeless, and can last for anywhere from 4 hours, to
several days (MRF, 2015). Although much research has already been done on migraine
headaches and their various causes and symptoms, there has been very little actual concrete
evidence found about them, and there are many questions floating around that are still asking to
be answered; Therefore, throughout this essay, I will be examining the various causes of
migraines in both men and women, the potential treatment options, and the outlook for myself
and my fellow sufferers for the future.
First and foremost, it is important to understand the pathophysiology of the migraine
headache, and how it begins to take hold of its sufferers. When asked what he thinks about
headache progression, Dr. Charles, from the Department of Neurology at the UCLA School of
Medicine, replied:
It makes me think about a patient who has episodic migraine that occurs infrequently,
lets say once a month or once every other month, who at some point in the course of
their life begins having headaches much more frequently, lets say 2 or 3 or 4 times per
week. Accompanying that, there may be a change in the quality of the headache, where it
becomes somewhat less classic for episodic migraine and has fewer of the typical
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features that we consider associated with migraines. (Goadsby, Burstein, Charles, and
Schoenen, 2014).
Similarly, Dr. Burstein described headache progression as:
Maybe another aspect of the progression of headache is defined by treatment. When
younger patients get a migraine, they go to sleep. When they wake up, their migraine is
gone. They then progress to a point where they are unable to sleep off the migraine. They
combine sleep with over-the-counter drugs such as nonsteroidal antiinflammatory drugs

(NSAIDs) in order to abort the migraine. As the disease progresses, they

need something

stronger than sleep and NSAIDs. As the disease continues to progress and

they develop symptoms such as depression, anxiety, and fatigue, they benefit less from sleep
and

NSAIDs and seek alternative therapies, such as triptans. (Goadsby, Burstein, Charles,
and Schoenen, 2012).

Essentially, this headache progression is how a sufferer of mimic and episodic migraine (<14
headache days/month) can progress into suffering from chronic migraine (>15 headache
days/month) (Goadsby, Burstein, Charles, and Schoenen, 2012). In some cases, this progression
can almost be reverted, as some patients have reported their headache severity and frequency
decreasing after initially increasing into the chronic range; however, there is still a portion of the
population of migraine patients that permenantly progresses into the Chronic Migraine stage
(Goadsby, Burstein, Charles, and Schoenen, 2012).

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Aside from changes in types of headaches, duration, frequency, pain levels, and
symptoms, there also exists, chronic changes in brain structure and function, particularly in
areas related to pain processing, in patients with migraine. That issomething that may be
occurring in patients who have progression of migraine, that theres a plasticity of the brain that
results in these structural and functional changes over time. (Goadsby, Burstein, Charles, and
Schoenen, 2012). These changes include structural changes in the brains shape, particularly in
areas in the brain associated with pain and pain management, and white matter lesions appearing
on MRI scans, though these generally only occur in patients who experience an aura with their
migraine headaches (Goadsby, Burstein, Charles, and Schoenen, 2012). There is also an
increased risk of stroke and other aneurism-like issues; however, according to Dr. Goadsby:
I find the cognitive facts very reassuring for patients. I also find it reassuring to be able
to tell them, even those with small changes, that as long as they live to even 75, they
wont have any particular problems, (Goadsby, Burstein, Charles, and Schoenen, 2012).
Patients who experience episodic, aura-free migraine have the highest chances at successful
treatment, as their symptoms and headaches are unlikely to change over time; treatment becomes
a whole new devil when a patient comes in experiencing even just chronic migraine, let alone
chronic migraine with an aura. (Goadsby, Burstein, Charles, and Schoenen, 2012). Though these
changes seem more dangerous than they are, very little evidence has been found to prove that
these changes will have any permenant effect on the brain; For instance, according to Dr,
Schoenen:
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The problem is that many of these changes do not seem to be very

specific to migraine.

They are merely a consequence of the recurring head

pain and also found in other pain

disorders. Very few are specific to

migraine. When patients develop chronic migraine,

central sensitization

occurs, and plastic changes appear in brain areas involved in pain

processing and control. These areas are not specific to migraine.
(Goadsby, Burstein, Charles, and Schoenen, 2012).
These changes are real, and they are happening in migraine patients, but there is no one change
that is occurring in a migraine patient that isnt occurring in another patient that suffers from
chronic pain.
The first thing every single patient coming in for migraines is told to do is keep a journal,
often for several months, that keeps track of every migraine day and every symptom in the hopes
of finding a trigger for the migraine attacks. However, because the reliability of assessing these
[trigger] factors is retrospectively unknown, it is often extremely difficult to deduce a cause,
trigger, or warning sign from only a list of activities and symptoms (Zebenholzer, Frantal,
Pablik, Lieba-Samal, Salhofer-Polanyi, Wber-Bingl, and Wber, 2016). Though this method
is useful in bringing to the surface activities and foods that a migraine sufferer may want to
avoid, there is very little reliability in the method itself, especially across the board in a large
group (Zebenholzer, Frantal, Pablik, Lieba-Samal, Salhofer-Polanyi, Wber-Bingl, and Wber,
2016). Throughout the PANIMA study, patients were asked to fill out two questionnaires; In the
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first questionnaire the patients assessed their lifestyle, in the second they rated for each factor the
likelihood of triggering a migraine attack, and in [their] diary they recorded the daily presence of
these factors irrespective of headache, (Zebenholzer, Frantal, Pablik, Lieba-Samal, SalhoferPolanyi, Wber-Bingl, and Wber, 2016). In the end, it was concluded that questionnaire
assessment of lifestyle is reliable [in most cases], whereas trigger factors are overestimated
and/or underestimated in retrospective questionnaires, (Zebenholzer, Frantal, Pablik, LiebaSamal, Salhofer-Polanyi, Wber-Bingl, and Wber, 2016). So, essentially, the primary method
for migraine diagnoses and treatment is still a highly flawed system, leaving a vast majority of
migraine sufferers looking for a more reliable form of diagnosing their syndrome.
The most common forms of diagnosis for migraine headaches include various diagnostic
imaging tests, physical examinations, diaries of symptoms and potential triggers, and
neurological reactions and functions exams (MRF, 2015). These methods have proven to be
effective when done by an effective doctor, but many patients still end up waiting on treatment
and preventative care due to a lack of general knowledge. The average patient starts out by
seeing a primary care physician, often with a general list of their symptoms and the measures
they take to manage the pain and symptoms that come with migraine headaches. In my
experience, this primary care visit will result in eons worth of questions being asked, many of
which have absolutely nothing to do with you and your headaches, only to be told to keep a
journal or diary for at least 90 days before they come back. So like all migraine sufferers, we
listen and dont come back until the appointed date, journal in hand, ready to talk about what is

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causing this debilitating disease, only to be told that your only options are to start on a medley of
drugs, or to be sent away to do more journaling that ultimately gets you nowhere. Its a
frustrating cycle, and it leaves many patients feeling as though there is nowhere for them to turn,
and as if there is no possible end to their suffering.
It is a well-known fact, across the board, that migraine is often under-recognized,
misdiagnosed and inadequately treated in the primary care setting, (Mined, Tishler, Loder,
Silbersweig, 2015). The best way to treat and manage a headache is to get it diagnosed early on;
finding help and treatment will go so much smoother when a patient can tell a doctor I have
chronic migraine syndrome. These are all my symptoms and when I have headaches most
frequently, rather than relying upon I sometimes get headaches that make me have to stay
home from work/school/etc. Unfortunately, a large majority of patients are left with only being
able to see a primary care physician, many of whom are, according to Minen. Tishler, Loder, and
Silbersweig (2015), unfamiliar with migraine symptoms, unfamiliar with treatment and
prevention plans, and sometimes even struggle to know when to recommend basic diagnostic
tests and examinations. Many physicians, similarly, do not immediately think migraine when a
patient comes in complaining of frequent headaches; many physicians, think of tension
headaches, cluster headaches, or sinus headaches, rather than immediately jumping to migraine
headaches, and gradually working their way back from an initial diagnosis (Buse, Kurth,
Silberstein, 2012). This quick judgement will result in many cases of misdiagnosis as physicians
work off of a flawed initial diagnosis.

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To prevent this endless cycle of misdiagnosed headaches and syndromes, it is important

that primary care physicians learn to ask open-ended questions, that work to evaluate the
disability and quality of life for their patients (Buse, Kurth, Siblerstein, 2012). These openended questions will prompt patients to share more, according to Buse, Kurth, and Silberstein
(2012) and will provide more in-depth data on what their headaches are to them. The most
important steps we can take are going to be education based as we increase knowledge of
migraines in primary care physicians. These PCPs can increase their understanding of migraine
headaches, and in return be able to provide more in depth and responsive care to the migraine
sufferers they treat.
It also becomes vitally important that PCPs learn about preventative care, and learn how
to adapt treatment and prevention plans to a patients ever-adapting needs. Preventative care is
important to treat headache progression; though headache progression will never really stop,
preventative care offers steps to prolong the progression, and to combat the worsening pain and
symptoms that come with the progression of migraine headaches (Goadsby, Burstein, Charles,
and Schoenen, 2012). According to Dr. Charles:
[E]ven with preventative therapy, migraine finds its way around them,
and even patients

on preventative therapy end up having progression.

So I think until we better understand

the process, we cant really say

with confidence that early preventive therapy is

something that is going

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to prevent the progression of the disorder, (Goadsby, Burstin, Charles, and

Schoenen, 2012).
Even if preventative care doesnt always work the way it is supposed to, it is crucial to the
treatment of migraine headaches, and to the management of symptoms as they begin to appear in
the patient.
Over the years, as understanding of migraines has increased, it has also become
necessary for the range of treatment options to increase. No one migraine is the same as any
other, and the same goes for the migraine patient; therefore, a wide variety of treatments has to
exist to serve as big of a portion of the population as possible. Some of the most promising
treatments include Comorbidity therapies, Cognitive Behavior Therapy, subcutaneous steroid
application, and various pharmaceutical therapies.
Comorbidity therapies are enacted when physicians and/or patients believe that a
psychological issue, such as anxiety or depression, could be a factor in migraine severity,
according to Buse, Kurth, and Silberstein (2012). When, Migraine is comorbid with many
medical and psychiatric conditions, including depression and anxiety, it means that the
migraine headache occurs in association with preexisting psychological issues (Buse, Kurth, and
Silberstein, 2012). It has been found that patients with psychiatric comorbidities with
migraine,, especially patients with depression or anxiety, have been associated with poor
treatment outcomes, treatment refractoriness, and problems with adherence (Buse, Kurth, and
Silberstein, 2012). Because patients with psychiatric comorbidities have been shown to have a
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poorer reaction to pharmacological treatments, it has been broadly recommended that primary
care physicians and neurologists may want to consider opportunities for therapeutic two-fers
or using treatments that will have benefit for both conditions when possible, such as prescribing
an antidepressant (most commonly amitriptaline) to prevent the migraines, and help to treat the
underlying cause of the migraines (Buse, Kurth, and Silberstein, 2012). Like all treatments, there
are some patients with comorbidities that will have either a bad reaction, or no reaction, to a
comorbidity therapy, and it has been found that many primary care physicians have trouble
avoid[ing] medications that may have adverse events that exacerbate or complicate the
comorbidity (Buse, Kurth, and Silberstein, 2012). This treatment plan works for many
individuals, but leaves many others in search of the next treatment plan that will work for them.
Cognitive behavior therapy (CBT) is a short-term, goal-oriented psychotherapy
treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change
patterns of thinking or behavior that are behind people's difficulties, and so change the way they
feel, (Martin, 2015). Essentially, its a short term, guided therapy that helps migraine patients
deal with their emotional and physical side effects over time , and usually provides patients with
the tools to continue the therapy on their own time after treatment has concluded (Harris ,
Loveman, Clegg, Eastman, Berry, 2015). Through a systematic review of CBT in addition to
several treatments offered, done by Harris, Loveman, Clegg, Eastman, and Berry (2015) it has
been found that CBT alone shows no statistical improvement in symptoms or life quality , but
there has been mixed results in favor of CBT in addition to pharmacological and behavioral

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therapies. More research needs to be done on the topic , as there has not been conclusive results;
according to Harris, Loveman, Clegg, Eastman, and Berry,
these findings were mixed, with some studies providing evidence in support of the
suggestion that people experiencing headaches or migraines can benefit from CBT , and
that CBT can reduce the physical symptoms of headache and migraines . However, all the
results must be interpreted with caution due to the lack of statistical power and
methodological limitations of the studies, as well as the large number of different
interventions and comparators employed in these studies, (2015).
Meaning, there is hopes here of a treatment plan that will appease to patients who are unable to
utilize a pharmacological intervention, as well as preventative care for thousands of migraine
suffers. Much more research needs to be done, and more studies must be done, but if the
treatment were to be explored, there could be conclusive evidence that CBT becomes a viable
option for more patients and suffers.
Subcutaneous steroids are applied to patients with migraine syndrome who suffer from
more moderate to severe form of the disease; these steroids , including, parenteral
corticosteroids, and, the botulinum toxin A, are locally injected into the base of the patients
skull in an attempt to reduce pressure pain and help to manage some of the symptoms that come
along with migraine syndrome (Nikkah, Ghandehari, Jouybari, Mirzae, Ghandehari, 2016). This
therapy is not very common, and is used mostly as a last-case-scenario when other
pharmacological and behavioral therapies have failed; that being said, according to Nikkah,

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Ghandehari, Jouybari, Mirzae, and Ghandehri, [s]ubcutaneous injection of methylprednisolone

has considerable abortive and preventive therapeutic effects in patients with severe refractory
migraine (Nikkah, Ghandehari, Jouybari, Mirzae, Ghadehri, 2016). This topic has been very
sparsely researched, and many migraine patients have heard of this therapy as an option , but few
have had the opportunity to talk about the side effects or benefits that they may take away from
the therapy. Should the research happen, and the steps taken, this could become a very reliable
and safe method of treatment for patients suffering from an extremely severe form of migraine
syndrome.
The final, and most common, therapy is a combination of pharmacological treatments
that range from basic NSAIDs, to prescribed pain management drugs (Goadsby, Burstein,
Charles, Schoenen, 2012). Throughout headache progression, the necessity for pain medication
becomes more and more apparent, as a person is required to go from relying on ibuprofen , to
moving onto a narcotic, like ketorolac, or an opiate (Buse, Kurth, Silberstein, 2012). These
pharmacological therapies could be all preventative as well , where patients are given
medications that treat the underlying cause of their headaches, in the hopes of preventing more
headaches from occurring.
Migraines as a disease are a scary thing that we dont understand as much as we like to
think we do, but migraines as a research topic are becoming more and more popular with age .
Migraine headaches are a neurological condition that usually results in nausea, one-sided-pain,
photophobia, sensitivity to sound, and muscle weakness. These headaches are largely

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misunderstood and misdiagnosed, and there are many factors about them that we do not
understand. Similarly, there are many treatment options out there for patients, but only for those
who have the resources to find them; a lack of primary care physician knowledge combined with
a scarcity of neurologists who see migraine patients leave many migraine sufferers undiagnosed
and untreated for their various headaches and symptoms . Much more research needs to be done,
and more care and time needs to be committed to patients who come in complaining of migrainelike pain and symptoms. With proper education and preventative steps taken, in both patients and
physicians, the improvement of headache and migraine suffering is inevitable , and will open
many new doors to possible treatment options and preventative care methods.

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References Page
Burstein, R., PhD, Charles, A., MD, Schoenen, J., MD, PhD, & Goadsby, P., MD, PhD. (2012,
August 10). Pathophysiology of Headache Progression. The Medical Roundtable.
Retrieved April 14, 2016.
Summary: I used this article mostly to describe the basics of migraine headaches,
as some of the information can be difficult to grasp without
actual

definitions and facts. It mostly described how headaches

transform,

and how these transformations effect our brains.

Harris, P., Loveman, E., Clegg, A., Easton, S., & Berry, N. (2015). Systematic review of
cognitive behavioural therapy for the management of headaches and migraines in adults.
British Journal of Pain, 9(4), 213-224. doi:10.1177/2049463715578291
Summary: This article was found to use as evidence for the broadening of the
treatment options for migraine patients. Before the recent
years,

treatments really only included pharmaceutical interventions;

treatments have transformed vastly in the last decade.

Lipton, R. B., MD, Buse, D. C., PhD, & Silberstein, S., MD. (2012, July 09). Epidemiology,
Assessment, and Diagnosis of Migraine. The Medical Roundtable. Retrieved April 16,
2016.
Webster-Marquis 14

Summary: I chose this article because it provided detailed descriptions of the

different diagnosis pathways that patients take, as well as the
issues

with the process that many patients currently go to; these holes

in the

system are mostly due to lack of knowledge of the steps to take

in

PCPs, the article examines exactly why, and what we can do

about it.
Martin, B., Psy. D. (2015). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved
April 27, 2016.
Summary: This article was simply a description of a therapy for migraines that
involves changes in habit and attitude, rather than using a
pharmaceutical remedy; the cognitive behavior therapy
essentially

studies the improvement of symptoms (if there are any)

in patients

who practice abnormal practices to treat their

migraines.
Minen, M. T., Loder, E., Tishler, L., & Silbersweig, D. (2015). Migraine diagnosis and
treatment: A knowledge and needs assessment among primary care providers [Abstract].
Cephalalgia, 36(4), 358-370. doi:10.1177/0333102415593086
Summary: This was an article I pulled up to do some deeper research into the
inadequate treatments available to migraine patients with most
PCPs;

essentially. Many primary care physicians are unequipped to

accurately diagnose and plan out treatments for patients

based on a

lack of knowledge and resources.

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Nikkhah, K., Ghandehari, K., Jouybari, A. G., Mirzaei, M. M., & Ghandehari, K. (2016,
January). Clinical Trial of Subcutaneous Steroid Injection in Patients with Migraine
Disorder. Iranian Journal of Medical Sciences. Retrieved April 15, 2016.

Staff, M. C. (2014, June 4). Migraine. The Mayo Clinic. Retrieved January 24, 2016.
Summary: I wanted an accurate definition of what a migraine headache was, in
the absolute simplest words that I could find; I decided to go
with

Mayo Clinic, because they are a monitored medical resource

website

that is highly rated and trusted.

Xue, T., Yuan, K., Zhao, L., Yu, D., Zhao, L., Dong, T., . . . Tian, J. (2012). Intrinsic Brain
Network Abnormalities in Migraines without Aura Revealed in Resting-State fMRI.
PLoS ONE, 7(12). doi:10.1371/journal.pone.0052927
Summary: This article didnt get used much in the paper, but I made a few
reference to some of the findings theyve had in the way the brain
changes when exposed to severe, constant, or chronic pain, and the
ways this can affect the brain and the headaches.
Zebenholzer, K., Frantal, S., Pablik, E., Lieba-Samal, D., Salhofer-Polanyi, S., Wber-Bingl, ,
& Wber, C. (2015). Reliability of assessing lifestyle and trigger factors in patients with
migraine - findings from the PAMINA study. Eur J Neurol European Journal of
Neurology, 23(1), 120-126. doi:10.1111/ene.12817

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Summary: This article was a study in how reliable current assessment factors are
to the average patient. Its clear that there are issues with how
patients

are currently diagnosed, and this article seeks to define

specific issues

with the methods PCPs use.

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