O P Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai,
Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400
Migraine is a very common disease and is now affecting more than 30% of the
population. The more you read about the disease, the better justice you will
be able to do to your patients. Once the attacks of migraine start, the illness
lasts life time. Thus, the family physician is likely to witness different phases
of this disease during the life time of the patient. During these phases, the
patients get extremely upset thinking that they have some other disease like
a brain tumour.
I can compare the life history of
this disease to hypertension which is also not a "disease" but the
illness makes the patients handicapped with which they will have to live life
In the past, I coined terminology of "status
migrainous". During this phase, the patientís migraine headache waxes and
wanes and can go on for a couple of days like the symptoms in a case of status
asthmaticus or status epilepticus. The equivalent of this phase in hypertension
is an entity of malignant hypertension where the patient has frank papilloedema
or retinopathy along with nephropathy and cardiac hypertrophy. Both these entities
have become rare because of the better management of hypertension and migraine.
For the last few years, we are seeing patients of hypertension who develop "Accelerated
hypertension", during which phase they need larger doses of drugs or an
addition of a new drug and when the patients and their relations get extremely
upset and frightened. This phase is a transient phase, the cause of which is
not understood and lasts only for a couple of weeks. The patient can then go
back to their original medicine and the dose which he was taking earlier.
I am now coining a new terminology of "Accelerated
migraine" which we see very often in private practice. In this phase of
the illness, the migraine patient starts having headaches more or less daily
or 4-5 days in a week. It is important to exclude tension headache superadded
on migraine which is much more commonly seen then "Accelerated migraine".
Patients having this entity will need more of tranquillisers and psychotropic
drugs. Tension headaches are dull and constant and last more or less throughout
the day. However, patients of "Accelerated migraine" start getting
migraine headaches nearly daily or on alternate days with intervening period
of few hours which is devoid of any headaches. These headaches are severe and
often associated with nausea and/or vomiting.
The most important part of the management is to convince and assure the patient
that this is only a different phase of illness which will last only for few
days or weeks before the migraine headaches become occasional or less frequent
like in the earlier days. Affording patients can be sent for an MRI to convince
and assure them that there is no other new disease in the brain.
Never give Ergot to these patients because of the fear of side effects and Ergot
headaches which will produce difficulty in diagnosis, in addition to lack of
response. In young patients Sumatriptan should be used very freely. The patient
should be put on Betablockers or Flunarizin. If they are already getting these
drugs, then they can be switched over to Methisergide which is an extremely
effective drug. Only if the drug is given for more than 3-6 months, sonography
may be done to pick up hydronephrosis as the side effect.
Finally, I must stress that all the common illnesses should be taught, remembered
and treated in the same fashion. To use words like transformed migraine etc.
is not right. Even angina pectoris patients can develop a phase when they develop
"accelerated angina pectoris" which should be then treated on the
same lines of unstable angina. Thus, the terminology of accelerated migraine
should be promoted like accelerated hypertension and accelerated angina pectoris,
when the treatment needs to be altered. All the patients will be relieved and
will go back to the original status of experiencing occasional migraine headaches.
In case of angina patients, the prognosis cannot be granted and will follow
the pattern of unstable angina.