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O P Kapoor

Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai,
Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

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 time.

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.

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