Atypical migraine: causes, symptoms, diagnosis and treatment

Word Migraine is derived from Greek origin Hemikrania, which means Pain on one side of skull. Migraine is characterized as a chronic Neurological disorder. It results in severe and moderate headaches with other autonomic nervous system symptoms. The condition affects normally one half of the head and lasts from 4 to 72 hours and is worsened by any type of physical activity. One third of migraine suffering patients feel a sensory, visual, language or motor disturbance that signals the upcoming headaches.

This feeling is termed as Aura. However, it may cause little or no headache whatsoever. The classic cause for migraine is considered to be genetic or environmental factors. Two third of patients have a genetic history running in their lineage. Hormonal changes during puberty cause more migraines among boys relative to girls. Overall the rate of women suffering with migraine is two to three times more than that of men. Migraine risk is decreased normally during pregnancy. Another cause for migraine is considered to be a Neurovascular disorder. It means the rise in excitement of cerebral cortex. Disorders of trigeminal nerve make a person more susceptible to this condition.

Types of Migraine

There are generally two types of migraines, which are as following.

Typical Migraine

Typical Migraine patients are normally 15 to 30% and it is the one accompanied with aura. This type of migraine has four stages to an onset of headache but not necessary for them to be experienced all at the same time or experience at all. These phases are as follows.

• Prodrome: a phase occurring hours or days before headache.
• Aura: a phase that signals the headache.
• Pain: the headache phase.
• Postdrome: a phase with end of migraine along with effects experienced.

Atypical Migraine

Typical Migraine is the one which is accompanied with the aura and Atypical Migraine is the one without aura. The doctors differentiate typical and atypical migraines on the basis of one or more classic symptoms. In case of atypical migraine there is sometimes even the absence of headache itself. There are three possible phases of an Atypical Migraine, which are give below in detail. It is not necessary for patient to go through all or any of these phases.

Prodrome Phase

60% of the patients with atypical migraine go through this stage. These are the prodromal symptoms that a person suffers normally two or three days before the start of pain. These symptoms are variable and are listed below.

• Mood changes
• Irritability
• Depression
• Euphoria
• Body fatigue
• Stiffness of neck muscles
• Constipation

Pain Phase

Atypical Migraine patients generally skip the Aura Phase and jump right to the Pain Phase. As the name of this phase indicates, the patient starts experiencing severe headaches. The migraine headache is one sided and throbbing, ranging moderate to severe in intensity. However, patients with atypical migraine in 70% of cases can have bilateral pain alongside neck pain. The less common area of pain is the top of the head and back. The pain last generally from 4 to 72 hours among adults and 1 hour in children. The frequency of migraine attacks vary in people. It may be few in a lifetime to several in a week. The average attack frequency is once in a month.

Postdrome Phase

This phase is the one which comprises of aftereffects. The Postdrome phase causes aftereffects listed below.

• Sense of pain in area of migraine.
• Impairment in thinking after the attack.
• Feeling a hangover state or fatigue.
• Head pain
• Cognitive disorders
• Gastrointestinal problems
• Altered mood changes
• Malaise
• Depression

There are some cases where the patients of former migraine attacks feel refreshed. However, this can vary after every attack.

Causes of atypical migraine

The causes for atypical migraine are still unknown but are considered to be the result of environmental and genetic factors. It usually runs in families. There is a misconception about migraines to be common in people with high intelligence. Many biological events and triggers cause psychological conditions like depression, anxiety, bipolar disorder that are responsible for atypical migraine. Following are some of the causes for atypical migraines.

Genetics

There is a chance of 30 to 50 percent for twins to be born with migraine as an influence of genetics. Certain variants of genes put a person to the increased risk of getting mild to moderate migraines.

Various triggers

Atypical migraine starts with a trigger in patients for some this influence is major and for some is minor. Various things are marked as triggers but their strength and importance is still unclear. Following are some of the most important triggers.

• Physical stress
• Emotional state
• Lack of sleep
• Skipping routine meals
• Caffeine intake
• Alcohol consumption
• Environmental effects like extreme heat or cold
• Allergic reaction to specific foods e.g. nuts, pickle foods or chocolates.
• Foods containing Amino Acid Tyramine commonly in red wine and aged cheese.
• Exposure to bright light
• Loud noise

Physiological attributes

Some of the triggers for migraine attacks are physiological in nature with common examples being physical or emotional stress, hunger and body weakness. Among women, migraine occurs during menstruation. Other hormonal triggers include the following.

• Menarche
• Use of oral contraceptive
• Pregnancy
• Perimenopause
• Menopause

These hormonal changes are common triggers of Atypical Migraines. However, migraine attacks don’t occur during second and third trimester of pregnancy.

Dietary effects

Dietary factors in relation to Atypical Migraine are only reported by patients on their own. They are not confirmation that these foods actually trigger any attack of migraine. Following dietary constituents may trigger atypical migraine:

• Tyramine
• Monosodium Glutamate (MGS)

Environmental aspects

A review has been presented for the effects of indoor and outdoor environment as a potential trigger. It is suggested to patients to take some prevention to indoor air quality and use protection outdoors if the weather is intense cold or hot.

Cortical spreading depression

The main cause for atypical migraine is termed as Cortical Spreading Depression. It spreads across the cortex of brain. It travels from occipital lobe to parietal lobe and to the temporal lobe. It is defined as burst of neuronal activity followed by inactivity. The explanation for this outburst is described by active NMDA receptors that make calcium enter the cell. This burst results in decrease blood flow to cerebral cortex for 2 to 6 hours. Doctors believe that the downward flow of this cortical spreading depression triggers head and neck pain.

Signs and symptoms of atypical migraine

As the Atypical Migraine is different form Typical Migraine so there are numbers of signs and symptoms that may be help differ both. It was described earlier that Atypical Migraine occurs without Aura Phase and sometimes even the absence of headache itself. There are several signs and symptoms of Atypical Migraine that are as follows.

Facial Pain

One of the symptoms of Atypical Migraine includes facial pain. The pain ranges from moderate to severe. It is either constant or short lived and usually intense around the eyes area. The facial pain although being sensitive to touch can be relieved by massage or by applying pressure to certain areas. If the pain is in the mouth or jaw, the doctor first checks for decayed teeth or Temporomandibular Joint Disorder (TMJ) before concluding the type of migraine to be Atypical.

Abdominal Disorders

The main type of pain associated with migraine is headache but in some case of Atypical Migraine there are certain abdominal disorders that can be observed as well. One of the most common of abdominal disorders is Cramping accompanied with nausea and vomiting. The cramping pain as reported by women is the same as in case of menstruation. These pains might or might not be followed by Prodrome and lasting from few minutes to several hours. These symptoms are also followed by Cyclical Vomiting Syndrome and Benign Paroxysmal Vertigo.

Neurological disorders

Atypical Migraine can be very serious if not properly treated as in severe cases there are neurological issues like that of a stroke. Sometimes an Atypical Migraine patient suffers numbness or paralysis of an arm or a complete side of a body. Some patients also experience a tingling feeling in one side of their body. All these effects last not more than a couple of minutes and are without any damage. However, it is best to seek medical treatment in such cases as soon as possible.

Visual effects

Atypical Migraine patients also suffer from visual problems. Some of these visual disturbances are as follows.

• Rainbow like color in vision.
• Floating black dots in patient’s field of vision.
• Flashes of light in zigzag pattern.

All these issues are due to patient’s sensitivity to light and patient prefers rest in dark rooms.

Other symptoms

Other common systems are classified into two types which are the following.

Physical symptoms

• Diarrhea
• Nausea
• Vomiting
• Cravings for certain foods
• Lack of appetite
• Parched feeling
• Frequent urination
• Chills and shivers
• Weakness

Emotional Symptoms

• Confusion in speaking
• Cognitive impairment
• Euphoria (state of happiness)

Diagnosis of atypical migraine

The diagnosis of Atypical Migraine is made on the basis of signs and symptoms. Neuroimaging testing is not required for diagnosis. It can however be used to diagnose other causes of headaches if patients history does not confirm migraine. The International Headache Society (IHC) made following criteria for the diagnosis of atypical migraine. The criteria is named as “5, 4,3,2,1 criteria”. The diagnosis method is following in detail.

• 5 or more attacks. Two attacks are also sufficient for diagnosis.
• Duration of 4 hours to 3 days.
• 2 of the following conditions.
  • Unilateral
  • Pulsating
  • Mild or intense pain
  • Impairment in physical activities due to pain
• One of the following.
  • Nausea or vomiting
  • Photophobia or Phonophobia

If the patient is diagnosed with this method and experiences two of the following, including photophobia, nausea or inability to work then the diagnosis is positive. If the patient has four out of five of the following conditions then the chances of the condition being atypical migraine are 92 % and if less than three then the chances are 17 %. These five conditions are as follows.

• Throbbing headache
• Time period of pain 4 to 72 hours.
• Unilateral pain
• Nausea or vomiting
• Inability of performing routine physical activities.

Risk factors of atypical migraine

Below are some of the risk factors associated with Atypical Migraine.

• Approximately 1 billion people suffer from migraine. 80 % of the people suffer from atypical migraine.
• In the USA about 6% men and 18% women get migraine problems.
• In the European countries 6 to 18 percent men and 14 to 35 percent women receive migraine.
• The rate of migraine patients in Asia and Africa is lower than that of Western countries.
• The age in which migraines usually start is in between 15 to 24 years and the age where these attack are more frequent is 35 to 45 years.
• In boys it usually starts during puberty and in women during their adolescence becoming persistent for the rest of their life.

Prevention of atypical migraine

Prevention for atypical migraines is recommended to patients who have headache persisting for more than two days a week and are not able to tolerate medications. The goal of these preventive measure is to minimize the frequency, painfulness, duration of attacks and also to increase effects of abortive therapy. Following are different ways you can prevent atypical migraine attacks:

Medication

The first precaution for migraine attacks involves the use of medication. Medications are considered to be effective if they reduce the frequency and pain by 50%. Some of the medications suggested by doctors for the first time use include the following.

• Topiramate
• Sodium Valproate
• Metoprolol
• Gabapentin
• Timolo
• Frovatripitan
• Amitripityline
• Venlafaxine

There is a variation in recommendations for Gabapentin. Angiotensin-converting enzyme inhibitor or Angiotensin II receptor is the Angiotensin inhibitions that reduce the migraine attacks. Botox is also reported to be useful for chronic headaches. One alternative medicine is the extract of Butterbur root, which is very helpful.

Therapies

Alternative therapies are suggested if the medicational prevention does not prove to be effective. Acupuncture is considered to be one of most effective therapies having fewer adverse effects. Some other alternative therapies include:

• Chiropractic manipulation
• Physiotherapy
• Massages
• Relaxation

Medical devices and surgery

When anti-migraine medications do not work or instead result in Medication Overuse Headache then medical devices like Biofeedback and Neurostimulators play a role as a prevention measure. The biofeedback allows patients to be conscious of their physiological aspects. If a patient is aware of these physiological parameters, they try to control them which is helpful in the treatment of ailment. Neurostimulators are like pacemakers. They are implantable and have effective results in case of severe frequent attacks. A Transcutaneous Electrical Nerve Stimulation device is approved in the USA for prevention against migraine attacks. The surgery for atypical migraine is recommended for patients who do not improve with medications. The surgery involves decompression of specific nerves around head and neck.

Treatment of atypical migraine

The treatment of atypical migraine includes three important steps.

• Avoiding trigger
• Rapid control of symptoms
• Prevention by the means pharmaceutical drugs

Use of medication is effective in case of severe attacks. Below are some of the treatments measures for atypical migraines discussed in detail.

Coping with migraine

One of the treatments involve acute control of symptoms. For this there is a self help five step method which has been proven useful in many cases. The steps are below.

Routine diary of symptoms

This step involves keeping track of your daily life that includes your sleep, stress, food and beverages and all other possible triggers. With this also keep track of the starting and ending symptoms of your migraine type.

Consulting occasionally with doctor

Keeping the diary is the first step, after that you have to contact your doctor. Talk to him about your diary and tell him about all your findings as it will help him diagnose your condition in a better way. The reason for this is sometimes in rare cases the migraine attacks are a sign of serious other medical problems like stroke or bleeding inside brain.

Using effective medications

There is a wide range of medications for the treatment of migraine. Migraine Research foundation has listed 100 medications. Different drugs can be tested for treatment until you find the most suitable one.

Observe prevention

Avoid the migraine triggers. Preventions as described earlier are effective for suppressing the attacks even before they happen.

Self care

The last and foremost important step of this program is self care. You have to be sincere with yourself. While following the aforementioned steps, you must take proper care of your diet, take plenty of rest, take exercise on regular basis, and remain stress free. Following all these steps has been proven helpful in the treatment of Atypical Migraine in its early stages.

Medical Management

Medications are to be used in earlier cases of migraine attacks. However, the medicines should be used as prescribed because self-medication or abuse can lead to Medication Overuse Headache. Medication overuse headache can worsen your migraine, making it more frequent and severe in nature. Common medications that can worsen your atypical migraine due to their frequent and unchecked use are following.

• Triptans
• Ergotamines
• Analgesics
• Narcotic Analgesics

To avoid aforementioned condition, doctors recommend to take simple analgesics that should not be used more than 3 days a week. Following are some medicines that can be used after the recommendation of doctor:

Analgesics

Patients suffering from mild to moderate symptoms of atypical migraines are advised to begin their initial treatment with simple analgesics. Common examples include:

• NSAIDs (Non steroidal anti inflammatory drugs)
• Combinations of paracetamol, acetylsalicyclic acid and caffeine.

There is substantial evidence that NSAIDs help with atypical migraine. Ibuprofen is strongly recommended as it treats about half of the patient population in early stages. Aspirin is also considered to be similar in effect as that of Sumatriptan for treatment. One of the known intravenous drugs to be used is Ketorolac. Paracetamol alone or combined with Metoclopramide can be used effectively with little side effects. In third trimester of pregnancy, combination of Paracetamol and Metoclopramide is considered safe to use.

Triptans

Triptans are used in case of patients suffering from mild to severe symptoms and those who do not respond to simple analgesics. One of the most commonly suggested Triptans is Sumatriptan as it treats normally 75 percent of patients from both nausea and pain. Triptans are available in the following forms.

• Oral
• Intravenous
• Nasal sprays
• Dissolvable oral tablets

All of the Triptans generally have same side effects but individuals respond to specific ones. Common side effect of this drug is flushing (Vasodilation i.e. increase flow of blood). It is advised not to be used by patients suffering from following conditions.

• Cardiovascular diseases
• Neurological disorders

Although they are not the most recommended medications, but still no evidence of harm has been brought up. They are not addictive but continuous use for more than 10 days a month can cause medication overuse headache.

Ergotamines

Ergotamines and Dihydroergotamine are the most commonly prescribed medications for atypical migraines. They are similar in effect to Triptans and are less expensive. The side effects are benign in nature. They are deemed to be most effective treatment in severe cases. Dihydroergotamine is available in both nasal spray and Injectable form.

Other common medications

Other drugs that have shown promise in the treatment of migraine include:

• Metaclopramide in intravenous form
• Lidocaine in intranasal form

Metoclopramide is to be administered only in the case of emergency. Single dose of Dexametasone when given with standard treatment of migraine reduces the headache by 26 percent at that time. Opioids and Barbiturates are advised as a treatment for migraine headaches. Some antidepressants also help in reducing the frequency of migraine attacks common examples of them include following.

• Prozac
• Serzone
• Paxil
• Pamelor
• vivactil

Classification of medications to treat atypical migraine alongside possible side effects and generic names is as follows.

Type	Medical name	Brand name	Side effects
Over the counter or analgesics	Ibuprofen	Motrin	Stomach disorders, rashes or swelling
	Combination of Aspirin, Acetaminophen and Caffeine	Excedrin Migraine	Anxiety, lack of sleep, allergies, liver disorders, vomiting, feeling dizzy and sensation of heartburn.
	Acetaminophen	Tylenol Valorin Excedrin	Liver problems, allergies and rashes.
	Naproxen	Aleve	Risk of heart attack, Stomach disorders, stomach bleeding, nausea and vomiting, liver failure, rashes.
Ergotamins	Dihydroergotamine	Ergomar DHE-45 injection  Migrainal Intranasal.	Nausea and numbness of toes and fingers.
Triptans	Sumatriptan succinate	Imitrex injection and oral or intranasal Zecuity also available in form of skin patch	Tingling of one side of body, flushing, feeling dizziness, fatigue, burning and tightness of body, chest problems and nausea.
	Zolmitriptan	Zomig	Same as above
	Rizatriptan	Maxalt	Same as above
	Naratriptan hydrochloride	Amerge	Same as above
	Almotriptan	Axert	Same as above
	Frovatriptan	Frova	Same as above
	Eletriptan	Relpax	Same as above
Combination of Triptans and NSAIDs	Combination of Sumatriptan and Naproxen	Treximet	Increased risk of heart attack or stroke, discomfort in areas of head, jaw, chest and arms, tingling in one side of body, thoracic problems, cramping of body muscles, flushing, nausea, vomiting, rashes and liver disorders.

Home remedies

There is necessarily no need for a patient of atypical migraine in its early stage to take medication or consult a doctor. If the pain is mild or moderate, it can be relieved by some simple home remedies. Some of these common and simple remedies are as follows.

• When suffering from migraine headache take an ice pack and apply it to the sore area of your face, neck, temples and head.
• Taking a warm bath, taking a nap or a little walk always works wonder to your headache.
• Massaging the back, neck and head is also very helpful in the soothing of headache.
• A simple method for relieving from headache is to press the sore area of your head with index finger for 7 to 15 seconds and then release it.
• Atypical migraine patients are often sensitive to light. Such patients should relax in a low lit room to release the pain and tension from the head, back and neck.
• One of the reasons for atypical migraine is considered to be excess muscle contraction in neck. For this you can take physical therapeutic exercises.

References

http://en.wikipedia.org/wiki/Migraine

http://www.webmd.com/migraines-headaches/what-are-silent-migraines?

http://www.patientslikeme.com/conditions/475-atypical-migraine

http://www.webmd.com/migraines-headaches/guide/migraine-treatment

http://www.relieve-migraine-headache.com/atypical-migraine-and-symptoms.html