All About Migraines in Dentistry

Migraines are intense headaches with additional symptoms

Migraines are intense headaches with additional symptoms

Duration

Lasts between 4 and 72 hours. In children, migraine attacks are almost always accompanied by severe nausea, vomiting, and dizziness.

Course

In its natural course, the frequency and severity of migraine attacks decreases after the age of 45. This is not exclusively related to menopause, as the decrease of frequency and severity of migraine attacks occurs in men of that age as well. During pregnancy, a decrease in migraine frequency beginning at the end of the third month has been shown in approximately 60-80 % of cases.

Appearance - Clinical

Migraines are characterized by severe, often one-sided, pulsating, throbbing headaches that increase in intensity during physical activities. Individual attacks are accompanied by a lack of appetite (almost always), nausea (80 %), vomiting (40-50 %), photophobia (60 %) and phonophobia (50 %), and hypersensitivity towards certain odors (10 %).

When the headaches are one-sided, they may change sides within the course of a single attack or from one attack to the next. The headaches often start in the neck, which is why it is often falsely assumed that there is a causal correlation between the cervical spine and the migraine. The headache then spreads over the head and temple region all the way into the face.

Prior to the headache phase itself – and less often during the headache phase – about 10-15 % of patients experience a period of neurological stimulus and visual loss phenomena that is referred to as the “migraine aura.”

In the past, this type of migraine was identified as a “migraine accompagné” or classical migraine. Most patients suffer from stimulus and visual loss phenomena of the visual brain regions with unsystematic vision disorders, the perception of flashes of light and fortifications (jagged lines of light), and defects in the visual field.

In addition to visual disorders, sensibility disturbances, nerve deficiencies, speech and language disturbances, dizziness and equilibrium disturbances may occur. In the migraine aura period, it is typical for symptoms to develop over a period of 10-20 minutes and then slowly subside again. The symptoms cannot be associated with brain-specific vessel territories. Afterwards, the actual headache phase begins. In rare cases, isolated auras without any headache may occur.

Illnesses Differentiating from the Migraines – Differential Diagnosis

Tension headache, organic causes, medication-induced headache

Special Forms of Migraine

The menstrual migraine is understood as a migraine attack that occurs exclusively or almost exclusively within a close temporal relationship with the monthly period. These attacks are often longer than normal migraine attacks.

Disease Mechanism - Pathophysiology

Many twin studies have already pointed towards the fact that there is a high probability that migraine constitutes a hereditary disease. For a special type of migraine, namely the familial hemiplegic migraine, in which an almost complete hemiplegia paralysis occurs within the course of the aura, genetic defects on chromosome 19 and chromosome 1 have been identified. The gene on chromosome 19 codes for a P/Q calcium channel mainly present in the brain, so it has to be assumed that the migraine – as with other neurological diseases – probably constitutes a so-called ion channel disease.

These diseases involve temporary functional disorders of ion channels, which then lead to reversible neurological deficiencies.

The affected calcium channel is almost exclusively found at neurons of the central nervous system. It has its highest density in the brainstem in the pain processing systems region and in the occipital pole region. This could explain why aura symptoms are primarily visual in nature.

The fact that genetics plays an important role in migraines also explains why the disease itself is incurable. It is only possible to treat acute migraine attacks and, in cases of frequent attacks, to perform an effective prophylaxis.

Trigger Factors

These are biological factors or environmental influences that can (but do not have to) trigger a migraine attack given a corresponding inner reaction readiness.

Hormonal fluctuations in women are significant trigger factors. This explains the accumulation of migraine attacks during the period and during ovulation. During the initial taking of hormonal preparations, either for conceptive purposes or after menopause for the treatment of discomforts within the course of menopause or for prophylaxis for osteoporosis, the first manifestation of migraine or a deterioration of an existing migraine may occur.

With regard to the area of behavior, changes of the circadian rhythm are possible trigger factors, which could partially explain why migraines occur more often on the weekend than during the week. Environmental factors such as flickering light, noise, higher altitudes, cold temperature, and smoky rooms can possibly trigger migraine attacks. Psychological factors are anxiety, stress, and relief reactions after stress.

Substances able to trigger migraines are alcohol (particularly in the form of red wine) and, very rarely, foodstuffs such as certain types of cheese and chocolate. Also, fluctuations in caffeine levels (in case of regular consumption of caffeine) can lead to migraine attacks. Mentioned most often, but therapeutically without importance, are weather influences.

Epidemiology

A migraine is one the most frequent forms of headaches. About 6-8 % of all men and 12-14 % of women suffer from migraines. Prior to puberty, the frequency of migraines is 4-5 %. Boys and girls are affected equally. The highest incidence of migraine attacks occur between the ages of 35 and 45. During this phase of life, women are three times as affected as men.

Also, migraine attacks usually last longer and are more intense in women. This also explains why women are clearly overrepresented in clinical studies for the treatment of migraines. Migraine frequency is the same in almost all the global populations surveyed to date. Only China and Japan show somewhat lower migraine rates.

Diagnosis

Diagnoses of migraines are purely clinically based on the patient’s medical history. Part of the diagnosis is a thorough neurological and physical examination and, in case of doubts in the diagnosis, an imaging diagnostic such as a computer tomography (CT) or, in rare cases, an MRT.

In the CT, almost all symptomatic causes of headaches such as tumors, bleedings, CSF circulatory dysfunctions or vascular formations are visible. If the migraine has been present for a long time, if the attacks are typical, and if the frequency and severity of the attacks has not changed, then there is no reason to perform a computer tomography or a magnetic resonance tomography (MRT).

Therapy

Success criteria for successful treatment of a migraine attack are: An improvement of the headaches from severe or moderate to light or headache-free within two hours of application of the respective preparation and a reproducible effect in two out of three migraine attacks.

Guidance for the Patient/General Measures

If possible, shielding the patient from stimuli should be done in a darkened, low-noise room. For many patients, sleep is helpful. A local ice treatment (ice bag) is effective as an analgesic. There are no controlled studies for any of these measures.

Migraine Prevention - Prophylaxis

The indication for a medicinal prevention of the migraine arises from:

  • More than three migraine attacks per month that do not respond treatment and/or if side effects of the acute therapy are not tolerated
  • Migraine attacks lasting more than 48 hours
  • Migraine attacks that are subjectively perceived as intolerable by the patient;  complicated migraine attacks (manifest neurological deficiencies lasting for more than seven days)

The purpose of the medicinal prophylaxis is a reduction in the frequency, severity, and duration of the migraine attacks and the prophylaxis of the medication-induced, permanent headache. An optimal migraine prophylaxis achieves a reduction in the frequency, intensity, and duration of the attacks of at least 50 % of migraines. At first, the patient will maintain a headache calendar for four weeks in order to document the attack frequency and the success or failure of the respective headache medication.

Ineffective Therapies

Ineffective medicinal therapies include bromocriptine, antiepileptic medications carbamazepin, diphenylhydantoin and primidone, diuretics, clonidine, estrogens and gestagens, lithium, neuroleptics, proxibarbital, and selective serotonin re-uptake inhibitors.

Of the non-medicinal procedures, autogenic training, chiropractic therapy, manual therapy, tooth extraction, bite splints, cellular therapy, local injections into the neck or the scalp, neural therapy, stimulation currents, magnetic field therapy, Psychophony, ozone therapy, tonsillectomy, foot reflex massage, treatment of alleged mycotic infections of the colon, removal of amalgam fillings, hysterectomy, and classic psychoanalysis are either ineffective or are not grounded in scientific evidence.

Comment and medical assessment of the so-called “Psychophony procedure” for the treatment of a migraine

So-called Psychophony is a procedure in which biological data gained by means of EEG are transformed by computer in sounds. In turn, these sounds are supposed to influence illnesses in a positive way.

Psychophony is an ineffective procedure for treating migraines, both with regard to attack copying as well as migraine prophylaxis. The therapeutic procedure described in the patient information of the Psychophony cannot be reconciled with the current modern disease-causing perception of the migraine.

In summary, it can be said that the Psychophony is not scientifically valid and that documents on its effectiveness are lacking in recognized publications.

The fact that good therapeutic results are discussed via the Internet or in advertisements in the press in no case replaces scientifically validated proof and evidence.

This post is also available in: German

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