“The wisdom of medicine is not only in treating disease, but also in understanding the person living with it.”
What is migraine?
Migraine is one of the most common neurological disorders worldwide. It is a major cause of reduced quality of life and impaired work productivity and one of the leading causes of disability among the younger population. According to global epidemiological data, migraine affects approximately 12 to 15% of the total population. Women are affected three times more frequently than men, which is associated with hormonal fluctuations and the influence of oestrogens. The highest prevalence is observed among people aged 20 to 50 years, a period when the disease has the greatest social and economic impact.
Although often experienced as a simple headache, migraine is a complex neurovascular disorder that involves changes in the activity of the brain, nervous system, and blood vessels. It is characterised by recurrent attacks of moderate to severe headache, most often localized on one side of the head. In addition to the pain, patients often experience nausea, vomiting, and increased sensitivity to light, sound, or smells.
The most common migraine triggers are: stress, strong odours, insomnia, fatigue, irregular diet, menstrual cycle, hormonal changes, weight changes, caffeine, alcohol.
Some patients also experience migraine aura – a group of transient neurological symptoms that precede the headache or occur during the attack. They most often manifest as bright or dark spots in the visual field, zigzag lines, blurred vision, a tingling sensation in the face or extremities, and speech difficulties. The aura usually lasts from 5 to 60 minutes and is the result of transient changes in the activity of brain cells.
Phases of a migraine attack
Migraine with aura most often progresses through four consecutive phases, although not every patient experiences every phase during each attack.
Prodrome phase (premonitory phase) – occurs a few hours to 1-2 days before the attack. The patient may experience fatigue, mood changes, irritability, reduced concentration, frequent yawning, increased appetite, or neck stiffness.
Aura phase – lasts from 5 to 60 minutes and is a temporary neurological symptom. (visual phenomena, facial tingling, speech difficulties)
Headache phase – follows the aura or, less commonly, occurs simultaneously with it. The pain is most often unilateral, throbbing, and of moderate to severe intensity. The attack lasts from 4 to 72 hours and is often accompanied by nausea, vomiting, photophobia, and phonophobia.
Postdrome phase (recovery phase) – after the headache is over, patients often feel exhausted, have poor concentration, general weakness, or a feeling of “brain fog.” This phase can last from a few hours to a day.
Diagnosis and treatment of migraine
The diagnosis of migraine is is primarily clinical and is based on a detailed medical history, symptom profile, and neurological examination. There is no specific laboratory test for migraine, but additional examinations such as magnetic resonance imaging (MRI) or computed tomography (CT) can rule out other diseases, especially if there are alarming symptoms such as sudden severe headache, neurological deficit, or a change in the character of previous attacks
Keeping a headache diary often helps identify triggers and monitor the success of therapy.
Migraine treatment is divided into acute and preventive (prophylactic) treatment.
Acute treatment aims to quickly stop the migraine attack and reduce associated symptoms. For mild to moderate attacks, first-line treatment consists of non-specific analgesics (such as aspirin and paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs). For moderate to severe migraine, triptans remain the treatment of choice and are most effective when taken at the onset of an attack. Because of their vasoconstrictive effects, caution is required in patients with cardiovascular disease. In recent years, gepants, a new class of medications acting as CGRP receptor antagonists, have been developed. Unlike triptans, they do not cause vasoconstriction.
Preventive treatment aims to reduce the frequency, duration, or severity of migraine attacks, thereby improving the patient’s quality of life and overall functioning. Beta-blockers, particularly propranolol, are among the most commonly prescribed preventive therapies. Antiepileptic drugs, such as topiramate, also play an important role in migraine prevention, although their use may be limited by potential adverse effects. Antidepressants, especially amitriptyline, are beneficial in patients with comorbid psychiatric conditions, such as depression or anxiety, which frequently coexist with migraine. Other preventive options include botulinum toxin therapy.
Over the past decade, significant advances have been achieved with the development of monoclonal antibodies targeting calcitonin gene-related peptide (CGRP), such as fremanezumab. These therapies have demonstrated high efficacy together with a favourable safety profile and are administered once every 1-3 months. In addition, innovative intranasal preventive approaches are now available in the form of a nasal spray that creates an osmotic polymer film on the nasal mucosa, mechanically helping to remove CGRP and other pro-inflammatory mediators associated with migraine attacks.
One of the problems frequently encountered in clinical practice is medication-overuse headache. It most commonly occurs when patients take excessive amounts of analgesics in an attempt to control migraine pain, ultimately reducing the effectiveness of these medications. Headaches may also occur when frequently used medications are abruptly discontinued. It is generally recommended that analgesics should not be used more than 15 days per month.
Equally important are lifestyle changes: regular sleep (7-9 hours), a balanced diet, sufficient hydration, regular meals without skipping, regular physical activity, and avoiding individual triggers such as stress, alcohol, or certain foods.
Migraine is a chronic neurological disorder with a substantial impact on patients’ physical, psychological and social functioning. Early recognition of symptoms, accurate diagnosis and an individualised treatment approach can significantly improve disease control and quality of life. Today, thanks to new therapeutic options and a better understanding of migraine pathophysiology, an increasing number of patients are successfully managing their symptoms and leading active, productive lives.
“The goal of treatment is not just to reduce pain, but to restore a person’s freedom to live without its limitations.”