May 10, 2009
Sushanth was cycling home from school when he suddenly felt a pain in his head. It was so crippling that the boy, then in class eight, fell off his cycle. Little did his doctor suspect that it could be migraine.
The pain turned worse in class 10. Sushanth's worried parents pleaded with him not to strain. The blood tests and X-rays revealed nothing. Sometimes the pain surfaced as pricks behind the eyes. The ophthalmologist prescribed eye drops. When the pain appeared behind his ears, Sushanth saw the ENT specialist. He was told he had sinusitis.
The headaches worsened before his plus-two board exams. This time he went through MRI and CT scan; again there was nothing wrong. He was finally diagnosed with migraine. The pain would last for more than two days, followed by drowsiness and a feeling of unease for another couple of days. Painkillers gave him little respite from the headache; instead, they contributed to his poor concentration.
Why did it take so long for Sushanth to be diagnosed with migraine? “Diagnosis of migraine is complicated as it is not revealed through specific medical tests but based entirely on patient-reported symptoms,” says Dr R. Srinivasa, head of neurology, M.S. Ramaiah Medical College and Hospital, Bangalore. “We have to understand the headache patterns through questions posed to the patients. A doctor has to devise questions in such a way as to find maximum evidence to diagnose the problem as headache, that, too, migraine.”
Migraine is one of the common primary headaches, the other two being tension-type and daily chronic headaches. It is believed to be more prevalent than conditions such as rheumatoid arthritis, asthma, diabetes and osteoarthritis. “But it is grossly underestimated in our society as the disability is not apparent like in the case of an injury,” says Dr Sumit Singh, who runs a headache clinic at All India Institute of Medical Sciences, Delhi. The only other certified headache clinics in India are at the Jaslok Hospital and Lilavati Hospital in Mumbai, set up by Dr K. Ravishankar in the 1990s.
Migraine is a hyper-excitable state where specific neural tissues in the brain respond differently to a variety of stimulations like light, sound, food (monosodium glutamate, red wine and chocolate, for instance), travel, hormones, and psycho-social factors. “The main triggers in a tropical country like ours are weather, pollution, application of vermilion, smell of incense stick and rituals like fasting,” says Dr Arabinda Mukherjee of Kolkata's Vivekananda Institute of Medical Sciences, who sees about 40 migraine patients a month. While 80 per cent of them have common migraine, 20 per cent report classical migraine with aura, where the headache is accompanied by transient neurological symptoms. “Studies have shown migraine with aura causes certain changes in the brain which may cause stroke-like phenomena or dementia in old age,” adds Mukherjee.
Phonophobia, photophobia, nasal congestion, anxiety, dizziness, dehydration, lowered mood levels, fatigue, poor concentration and depression are some of the symptoms accompanying migraine. In rare cases, the migraineur (person with migraine) may also experience hallucinations, which is called the Alice in Wonderland syndrome. Writer Lewis Carroll is said to have been a migraineur and it is assumed that much of the imageries in his writings were inspired by his own auras.
Research is yet to find answers to the root cause of migraine. “It is a neurological disorder that can be triggered by internal and external stimulations. Most treatments are symptomatic. Basically, there are two forms of treatment: for more and less frequent attacks,” says Dr Thimmappa Hegde, head of Narayana Institute of Neurosciences, Narayana Hrudyalaya, Bangalore.
An occasional migraine is generally treated with painkillers given in the right dose. For attacks that occur more than 4-5 times a month and last for days, doctors go with prophylactic or anti-epileptic drugs (meant to be taken over a stretch of 2-3 months even in the absence of migraine).
Says Singh: “Treatment of migraine involves two aspects—identifying the triggers and management with drugs. I ask all my patients to maintain diaries to identify specific triggers. If I'm treating a young man, I would avoid those drugs that may affect his potency or if it is a young woman, I would avoid drugs that may cause weight gain.”
For patients with intractable migraine, Singh advises Botox, which can be given around the head. “We are convinced of its use after clinically studying its effect on 40 patients. It has no sedation side-effect, which is suitable for people like pilots suffering from migraine as they cannot be given drugs,” he adds.
Another latest effective treatment is occipital nerve stimulation where a pacemaker-like object is placed subcutaneously to stimulate the occipital nerve behind the ear. According to Singh, it is an expensive treatment (about 02.5 lakh) and has few takers in India.
No matter what the drug is, a scrupulous use alone can go a long way in managing migraine. “I always tell my patients, migraine is your friend who calls you before visiting. You get early signals, which is when you should use the painkillers. Once it reaches the peak, no amount of painkillers can relieve it, they will only contribute to side-effects like drowsiness and weight gain,” says Srinivasa. “Several routine drugs—analgesics like paracetamol, antacids like ranitidine and beta-blockers used to treat migraine—can cause rebound headaches if overused. It is a never-ending cycle. People start popping pills indiscriminately, only to have more headache. It may change the character of the headache—migraine can become a daily chronic headache, which is very difficult to treat,” he adds.
When 30-year-old Gangambika, a housewife, was told she had migraine and there was no cure for it, she stopped going to doctors. She had been prescribed vasograin, which she popped whenever the attack surfaced. “I've had these headaches for the last 10 years now and they grew worse with time. When there was an attack I could not take any sound or light, couldn't even lift my head up. Sometimes, I would end up taking 3-4 pills a day to no avail. When I realised I was getting addicted to vasograin I decided to try homoeopathy and it seems to be working,” says Gangambika.
Migraine is said to be three times more common in women than men; the cause, again, is unknown. The onset of migraine is 10-25 years, though children as young as three can suffer from it. “Most often the symptoms in children are not detected. The first thing to do when a child complains of headache is to believe the child and not mistake it for an excuse to miss school,” says Hegde. Migraine is genetic and it is possible to determine from the genes whether a child is likely to suffer from it.
Gangambika's daughter complained of headache when she was eight years old. “She could never take the TV sound, music in the car or any other noise. Sometimes she would come back from school and start crying. It was terrible to see her suffer and I could easily relate to it. She, too, is much better after homoeopathy treatment,” says Gangambika.
The mother-daughter duo went to Dr Deepak Shah, a homoeopath in Bangalore, who is trained in the art of spinal healing. “It is an evidence-based approach to wellness. Gentle precise touches to the spine sends signals to the brain to create new wellness-promoting strategies,” says Shah.
He resorts to spinal healing only when the migraine is severe. Three years ago, 38-year-old Manjula S., a housewife in Bangalore, went into 36 hours of coma following high fever. Ever since the incident, she developed severe headache, which was diagnosed as migraine.
“The migraines were unbearable. They were severe just before my menstrual cycle. I was prescribed sibelium (a prophylactic) but it would make me drowsy. For the last nine months I've relied on spinal healing and it seems to be working,” says Manjula, adding how she would do anything, try any treatment just to get rid of the pain in her head.
At Shah's clinic, The Healing Touch, he also uses like yoga and meditation to provide a holistic approach to migraine. Ever since he introduced spinal healing, which involves an average of six sessions of 25 minutes each, Shah says he has had a success rate of almost 90 per cent.
“Medicines affect individuals differently. More doctors are now open to holistic or comprehensive therapies like yoga and meditation. But it is not enough to rely on therapies alone. People should complement them with lifestyle modifications like regular food, sleep and exercise,” says Hegde.
Countries like Canada, Germany, the US, and more recently, Russia, have embarked on studies to determine the burden of migraine on their societies and the trigger factors. For instance, Internal Medicine, a journal published in the US, reports that migraine costs American employers about $13 billion a year because of missed workdays and impaired work function. There is statistics to even show that migraine in the US is responsible for about 112 million bedridden days a year! In Germany the loss estimated from migraine is $60 billion per year. Similar studies to record the burden and trigger factors of migraine in Indian society have been few and far between.
Recently, the International Headache Society and the WHO launched a large epidemiological study to look at the prevalence and incidence of migraine in India. “The study has just begun and I am one of the investigators. There are seven experts across the country to look at different regions. It may take about two years to complete,” says Srinivasa.
To arrive at any estimation of the burden of migraine on our society, it has to be first considered seriously both by doctors and patients. Says Srinivasa: “Migraine has to be treated as a disorder and not a symptom; that is the first step.”
Control migraine at the earliest
Aman Khurana, 18, is proud that he takes after his mother. Migraine helped him understand her. Aman's mother gets pulsating pain which starts from her eye and radiates towards the back of the head. “I have seen my mother suffer,” says Aman, a student at Delhi University. “She can't go out or work when she has pain. She locks herself in a quiet room for hours together. I would never have understood her situation if I had not got migraine the day I had to appear for my medical entrance examination. Probably, it was the stress that triggered it. It was so severe that though it subsided in half an hour after I had a painkiller, I could feel the heaviness in my head for a long time. It was as if my brain was floating in some fluid.”
Aman has been living with this pain for the last two years. When acupuncture and homoeopathy didn't help, he consulted his family physician, who has prescribed prophylactic treatment. “My doctor says that migraine can lead to neurological problems, even brain haemorrhage at a later stage,” he says. “So it is better to control it at the earliest.”
Women are more than twice as likely to suffer from migraine than men. About 3,000 migraine attacks occur every day per million people.
Dry mouth increases a person's risk of mouth infections, like thrush, gingivitis and tooth decay, and it makes it difficult to wear dentures. It is not a normal part of ageing.