Introduction
About 70 to 75 % of people with migraine do not experience an “aura” before the pain starts. While 25 % experience an “aura” before the actual migraine attack. Migraine without aura is also called common migraine or hemicrania simplex. Studies show that migraine with aura present an increased risk of ischemic stroke, while migraine without aura possesses no such risk. Aura may come as a warning sign before the pain starts or can occur during a migraine. Aura is transient sensory changes, usually obstructive visual symptoms that last for five minutes to an hour. The aura phase is absent in migraine without aura. A common migraine, which is one without aura, is one experienced by most people and lasts for four hours to three days.
What Are the Causes?
There are several theories associated with the pathophysiology of migraine. The dilatation of cerebral vessels is found to be one possible cause of migraine. Most studies show a peripheral origin of migraine. Studies show that chemicals like serotonin, dopamine, and calcitonin gene-related peptides play a role in migraines. Other causes of migraine are
- Genetic- If one or both parents have a history of migraine, there is a 50 to 75 % chance that their child will get migraine.
- Estrogen- Some studies show a relationship between estrogen levels and migraine. Low estrogen levels are said to trigger migraines. Low estrogen levels are also associated with a decrease in serotonin levels, which also triggers migraine.
- Menstrual Migraine- It is often seen that women have their migraine attacks just before, during, or just after their periods. However, the actual relationship link requires further study.
- Other Triggers- Migraines are associated with some triggers in 76 % of patients. The common triggers include stress, smoking, alcohol, exercise, lack of sleep, weather changes, skipped meals, exposure to light, etc.
How Is the Condition Diagnosed?
The diagnosis is mainly based on clinical characteristics. The personal, familial, and medical history of the patient is reviewed. Generally, the imaging studies are normal. According to the International Classification of Headache Disorders (ICHD-3), a person who has five migraine attacks and meets the following criteria is said to have a “migraine without aura”:
1. Headache for a duration of four hours to three days if untreated or in failure of treatment.
2. Headache has at least two of the following features:
- Unilateral pain (pain on one side)
- Moderate or severe pain intensity.
- Throbbing pain.
- Pain is worsened by physical activity.
3. The person with the headache also presents with at least two of the following symptoms:
- Nausea and vomiting.
- Photophobia (sensitivity to light).
- Phonophobia (sensitivity to sound).
4. The headache is not related to other disorders.
In children, the duration of headaches is shorter. In children and adolescents (below 18 years), the duration of pain is 2 to 72 hours if untreated or treatment is unsuccessful. In case the child with a headache falls asleep, then the sleeping period is also considered part of the pain duration.
What Are the Three Phases of Migraine Without Aura?
The migraine attack starts with a headache and has three phases:
1. Premonitory Phase:
This phase exists for both migraine with aura and without aura and starts hours before the migraine attack. The symptoms are due to hypothalamus activation. These are more common in females, starting one or two days before the attack. The symptoms are:
- Photophobia.
- Phonophobia.
- Craving for food.
- Mood changes.
- Diarrhea or constipation.
- Tiredness.
- Feeling cold
- Thirst.
- Restlessness.
2. Headache Phase:
The intensity of pain is moderate to severe. This phase is characterized by the following symptoms:
- Pain lasts for four hours to three days (if untreated).
- Throbbing pain.
- Photophobia.
- Phonophobia.
- Nausea and vomiting.
- The pain is worsened by physical activity.
- Unilateral pain with increasing intensity in the first few hours.
- The patient usually seeks dark places, and the pain resolves during sleep.
3. Postdrome Phase:
This phase occurs after headache termination due to persistent blood changes. The patient feels hungover and presents with the following symptoms:
- Lack of concentration.
- Mood changes.
- Fatigue.
- Dizziness.
- Euphoria.
What Is the Differential Diagnosis?
The following conditions should be considered in a patient with a migraine:
- Cluster Headache- It is an uncommon form of severe unilateral headache that occurs in a pattern. But it also presents with other symptoms like lacrimation, eye redness, sweating, and pallor.
- Tension-Type Headache- This condition presents as a common mild form of headache that creates a feeling of tightness around the head. Pain is bilateral and lasts for 30 minutes to 7 days. The affected person is usually active.
- Meningitis.
- Encephalitis.
- Cerebral aneurysm.
What Are the Treatment Options?
Treatment options for migraine with and without aura are almost similar.
1. Treatment of acute migraine. Treatment is immediate; a single large dose is given to stop the progression of the condition. Parenteral administration is done for patients with nausea, vomiting, and gastric stasis. The treatment options are:
- NSAIDS (non-steroidal anti-inflammatory drugs) - Naproxen, Aspirin, Acetaminophen, Ibuprofen, and Diclofenac.
- Triptans - Sumatriptan, Zolmitriptan, Almotriptan, Rizatriptan. Triptans are used with or without Naproxen. Combination therapy with NSAIDS is more effective.
- Anti-emetics- To decrease nausea and vomiting.
- Dexamethasone- Reduces recurrence.
- Peripheral nerve blocking.
2. Preventive treatment. The preventive treatment medication includes:
- Calcitonin gene-related peptide antagonist- Erenumab.
- Beta-blockers like Metoprolol and Propranolol.
- Antidepressants.
- Calcium channel blockers like Verapamil.
- Anticonvulsants like Valproate acid.
- Botox.
3. Other treatment options include:
- Yoga.
- Lifestyle modification.
- Detoxification.
- Acupuncture.
- Cognitive behavioral therapy.
- Relaxation training.
- Biofeedback.
4. Non-medication therapy. Several neuromodulation devices are used for the treatment of migraine without aura and include the following:
- Remote Electrical Neuromodulator (REN)- REN is used to stimulate nerves in the upper arm.
- Non-invasive Vagal Nerve Stimulator (nVNS)- Gammacore, is a device used to electrically stimulate the vagus nerve.
- Transcutaneous Supraorbital Neurostimulator (tSNS)-Cefaly device electrically activates forehead nerves.
- Single-Pulse Transcranial Magnetic Stimulator- The magnet is placed on the back of the head and turned on.
Conclusion
Migraine without aura is the most common form of migraine that does not present with the aura phase. Migraine can significantly affect the quality of one’s life, and the affected needs the support of family and loved ones to cope with it. However, there are several treatment options for prevention and even non-medical treatment options like acupuncture, yoga, and more.
