Migraine Headaches: Different Types of Migraines

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Guest: Dr. Bernard L. Maria - Pediatric Neurology

Host: Dr. Pamela B. Morris – Cardiology

Announcer: Welcome to an MUSC Health Podcast.

Dr. Pamela B. Morris: Hi! I am Dr. Pamela Morris and I am discussing migraine headaches today with Dr. Bernard Maria, who is Professor of Pediatrics and Neuroscience at the Medical University of South Carolina. He is also Executive Director of the Charles P. Darby Research Institute. Bernard, we have talked in an earlier podcast about diagnosing migraine headaches in children, but there are a number of different types of migraine headache.

Dr. Bernard L. Maria: That’s true, so in children who are having the typical headaches with throbbing and pulsating pain, and they are having issues with changes in coloration of their skin, they are looking pale, they are having some nausea. By far, the most common headaches are what we call common migraine, so that affects about one in ten children of school-aged children. Now beyond that, there are other types of headaches that are different, but are still considered migraine, that they still arise because of the same mechanisms in the brain related to a chemical called serotonin that affects brain blood flow and produces the pain associated with migraine. So an example is classic migraine and like common migraine where they can see sort of streaks of light or holes in their vision or flashing lights even before the pain begins. So, about one in ten children who have migraine have this classic version, it’s a little bit more common in adults than it is in children or teenagers. In addition to that, rare forms of migraine include confusional migraine. Now, this is an episode where a patient looks like they are having a stroke. The child cannot speak, but knows what’s going on around them, has the words in their head, but they can’t get the words out. They look just like they are having a stroke and the episodes can last several hours and then can or cannot be associated with pain. Another type involves hemiplegic migraine. There, they look like stroke also and they are not moving one side of their body.

Dr. Pamela B. Morris: This must be very frightening to a parent to see these symptoms in a child?Dr. Bernard L. Maria:It is, because you don’t expect to see stroke like you do in the elderly in a child. Now, children can have strokes, but migraine can produce this. In addition to confusional and hemiplegic migraine, we also have something called vertebrobasilar migraine. So, it involves the blood vessels that feed the brainstem and the brainstem is what keeps you awake. So, what happens as you go into a coma, suddenly into a coma cannot be aroused and you wake up, sometimes days later with the worst headache in your life and this is all due to changes in blood flow related to migraine. In addition, there are things like Alice in Wonderland syndrome where children perceive objects being much smaller than they actually are, that’s a part of the migraine phenomenon. So, you can see that migraine disrupts function of the brain and different regions of the brain can be affected to varying degrees and depending on how much of the brain is affected in addition to the pain, you could have all these different types of symptoms and signs.

Dr. Pamela B. Morris: You mentioned in the hemiplegic migraine and also in the vertebrobasilar migraine that there are symptoms of paralysis or coma. Are all of those findings reversible when the patient recovers from the migraine?

Dr. Bernard L. Maria: They are, and the children are perfectly fine. Otherwise, they can sometimes remember the early parts of what was going on, but usually have then a loss of consciousness associated with the episodes. They can remember what happened after them, but they aren’t left with any permanent deficits. They recover fully and then we work to prevent those episodes from having it again. Some of these forms migraine now have been shown to be related to our mitochondria. These little batteries that we have in everyone of ourselves at point mutations in the genes that regulate the proteins in these mitochondria can produce an energy failure fuel, sort of like your Duracell batteries died off and therefore your brain, which is very demanding of oxygen and energy has no place to go, it can’t function without these batteries. So, some of these diseases now have a genetic basis, but they present and are considered to be part of a migraine syndrome.

Dr. Pamela B. Morris :In an earlier podcast, you and I talked about some of the different forms of therapy for what I assume was more the classic migraine. Are the treatments the same for some of these more unusual forms of migraine?

Dr. Bernard L. Maria: So far, the approach of using treatments to abort or stop these episodes and using daily treatments to prevent the episodes are very similar in the different forms of migraine, all of which are reasonably effective in controlling and preventing their headaches. There is a worry in some of the rarer forms that because they?re so rare, these medications have never really been studied in them. So, for example, would a patient with a rare vertebrobasilar migraine be at risk of having a permanent injury or stroke if we use certain kinds of medications to reverse the episode. So, there is that concern and then caution in using those medications that are otherwise safe and effective in more common forms of migraine.

Dr. Pamela B. Morris: One final thing I wanted to talk about, you mentioned that all of these forms of migraine share a common mechanism, what is the mechanism of a migraine headache?

Dr. Bernard L. Maria: So, there have been many theories on what causes migraine and because of the high heritability or the fact that most of us with migraine have a family history of migraine, we know that genetics is the basic underpinning, but beyond knowing that you?re at risk for it because your mother had it or your grandfather had headache. We know that one chemical in the brain that is pivotal to producing migraine is serotonin. This is a chemical that is important in lots of functions in the brain including affect, mood, which may explain why patients with migraine can get very cranky, very moody, and sometimes are depressed with and without the headaches. Now, serotonin is released in the brain in an abnormal way, and medications that are targeted to serotonin’s ability to produce changes in the brain are very effective in migraine treatment like Imitrex, for example, which basically mimics some of the functions if serotonin and therefore cause brain cells to release less of it, but we know also that serotonin can affect our blood vessels on the scalp and cause inflammation by acting at the level of the brainstem. So, you need to think of migraine as being something that involves the brain, usually at the back of the brain, in the parietal, and occipital lobe of the brain all the away down to the brainstem and all the way up to the nerves that innervate the scalp, its whole pathway that is disrupted and migraine isn’t in any single place in the brain, it really is at multiple levels as a part of a circuit.

Dr. Pamela B. Morris: Dr. Maria, thank you so much for this interesting discussion about the different forms of migraine.

Dr. Bernard L. Maria: Thank you.

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