"My face feels like it’s splitting in two. I feel like barbed wire is going in and around my head with sharp points sticking in it." This description of a migraine attack by a 12 year-old girl makes it clear that she experiences something far more intense than a normal headache, and the sheer agony of migraine is graphically conveyed in this picture by the artist Sean McHone.

Essentially, migraine is a severe pain in the head, usually one-sided, that is frequently associated with nausea and vomiting. It is sometimes preceded by visual symptoms, such as flashing lights, zigzag lines or a blind spot, which constitute the 'aura'. Traditionally, the type of migraine associated with an aura has been termed 'classic migraine'. Non-visual auras also occur, with symptoms such as confusion, difficulty in speaking, or weakness of an arm or leg. The pain is described as an intense throbbing or pounding in the forehead/temple, ear/jaw or around the eyes, which may last as long as one or two days.

Most sufferers, however, are victims of 'common migraine' which may strike without warning or be preceded only by vague symptoms such as fatigue or mood changes. The headache phase of this type of migraine, in which pain may be bilateral, is often accompanied by abdominal pain, diarrhoea, nausea and vomiting. Both classic and common migraine can occur as frequently as several times a week. There are also some less common types with differing symptoms, which are described on the neurologychannel site.

The cause of migraine is unknown, but there is often a family history of the disorder and research in the past two years indicates that mutations on chromosomes 1 and 19 may be implicated. Many widely different stimuli, or triggers, have been identified which bring on an attack. These include alcohol, environmental changes, stress, lack of sleep, certain foods (cheese, coffee, chocolate), hormonal changes, hunger and lack of sleep. The exact mechanism is not known but it is thought that the nervous system responds to a trigger by creating a spasm in the arteries at the base of the brain, which constrict and limit the flow of blood. Simultaneously, platelets clump together and release serotonin, a powerful vasoconstrictor that further reduces bloodflow. The limited supply of oxygen reaching the brain produces symptoms associated with the aura, as well as reflex dilatation of the arteries. This dilatation triggers the release of prostaglandins and chemicals that produce inflammation and swelling, which stimulate pain receptors and cause the throbbing pain.

The number of sufferers is surprisingly high. A meta-analysis of studies conducted in North America and Europe, involving about 58,000 people, found that the prevalence of migraine is 17% in women and 6% in men. Unfortunately, only about one in five of these people seeks medical help. From the economic viewpoint, the impact of the disorder is huge – about $14 billion in the USA alone!

Acute episodes are treated with triptans (5-hydroxytryptamine1 receptor agonists), ergot preparations and barbiturates, while propanalol (a beta-adrenergic blocker), anticonvulsants and antidepressants may be used prophylactically, to reduce the number of attacks. If you want to learn more about the widely-used triptans, and new ones in the pipeline, have a look at the Association of the British Pharmaceutical Industry site. Also, recent trials have shown the anti epileptic topiramate to be effective in preventing migraine, significantly reducing both migraine frequency and the number of days on which rescue medication is required.

In the last couple of months, the results of some less conventional treatments have been published. In New Jersey, researchers investigated the theory that some migraines are triggered or exacerbated by opposing surfaces within the sinuses or nasal cavity pressing against one another and stimulating the trigeminal nerve. Twenty one patients underwent endoscopic surgery to remove intranasal contact points; the average number of days with headache fell from 18 to 8 per month, the average severity of headache dropped from 7.78 to 5.6, and 9 patients had no further symptoms.

At the Mayo Clinic, in about 50% of migraine sufferers who had treatment to close a patent foramen ovale between the left and right atria of the heart, their headaches stopped completely. It is postulated that in these patients minute fragments of clotting material pass from the heart, around the body and up to the brain. In migraine sufferers, the brain is believed to be hyper-excitable, and the material triggers a cascade of events that culminates in a migraine attack.

Moving more leftfield, one body of professional opinion believes that dental malocclusions can cause an imbalance and pain in other regions of the body. In particular, it is thought poor contact between the teeth can stretch the dura mater, stimulating the trigeminal nerve and causing headaches, including migraine. Thus by correcting the patient's dental problems, their other symptoms disappear, as the patients on this page testify. As an aside, I seem to recall reading that Liverpool football captain Steven Gerrard's chronic injury problems were cured in this way. I wonder if his dentist is on a percentage of the new contract........?

Derrick Garwood, a Freelance Medical Writer and Editor submitted this tour. Feel free to email Derek

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