Diagnosis of migraine: how to determine migraine by MRI or EEG

Headaches are one of the most common reasons why patients turn to neurologists. All factors that cause such disorders are conventionally divided into 2 groups: organic (they can be seen on MRI images) and functional. MRI is performed specifically to detect organic abnormalities of the brain, which include:

• tumor formations;
• hydrocephalus (accumulation of cerebrospinal fluid in the ventricles of the brain);
• aneurysms, stenoses and other vascular lesions;
• sinusitis, sinusitis and other inflammatory phenomena in the paranasal sinuses;
• cerebral hemorrhage;
• inflammation of the brain and its membranes (encephalitis, meningitis);
• congenital pathologies of brain structures.

Very often, the root cause of the disease cannot be seen in the images, and then the doctor determines its etiology based on indirect signs.

Another cause of migraine may be cerebral circulatory disorders, for which an MRI procedure in angio mode is prescribed. For diagnostic accuracy, the ideal option is to do an MRI at the time of an attack, when you can assess the intensity of blood flow and identify acute circulatory disorders.

During the procedure, radiologists can detect the so-called. "cervical artery syndrome", which can affect one side or spread to both vessels. This entails paroxysmal pulsating headaches, provoked by compression of the cervical artery and aggravated by head movements. The root cause of this phenomenon is usually trauma.

Migraine and comorbid disorders

If migraine is present, its clinical picture, diagnosis and treatment are closely related to a number of certain diseases. There is comorbidity or the fact that they are associated with a single pathogenetic mechanism.

Because of this, the patient’s quality of life is seriously deteriorated due to the manifestation of complications during periods of migraine exacerbations and between them.

Such ailments include:

• Sleep disorders
• State of anxiety or depression
• Digestive disorders (gallbladder contraction problems, stomach ulcers)
• Hyperventilation syndrome (signs of VSD)

Therapy for comorbid disorders helps prevent pain.

Clinical varieties

Diagnosis of the two types of disease is based on one distinctive feature. It's called a migraine aura, a complex of neurological conditions that appear either at the onset of an attack or just before it. So, migraine pain is distinguished with aura (less than 15% of clinical cases) and without it.

The aura develops in just 5-15 minutes, is observed for no more than one hour, and disappears with the onset of pain. In some patients, attacks are devoid of preliminary symptoms. However, in those who develop them, both types of the disease can alternate.

If for at least three months the main symptoms of migraine without aura occur more than 15 times per month, then the doctor will most likely diagnose chronic migraine. Along with this, the nature of the disease sometimes changes from case to case.

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Symptoms

The main symptom of migraine is headache. The headache is usually on one side, the nature of the pain is throbbing. The sensations intensify when moving or changing body position. The pain can always be in the same place or change location even within the same attack.

In addition to pain, signs of the disease include:

• Vomiting and nausea without relief.
• Change in sensitivity.
• Visual impairment.
• Speech impairment.
• Photophobia.
• Acute reaction to noise and sounds.

The listed symptoms occur before an attack and are its original harbingers. This phenomenon is called an aura.

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Main diagnostic symptoms

The main factor in determining migraine is the patient's history or complaints. Typically, patients note the following symptoms to a greater extent, which help to establish the severity of the pathology and make a diagnosis:

• Severe throbbing pain on the right or left side of the head
• Exacerbation with little physical effort
• Does not go away for a long time even when taking analgesic drugs (three hours - several days)
• Nausea and vomiting
• Discomfort in bright lights and loud noises

Attacks of the disease usually occur spontaneously. However, a number of factors can influence the frequency of their occurrence. Among them are emotional stress, non-compliance with the daily routine, nutrition, and changes in diet. Sometimes the onset of an attack can be caused by drinking alcohol or certain foods (chocolate, citrus fruits, cheese).

Characteristics of migraine

Migraine headaches are caused by a combination of dilation of blood vessels and the release of chemicals from the nerve fibers that surround these blood vessels.

During a headache attack, the dilation of the artery occurs, which is located on the outside of the skull under the skin in the temple area (temporal artery). This causes the release of chemicals that cause inflammation, pain, and further dilation of the artery.

Migraine, through stimulation of the sympathetic nervous system, leads to a feeling of nausea, diarrhea and vomiting. This stimulation also delays the emptying of stomach contents into the small intestine (affecting the absorption of foods), reduces blood circulation (leading to cold hands and feet), and increases sensitivity to light and sound.

According to research, approximately 12% of Americans suffer from migraines. Women get migraines more often than men.

This is a vascular headache that usually develops in people between the ages of 15 and 55. Approximately three-quarters of all migraine sufferers have a family history of migraine.

Diagnostic criteria

When a migraine occurs without an aura, assess for at least five attacks of pain in the head. The diagnosis is confirmed when certain criteria are met:

1. The pain does not decrease for four hours to three days without taking medications.
2. Discomfort in the head is located only in one area, has a medium or high level of intensity, pulsation, and intensifies with little physical activity.
3. Nausea, vomiting, chills, fear of light and loud sounds accompany the attack.

Based on the assessment of at least two migraine attacks with aura, the following diagnostic criteria must be present:

1. Motor weakness is not observed during the aura, but there are reversible disturbances in vision (lightning, flickering in the eyes, complete impairment), touch (tingling, numbness), and speech.
2. At least two symptoms from the following list are present:

• Signs appear within five minutes to an hour
• At least one aura symptom gets worse for five minutes or more
• Several aura symptoms occur in succession in less than five minutes
• Vision and touch are impaired on one side

1. Migraine sensations are the same as without an aura, but appear either during the aura or an hour after its onset.

Treatment in Development

Migraine therapy has two goals: to end acute attacks and to prevent the next attack. The latter could potentially prevent progression of the disease from an episodic to a chronic condition. In terms of efforts to stop acute attacks, migraine is one of the few pain conditions for which a specific drug—a triptan—has been developed based on an understanding of disease mechanisms. In contrast, efforts to prevent the onset of migraine are likely to face a much greater challenge, given that migraine can occur in an unknown number of brain regions (see above) and is associated with generalized functional and structural brain abnormalities. A number of procedures that attract attention are briefly discussed below.

Medications

The most promising drug currently in development is humanized monoclonal antibodies to CGRP. The development of these monoclonal antibodies targets both CGRP itself and its receptors. The concept is based on the localization of CGRP in the trigeminal ganglion and its significance in the pathophysiology of migraine. In recent randomized, placebo-controlled phase II trials, neutralizing humanized monoclonal antibodies against CGRP were administered by injection for the prevention of migraine recurrence and showed promising results. Notably, one injection can prevent or significantly reduce migraine attacks for 3 months.

Given our growing understanding of the importance of the prodrome and aura in the pathophysiology of migraine, drugs targeting ghrelin, leptin, and orexin receptors may be considered therapeutic developments based on their ability to restore hypothalamic function. All of this may be critical in reducing allostatic load and therefore initiating the next migraine attack.

Brain Modification

Neuroimaging studies showing that neural networks, brain morphology, and brain chemistry are altered in both episodic and chronic migraines justify efforts to develop techniques that broadly modify brain networks and their functions.

Transcranial magnetic stimulation, which is thought to modify cortical hyperexcitability, is emerging as one such approach. Another approach for generalized brain modification is cognitive behavioral therapy.

Purpose of the diagnostic test

When determining migraine it is important:

• Make a correct diagnosis
• Exclude other diseases with similar symptoms through differential diagnosis
• To prescribe a treatment regimen, find out the type of illness, severity, and frequency of attacks.

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Identifying the stage of the disease helps determine the components of treatment and its need.

Diagnostics

To make a diagnosis, the patient is examined and interviewed. An accurate diagnosis can only be made if the symptoms characteristic of migraine are distinguished from the manifestations of other diseases with similar symptoms. The following diagnostic measures are carried out:

• MRI.
• Electroencephalography.
• Angiography.

For migraines, examination usually does not reveal any organic cause. Diagnosis is made based on symptoms and whether they meet the criteria for migraine. Evaluated:

• Nature of pain.
• Its localization, intensity.
• Presence of vomiting and nausea.
• Presence of photophobia.
• The nature of the aura.

Features of the anamnesis

At the first appointment, patients with systematic headaches, such as migraines, are asked questions both about the nature of the attacks and about the features of their life. The doctor finds out what factors could have caused the development of the malaise.

Important information about:

• Hereditary factors - did any of the relatives have the same manifestations?
• Nutrition, lifestyle, bad habits, daily routine, sleep time
• Taking medications
• Circumstances preceding headaches
• Chronic diseases
• Stressful moments in life
• Injuries to the head, neck, back

Eye pain: is it a migraine?

Pain in the eyeballs is another symptom often referred to as ocular migraine. In fact, it can occur with various diseases, such as an acute attack of glaucoma, cluster headaches, sinus infections, etc.

In order to understand the real causes of eye pain during migraines, you need to visit a doctor and undergo an examination. Sometimes this symptom hides serious illnesses.

People who:

• over 50 years old;
• have never suffered from migraine attacks before;
• have chronic cardiovascular diseases.

The doctor deals with such patients especially carefully. It is imperative to exclude other, more dangerous possible causes: retinal detachment, blockage of the lumen of a vessel by a blood clot, pituitary tumor.

Symptoms of ocular migraine do not require treatment; as a rule, vision returns to normal within a few minutes. To prevent attacks, you need to avoid triggers - factors that usually provoke them. Your doctor may prescribe medications to relieve headaches.

Experienced doctors will examine you, prescribe an examination, reliably identify the causes of your symptoms and prescribe adequate treatment. You can make an appointment by calling +7 (495) 230-00-01. Call anytime.

The material was prepared by Natalya Yurievna, a neurologist at the Medicine 24/7 clinic, Candidate of Medical Sciences Lasch.

Visual diagnostics

After completing the history, the doctor begins a physical examination, including:

1. Measuring parameters of blood pressure, heart rate and respiration, body temperature
2. Determining the shape and size of the head by feeling and measuring
3. Eye examination (pupils, fundus)
4. Palpation of the temples to assess the condition of the temporal artery
5. Determining pain syndrome and muscle tension by palpation of the head, jaw, neck and shoulders
6. Study of pulsation of cervical vessels with a phonendoscope
7. Skin sensitivity assessment
8. Palpation of the thyroid gland to determine its size and condition
9. Study of reflexes, coordination
10. Analysis of psycho-emotional state

Palpation of the thyroid gland in the diagnosis of migraine to determine the size and location.
This technique helps to exclude pathologies with similar symptoms and identify neurological disorders accompanying migraine pain.

Examination by specialized specialists

If there are possible diseases that cause a similar headache, the neurologist will refer you to the following specialists:

1. Ophthalmologist – inflammatory and infectious processes in the eyes
2. Dentist – purulent dental pathologies
3. Otolaryngologist – inflammatory processes of the inner and middle ear, maxillary sinuses
4. Vertebrologist – pinched vertebral arteries

An examination by the listed specialists excludes either migraine or other diseases that provoke the development of a common headache. For example, cervical migraine has a distinctive symptom – difficulty swallowing.

Reasons for the development of the disease

The reasons may be different and not always obvious. Provoking factors may include:

• Narrowing of the lumen of arterioles, which leads to disruption of blood supply to the brain.
• Stress.
• Malfunctions of the endocrine system.
• Heredity, predisposition to chronic hypertension.
• Overwork.
• External stimuli - noise, vibration and others.
• Severe mental and emotional stress.
• In some cases, an attack can be triggered by certain foods (fish, cheese, nuts and others).

MRI and CT

Brain screening using computed tomography (CT) or magnetic resonance imaging (MRI) is ordered to rule out neurological problems, tumors, aneurysms, and other brain abnormalities. The brain and its electrical activity are also sometimes examined using electroencephalography (EEG).

MRI reveals ischemic causes indicating the presence of pathology. Studying the brain directly during an exacerbation of pain makes it possible to notice a sharp stretching/compression (spasm occurs) of the vessels of the head before an attack and a decrease in the speed of blood flow when it weakens.

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CT plays a role in identifying factors in the development of neurological disorders that can provoke migraine pain. Otherwise, the pain syndrome is most likely caused by an increase in intracranial pressure due to the presence of tumors or aneurysms.

MRI or CT - what to choose?

The neurologist assesses the need for instrumental diagnostics, relying on information from a survey and examination of the patient. In addition to choosing a research method, the doctor prescribes tomography parameters, diagnostic mode, which contrast agents can be used, etc.

MRI of the brain is an important step in diagnosing migraines

It is possible to determine migraine by MRI if abnormalities in the structure of the brain vessels have been identified. The procedure is carried out in the following cases:

• Traumatic brain injuries
• Severe hemodynamic disturbances
• Postoperative recovery period
• Risk of cerebral infarction
• Complaints of severe hemicrania during migraine

If no abnormalities were identified during the study, then computed tomography is used. It shows tumors or their absence.

Both methods complement each other and provide more information about the pattern of pain attacks. However, the choice always remains with the doctor.

Type of MRI used for headache pain

Diagnosis of migraine using MRI is carried out in angio mode. It is most effective to carry out the procedure during a migraine attack. Since it is possible to detect obvious deviations in the blood flow of the brain, including acute ones.

It is advisable to conduct a combined examination - MRI of the brain and angiography of the vessels of the head and neck. In this way, complete information about the state of the brain can be obtained.

How is MRI performed for migraine?

For complaints of recurrent headaches, MRI is prescribed to differentiate from severe organic brain lesions that have a structure similar to migraine. The pain caused by migraine cannot be eliminated with analgesics. Most often, people begin to uncontrollably take pills, which only worsen their condition.

When conducting a tomography study for migraine, the doctor follows a certain algorithm - scanning the brain, vascular bed, and cervical vascular system. If necessary, angiography data of the cervical vessels is added to this to assess the state of blood flow in the arteries.

On MRI images, migraine is manifested by multiple foci of ischemic origin, blood flow disturbances (recorded by a tomograph only during attacks). Immediately before a migraine attack, the blood vessels in the brain dilate, after which a sharp spasm occurs.