Migraine: Understanding its Origins and Key Facts

Migraines are a type of headache that affects approximately one billion people worldwide. Historically, the prevailing theory about migraines was that they were a vascular headache. This theory was based on the observation that the throbbing or pulsating pain that characterizes migraines was believed to be due to the dilation of blood vessels during a migraine attack. This theory was supported by the fact that pain could be alleviated by vasoconstrictors like caffeine or ergotamine.
However, recent research has led to a better understanding of the underlying mechanisms of migraine pain. The trigeminovascular pathway is now recognized as playing a crucial role in the pathophysiology of migraines. The activation of this pathway is responsible for the characteristic throbbing pain associated with migraines.
To understand the trigeminovascular pathway, it's important to have a basic understanding of the trigeminal nerve, which is the fifth cranial nerve. The trigeminal nerve is a sensory nerve that provides sensation to the head and face. Unlike the seventh cranial nerve, which is a motor nerve controlling facial movement, the trigeminal nerve has three branches:
1. Ophthalmic
2. Maxillary
3. Mandibular
During a migraine attack, all three branches can become activated, but the ophthalmic branch is the most involved. This branch contains nociceptor neurons and fibers that innervate the meninges and large cerebral arteries. Nociceptor neurons are sensory neurons that become stimulated during a migraine attack, releasing neuropeptides such as calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating polypeptide-38 (PACAP). This peripheral sensitization is responsible for the throbbing pain often described during a migraine attack.
The involvement of the trigeminal nerve in migraines can also result in facial pain. This pain can be unilateral or bilateral and is typically frontotemporal and/or periorbital, consistent with the sensory distribution of the ophthalmic division of the trigeminal nerve. Pain may also be present in the cheek area, presumably from activation of the second division of the trigeminal nerve. Less commonly, jaw pain can occur from activation of the third division of the trigeminal nerve.
Without effective acute treatment, the pain of a migraine attack can last up to 72 hours. During the pain phase of a migraine attack, sensitization can move from peripheral to central. As the stimulated pain pathway moves up to higher pain centers in the brain, including the thalamus and cerebral cortex, pain can worsen as central sensitization occurs. This phase of a migraine can be associated with cutaneous allodynia, characterized by sensitivity to light touch that ordinarily should not be painful. Examples include an individual expressing pain when light touch is applied to the scalp and finding a ponytail or shaving painful.
In Summary, migraine is a complex neurological disorder that can be very debilitating to an individual's daily life. The pathophysiology of migraine involves the trigeminovascular system (TVS). This refers to neurons and their axonal projections within the trigeminal nerve that project to the cranial meninges and meningeal blood vessels residing on the brain's surface.

This pathway plays a crucial role in the initiation and maintenance of migraine attacks. Treatment options for migraine have improved in recent years. However, more research is needed to develop better treatments that can effectively prevent and manage the condition.