Migraine Headache

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Definition/Description

Migraine is a chronic, episodic primary headache.  Migraine is thought to be a neurovascular pain syndrome with altered central neuronal processing (activation of brainstem nuclei, cortical hyperexcitability, and spreading cortical depression) and involvement of the trigeminovascular system (triggering neuropeptide release, which produces painful inflammation in cranial vessels and the dura mater).

Symptoms typically last 4 to 72 hours and may be severe. Pain is often but not always unilateral, throbbing, worse with exertion, and accompanied by autonomic symptoms (eg, nausea; sensitivity to light, sound, or odors).  Fortification spectra and other transient focal neurologic deficits occur in a few patients, usually just before the headache, also known as aura. Diagnosis of migraine can usually be made by history alone.  Treatment includes lifestyle changes (diet, exercise, sleeping habits), medications including NSAIDs, analgesics, serotonin receptor agonists, beta blockers, calcium channel blockers, and antiemetics.

Prevalence

Migraine headaches are the second most common type of primary headache. An estimated 28 million people in the United States (about 12% of the population) will experience migraine headaches at some point. Lifetime prevalence is 18% for women and 6% for men in the US.  It most commonly begins during puberty or young adulthood, waxing and waning in frequency and severity over the ensuing years and usually diminishing after age 50. In 90% of migraineurs, the first attack generally develops before the age of 40 years.  In women the frequency of headaches is highest during their reproductive years, when estrogen levels are higher, and decreases to some extent after menopause. About 45% of cases of migraine emerge during childhood or adolescence. Migraine with aura is more likely to develop at an earlier age than migraine without aura.

Characteristics/Clinical Presentation

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Associated Co-morbidities

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Medications

According to Clinical Neurology (6th ed), the following medications are generally used:

1. Acute Treatment:

Simple Analgesics

• Aspirin
• Naproxen Sodium
• Ibuprofen
• Acetominophen

Comments: May cause gastric pain or bleeding and rebound headache if used frequently.

Ergot Preparations

• Ergotamine/caffeine (Cafergot)

Comments: May cause nausea and vomiting (N/V); contraindicated by pregnancy or coronary or peripheral vascular disease (PVD)

• Dihydroergotamine

Comments: Use with metoclopramide (antiemetic)

Narcotic analgesics

• Codeine/aspirin
• Codeine/aspirin/acetominophen
• Meperidine
• Butorphanol

5-HT agonists (Serotonin Receptor Agonists)

• Sumariptan (Imitrex)
• Rizatriptan (Maxalt)
• Zolmitriptan (Zomig)
• Naratriptan (Amerge)
• Almotriptan (Axert)
• Frovatriptan (Frova)
• Eletriptan (Relpax)

Comments:10% incidence N/V; contraindicated by pregnancy or coronary or PVD, and with monoamine oxidase inhibitors (MAOI)

Other Agents

• • Caffeine/butalbital/aspirin (Fiorinal)
• Prochlorperazine

Comments: Can cause hypotension and drug-induced dystonia

2. Prophylactic Treatment

Antiinflammatory agents: 

• Aspirin
• Naproxen Sodium

Comments: May cause gastric pain or bleeding

Tricyclic Antidepressants

• Amitriptylline
• Nortriptyline
• Protriptyline
• Doxepin

Comments: May cause dry mouth, urinary retention, and sedation; contraindicated in glaucoma or prostatism

Beta Blockers

• • Nadolol
• Atenolol
• Timolol
• Metoprolol

Comments: Listed in descending order of efficacy; symptomatic bradycardia may occur at high doses; contraindicated in asthma and congestive heart failure; not to be used with calcium blockers

Ergot Alkaloids

• Methergine

Comments: Occurrence of retroperitoneal fibrosis with urethral obstruction and mediastinal fibrosis, although uncommon, should be monitored withe creatinine, ultrasonography, or intravenous urograms, and chest x-rays every 6 months; a drug holiday every 6 months is prudent

Cyproheptadine Comments: Drowsiness common early in treatment

Anticonvulsants

• Phenytoin
• Valproic acid
• Topiramate
• Gabapentin

Calcium Channel Antagonists

• Verapamil
• Nicardipine
• Flunarizine

Comments: Contraindicated by severe left ventricular dysfunction, hypotension, sick sinus syndrome without artificial pacemaker, or second- or third-degree AV nodal block; constipation is most common side effect; not for use with beta blockers

3. Other Agents

• Prochlorperazine
• Hydroxyzine
• Metoclopramide

Comments: Adjunct to treatment; improves enteric drug absorption and reduces nausea; dystonia and akathisia may occur and respond to IV benedryl

Diagnostic Tests/Lab Tests/Lab Values

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Causes

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Systemic Involvement

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Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

Due to the complexity of the pathophysiology and signs and symptoms attributed to migraine headaches, differential diagnosis is crucial for determining whether the headache is a medical emergency or a non-life threatening headache from other causes.  The following is a criteria developed by the International Headache Society classifying each type of headache into either primary, secondary, or other causes of headache with subclasses for each category for specific diagnosis. 

IHS Classification of Headaches

This classification is hierarchical and you must decide how detailed you want to make your diagnosis. This can range from the first-digit level to the fourth. First one gets a rough idea about which group the patient belongs to. Then one obtains information allowing a more detailed diagnosis. The desired detail depends on the purpose. In general practice only the first- or second-digit diagnoses are usually applied whilst in specialist practice and headache centres a diagnosis at the third- or fourth-digit levels is appropriate.

Part I: The Primary Headaches

1. Migraine

   1.1. Migraine without aura

   1.2. Migraine with aura

          In younger patients, several unusual disorders can mimic migraine with aura:

• Dissection of the carotid or vertebral artery
• Antiphospholipid antibody syndrome
• Cerebral vasculitis
• Moyamoya disease
• CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
• MELAS (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes) syndrome

         In older patients, migraine with aura can be mistaken for a transient ischemic attack, especially when the aura occurs            without headache. 

   1.3. Childhood periodic syndromes that are commonly precursors of migraine

   1.4. Retinal migraine

   1.5. Complications of migraine

   1.6. Probable migraine

2. Tension-Type Headache (TTH)

   2.1. Infrequent episodic tension-type headache

   2.2. Frequent episodic tension-type headache

   2.3. Chronic tension-type headache

   2.4. Probable tension-type headache

3. Cluster Headache and Other Trigeminal Autonomic Cephalgias

   3.1. Cluster headache

   3.2. Paroxysmal hemicrania

   3.3. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)

   3.4. Probable trigeminal autonomic cephalgia

4. Other Primary Headaches

Part II: The Secondary Headaches:

5. Headache attributed to head and/or neck trauma

   5.1. Acute post-traumatic headache

   5.2. Chronic post-traumatic headache

   5.3. Acute headache attributed to whiplash injury (S13.4)

   5.4. Chronic headache attributed to whiplash injury (S13.4)

   5.5. Headache attributed to traumatic intracranial haematoma

   5.6. Headache attributed to other head and/or neck trauma (S06)

   5.7. Post-craniotomy headache

6. Headache attributed to Cranial or Cervical Vascular Disorder

   6.1. Headache attributed to ischemic stroke or transient ischemic attack

   6.2. Headache attributed to non-traumatic intracranial hemorrhage (I62)

   6.3. Headache attributed to unruptured vascular malformation (Q28)

   6.4. Headache attributed to arteritis (M31)

   6.5. Carotid or vertebral artery pain (I63.0, I63.2, I65.0, I65.2 or I67.0)

   6.6. Headache attributed to cerebral venous thrombosis (CVT) (I63.6)

   6.7. Headache attributed to other intracranial vascular disorder

7. Headache attributed to non-vascular intracranial disorder

8. Headache attributed to a substance or its withdrawal

9. Headache attributed to infection

10. Headache attributed disorder of homeostasis

11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

12. Headache attributed to psychiatric disorder

Part III: Cranial Neuralgias, Central and Primary Facial Pain and Other Headaches

13. Cranial Neuralgias and Central Causes of Facial Pain

14. Other Headache, Cranial Neuralgia, Central or Primary Facial Pain

Case Reports

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Resources

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Recent Related Research (from Pubmed)

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References

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