Migraine Headache

Aka: Migraine Headache, Migraine, Classic Migraine, Migraine with Aura, Common Migraine, Migraine without Aura, Chronic Migraine Without Aura, Migraine Headache Diagnostic Criteria

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II. Epidemiology

  1. Gender
    1. Females more commonly affected overall (peak ratio 3:1)
    2. Prior to Puberty, males tend to have more Migraine Headaches
  2. Age
    1. Children
      1. Age 3 to 7 years: 1.2 to 3.2%
      2. Age 7 to 11 years: 4 to 11%
        1. Boys: 7 years old mean age of onset
        2. Girls: 12 years old mean age of onset
      3. Teens: 3 to 8%
    2. Adults
      1. Peak Prevalence at ages 20 to 50 years old
      2. Prevalence: 44.5 Million U.S. in 2009
      3. Women: 18-26%
      4. Men: 6-9%
      5. Stokes (2011) Headache 51(7): 1058-77 [PubMed]
  3. Most Migraine Headaches are undiagnosed
    1. Women: 59% are undiagnosed
    2. Men: 71% are undiagnosed
    3. Migraine Headaches account for 95% of Headache presentations
      1. Increases to 99% if patients say they have Migraine
  4. Chronic Migraine
    1. Up to 7% of those with Migraine history, will develop chronic Migraines
    2. May evolve from other Headache types
      1. Chronic Tension Headache
      2. Post-Traumatic Headache

III. Risk Factors: Migraine Headaches in General

  1. See Migraine Trigger
  2. Family History of Migraine Headaches
  3. Obesity
  4. Analgesic overuse
  5. Sleep Apnea or other sleep disturbance
  6. Head Injury
  7. Female gender
  8. Caffeine: >100 mg/day (OR: 2.9)
    1. Bigal (2002) Headache 42:575-81 [PubMed]

IV. Risk Factors: Chronic Migraine Headache (progression from episodic Migraine Headaches)

  1. Headache frequency
    1. Headaches per month 0-4: Odds Ratio 1
    2. Headaches per month 5-9: Odds Ratio 17.6
    3. Headaches per month 10-15: Odds Ratio 25.4
  2. Medication overuse
    1. Opioid overuse: Odds Ratio 4.4
    2. Triptan overuse: Odd Ratio 3.7
    3. Ergotamine overuse: Odd Ratio 2.9
    4. Analgesic overuse: Odds Ratio 2.7
  3. Obesity
    1. BMI >30/m2: Odds Ratio 5.5
    2. Consider secondary causes (e.g. Obstructive Sleep Apnea, Pseudotumor Cerebri)
    3. Diabetes Mellitus without Obesity does not appear to be an independent risk factor
  4. Head or neck injury
    1. Occurs more often in men (OR 3.3) than women (OR 2.4)
    2. Independent from time of injury and severity of Head Injury
  5. Other factors predicting progression to chronic Migraine Headaches
    1. Episodic Migraine Headaches lasting >72 hours
    2. Episodic Migraine Headaches that are severe, pulsating and with photophobia and phonophobia
    3. Chronic Pain (esp. chronic musculoskeletal pain)
    4. Cutaneous Allodynia
      1. Pain in response to non-painful triggers on touching the scalp or skin

V. Pathophysiology: Trigeminovascular activation

  1. CNS Platelet and Mast Cell aggregation
  2. Serotonin release from synaptic nerve endings
  3. Increase then decrease in blood brain Catecholamines
    1. Norepinephrine
    2. Epinephrine
  4. Alternating Vasoconstriction and Vasodilatation
    1. The vessel wall Stretching results in pain
  5. Replaces the prior theory of spasm
    1. Vessel Spasm
    2. Rebound vasodilation

VI. Types

  1. Types based on aura
    1. Common Migraine (without aura)
    2. Classic Migraine (with aura)
  2. Types based on frequency or timing
    1. Episodic Migraine (typically 1-2 Headaches per month)
    2. Chronic Migraine (>15 Headaches per month for more than 3 months)
    3. Menstrual Migraine
  3. Complicated Migraine
    1. Migraine with prominent neurologic signs
    2. Subtypes
      1. Basilar Migraine
      2. Hemiplegic Migraine
      3. Ophthalmoplegic Migraine
      4. Migrainous Carotidynia

VII. Symptoms

  1. Frequency
    1. Episodic Migraine Headache (>95% of Migraine Headaches)
      1. Typically occurs 1-2 times per month, up
    2. Chronic Migraine Headache (1 to 5% of Migraine Headaches)
      1. Occurs at least 15 times monthly for at least 3 months
  2. Prodrome (30% of patients)
    1. Precedes Headache by up to 24 hours
    2. Excitability and Irritability
    3. Increased appetite and cravings (especially sweets)
    4. Depression
    5. Sleepiness and Fatigue
    6. Yawning
    7. Heightened Perception to external stimuli
  3. Severity
    1. Disability is the marker of Migraine (highly debilitating compared with Tension Headache)
  4. Aura (20% of patients): See diagnosis below
    1. Visual aura (most common)
      1. Scotomata (visual scintillations, gradual, shimmering or zigzag pattern)
      2. Transient, fully reversible, colorful flashing lights or dark spots
    2. Atypical aura (carefully consider differential diagnosis such as Cerebrovascular Accident)
      1. Hemisensory aura (e.g. Paresthesias or numbness)
      2. Hemiparesis aura
      3. Dysphasia aura (or Dysarthria)
  5. Headache Phase
    1. Location
      1. Unilateral in 50%
      2. Often frontal in location
    2. Characteristics
      1. Pulsating, Throbbing Headache in 50%
      2. Dull, ache-type Headache in 50%
    3. Palliative measures
      1. Relieved with sleep
    4. Provocative measures
      1. Physical Activity (walking, climbing stairs)
    5. Timing
      1. Persists for 4 to 72 hours (untreated or failed treatment)
      2. Consider alternative diagnosis if lasts longer than 72 hours
        1. Rarely, Status Migrainosus can last longer than 72 hours
    6. Severity
      1. Moderate to severe pain
      2. Disabling symptoms
  6. Associated Symptoms strongly correlated with Migraine Headache
    1. Nausea or Vomiting
      1. Positive Predictive Value: 56% (m) 82% (f)
      2. Negative Predictive Value: 1.2% (m) 4.2% (f)
    2. Photophobia or Phonophobia
      1. Positive Predictive Value: 25% (m) 53% (f)
      2. Negative Predictive Value: 2.4% (m) 7.7% (f)

VIII. Symptoms: Common Triggers (Patient should keep a diary)

  1. See Migraine Headache Triggers
  2. See Tyramine-Vasoactive Amines
  3. See Medication Causes of Headache

IX. Imaging: Neuroimaging Indications

  1. First or worst severe Migraine Headache (see below)
  2. New onset Migraine Headache in age over 50-55 years old
  3. Sudden onset Headache
  4. Abnormal Neurologic Examination
  5. Not indicated in nonacute Migraine with normal exam
  6. Neff (2005) Am Fam Physician 71(6):1219-22 [PubMed]

X. Diagnosis: POUND Mnemonic

  1. Criteria (POUND)
    1. Pulsatile quality of Headache
      1. Could also represent photophobia (but not part of mnemonic)
    2. One day duration (ranges 4 to 72 hours)
    3. Unilateral Location
    4. Nausea or Vomiting
    5. Disabling intensity
  2. Interpretation
    1. Migraine Headache is 92% likely if at least 4 of the following criteria are present (in primary care, LR+24)
    2. Migraine Headache is 64% likely when 3 criteria are present
    3. Migraine Headache is 17% likely when <=2 criteria are present
  3. References
    1. Ebell (2006) Am Fam Physician 74(12): 2087-88 [PubMed]

XI. Diagnosis: Common Migraine without Aura (International Headache Society Diagnostic Criteria 3)

  1. Timing and general characteristics
    1. Five episodes or more
    2. Each episode (untreated or unsuccessfully treated) lasts 4 to 72 hours (>2 hours in age <18 years old)
    3. No evidence of Organic Headache or other more likely diagnosis
  2. Two of the following criteria
    1. Unilateral Headache pain
    2. Pulsating quality to Headache pain
    3. Symptom severity limits daily activities (moderate to severe intensity)
    4. Provoked by routine level of exertion (e.g. walking or climbing stairs)
  3. One of the following criteria occur with Headache
    1. Nausea
    2. Photophobia AND Phonophobia

XII. Diagnosis: Classic Migraine with Aura (International Headache Society Diagnostic Criteria 3)

  1. At least 2 Headaches that fulfill the following criteria
  2. One or more of the following, fully-reversible aura changes:
    1. Motor or Brainstem disturbance (fully reversible)
    2. Visual aura (fully reversible)
      1. Scintillating scotoma or fortification spectra
        1. Flickering lights, spots or lines in the central Visual Field
      2. Photopsia
        1. Flashes of light
    3. Sensory aura (fully reversible)
      1. Paresthesia
      2. Numbness
      3. Speech disturbance (Aphasia or dysphasia)
  3. Other characteristics (at least 3 of the following)
    1. Two or more symptoms occur in succession
    2. At least one aura symptom is positive
    3. At least one aura symptom is unilateral
    4. At least one aura symptom spreads gradually over 5 minutes
    5. Each individual aura lasts 5 to 60 minutes
    6. Headache follows aura within 60 minutes
  4. Other criteria
    1. Not attributed to other disorder

XIII. Diagnosis: Migraine in Children

  1. Five or more Headaches that last 2-72 hours
  2. Includes at least two Migraine characteristics
    1. Bilateral or unilateral temporal/frontal Headache
    2. Throbbing or pulsating quality
    3. Intensity moderate to severe
    4. Worse with routine exertion
  3. Includes at least one associated symptom
    1. Nausea or Vomiting
    2. Photophobia or Phonophobia
  4. Precautions

XIV. Differential Diagnosis

  1. See Headache Evaluation
  2. See Headache Causes
  3. See Organic Headache
  4. Analgesic Rebound Headache
    1. Always consider for patients with frequent Headache
  5. Conditions that may coexist with Migraine Headache
    1. Myofascial cervical Neck Pain
      1. Not exclusive to Tension Headache
      2. Present in 75% of Migraine Headache patients
      3. Triptan medications relieve Neck Pain and Headache
      4. Kaniecki (2002) Neurology 58:S15-20 [PubMed]
    2. Sinus Headache
      1. Migraine Headache criteria in 90% of Sinus Headache
      2. Schreiber (2004) Arch Intern Med 164:1769-72 [PubMed]
  6. Precautions
    1. Occipital Headache is uncommon in prepubertal children
      1. May occur with Increased Intracranial Pressure and warrants additional evaluation

XV. Evaluation: Headache with persistent neurologic deficit

  1. See Organic Headache
  2. Exclude Ischemic causes
  3. Exclude structural causes
  4. Exclude Inflammatory causes
  5. Exclude Metabolic cause

XVI. Evaluation: First or Worst severe Migraine Headache

  1. See Organic Headache
  2. No potent Narcotics until full evaluation
  3. Complete clinical and neurologic evaluation
  4. CT Head (or MRI Brain)
    1. Not indicated in typical Migraine Headache
    2. Use low threshold for Organic Headache symptoms
      1. Neurologic changes
      2. New onset Headache
    3. Organic causes of Headache identified by CT Head
      1. Subarachnoid Hemorrhage
      2. Intracranial Mass
  5. Lumbar Puncture
    1. Consider for meningeal signs, fever or ill appearance

XVII. Management

  1. See Migraine Management
  2. See Migraine Management in Children
  3. See Migraine in Pregnancy

XVIII. Course

  1. Mild episodic Headaches
    1. Most cases start with Migraine without Aura
    2. Relieved with OTC Medications
  2. Chronic episodic Migraine Headaches
    1. Unresponsive to OTC Medications
    2. Often presents at this stage
  3. Chronic progressive Migraine Headaches
  4. Chronic-Refractory Migraine Headaches

XIX. Complications

  1. Migraine with Aura is associated with a two fold increase in Cerebrovascular Accident
    1. Etminan (2005) BMJ [PubMed]
    2. Schurks (2009) BMJ [PubMed]
    3. Spector (2010) Am J Med [PubMed]

XX. References

  1. Ramdhan (2023) Crit Dec Emerg Med 37(5): 23-9
  2. Jackson (1998) CMEA Internal Medicine Lecture,San Diego
  3. Gilmore (2011) Am Fam Physician 83(3): 271-80 [PubMed]
  4. Ha (2019) Am Fam Physician 99(1): 17-24 [PubMed]
  5. Hainer (2013) Am Fam Physician 87(10): 682-7 [PubMed]
  6. Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
  7. Moore (1997) Am Fam Physician 56(8):2039-48 [PubMed]
  8. Noble (1997) Am Fam Physician 56(9):2279-86 [PubMed]
  9. Polizzotto (2002) J Fam Pract 51(2):161-7 [PubMed]
  10. Walling (2020) Am Fam Physician 101(7):419-28 [PubMed]
  11. Winner (1997) Headache 37:545-8 [PubMed]
  12. Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]

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