II. Epidemiology
- Gender
- Females more commonly affected overall (peak ratio 3:1)
- Prior to Puberty, males tend to have more Migraine Headaches
- Age
- Children
- Age 3 to 7 years: 1.2 to 3.2%
- Age 7 to 11 years: 4 to 11%
- Boys: 7 years old mean age of onset
- Girls: 12 years old mean age of onset
- Teens: 3 to 8%
- Adults
- Peak Prevalence at ages 20 to 50 years old
- Prevalence: 44.5 Million U.S. in 2009
- Women: 18-26%
- Men: 6-9%
- Stokes (2011) Headache 51(7): 1058-77 [PubMed]
- Children
- Most Migraine Headaches are undiagnosed
- Women: 59% are undiagnosed
- Men: 71% are undiagnosed
- Migraine Headaches account for 95% of Headache presentations
- Increases to 99% if patients say they have Migraine
- Chronic Migraine may evolve from other Headache types
III. Risk Factors: Migraine Headaches in General
- See Migraine Trigger
- Family History of Migraine Headaches
- Obesity
- Analgesic overuse
- Sleep Apnea or other sleep disturbance
- Head Injury
- Female gender
- Caffeine: >100 mg/day (OR: 2.9)
IV. Risk Factors: Chronic Migraine Headache (progression from episodic Migraine Headaches)
-
Headache frequency
- Headaches per month 0-4: Odds Ratio 1
- Headaches per month 5-9: Odds Ratio 17.6
- Headaches per month 10-15: Odds Ratio 25.4
- Medication overuse
- Opioid overuse: Odds Ratio 4.4
- Triptan overuse: Odd Ratio 3.7
- Ergotamine overuse: Odd Ratio 2.9
- Analgesic overuse: Odds Ratio 2.7
-
Obesity
- BMI >30/m2: Odds Ratio 5.5
- Consider secondary causes (e.g. Obstructive Sleep Apnea, Pseudotumor Cerebri)
- Diabetes Mellitus without Obesity does not appear to be an independent risk factor
- Head or neck injury
- Occurs more often in men (OR 3.3) than women (OR 2.4)
- Independent from time of injury and severity of Head Injury
- Other factors predicting progression to chronic Migraine Headaches
- Episodic Migraine Headaches lasting >72 hours
- Episodic Migraine Headaches that are severe, pulsating and with photophobia and phonophobia
- Chronic Pain (esp. chronic musculoskeletal pain)
- Cutaneous Allodynia
- Pain in response to non-painful triggers on touching the scalp or skin
V. Pathophysiology: Trigeminovascular activation
- CNS Platelet and Mast Cell aggregation
- Serotonin release from synaptic nerve endings
- Increase then decrease in blood brain Catecholamines
- Alternating Vasoconstriction and Vasodilatation
- The vessel wall Stretching results in pain
- Replaces the prior theory of spasm
- Vessel Spasm
- Rebound vasodilation
VI. Types
- Types based on aura
- Common Migraine (without aura)
- Classic Migraine (with aura)
- Types based on frequency or timing
- Episodic Migraine (typically 1-2 Headaches per month)
- Chronic Migraine (>15 Headaches per month for more than 3 months)
- Menstrual Migraine
- Complicated Migraine
- Migraine with prominent neurologic signs
- Subtypes
- Basilar Migraine
- Hemiplegic Migraine
- Ophthalmoplegic Migraine
- Migrainous Carotidynia
VII. Symptoms
- Frequency
- Episodic Migraine Headache (>95% of Migraine Headaches)
- Typically occurs 1-2 times per month, up
- Chronic Migraine Headache (1 to 5% of Migraine Headaches)
- Occurs at least 15 times monthly for at least 3 months
- Episodic Migraine Headache (>95% of Migraine Headaches)
- Prodrome (30% of patients)
- Precedes Headache by up to 24 hours
- Excitability and Irritability
- Increased appetite and cravings (especially sweets)
- Depression
- Sleepiness and Fatigue
- Yawning
- Heightened Perception to external stimuli
- Severity
- Disability is the marker of Migraine (highly debilitating compared with Tension Headache)
- Aura (20% of patients): See diagnosis below
- Visual aura (most common)
- Scotomata (visual scintillations, gradual, shimmering or zigzag pattern)
- Transient, fully reversible, colorful flashing lights or dark spots
- Atypical aura (carefully consider differential diagnosis such as Cerebrovascular Accident)
- Hemisensory aura (e.g. Paresthesias or numbness)
- Hemiparesis aura
- Dysphasia aura (or Dysarthria)
- Visual aura (most common)
-
Headache Phase
- Location
- Unilateral in 50%
- Often frontal in location
- Characteristics
- Palliative measures
- Relieved with sleep
- Provocative measures
- Physical Activity (walking, climbing stairs)
- Timing
- Persists for 4 to 72 hours (untreated or failed treatment)
- Consider alternative diagnosis if lasts longer than 72 hours
- Rarely, Status Migrainosus can last longer than 72 hours
- Severity
- Moderate to severe pain
- Disabling symptoms
- Location
- Associated Symptoms strongly correlated with Migraine Headache
- Nausea or Vomiting
- Positive Predictive Value: 56% (m) 82% (f)
- Negative Predictive Value: 1.2% (m) 4.2% (f)
- Photophobia or Phonophobia
- Positive Predictive Value: 25% (m) 53% (f)
- Negative Predictive Value: 2.4% (m) 7.7% (f)
- Nausea or Vomiting
VIII. Symptoms: Common Triggers (Patient should keep a diary)
IX. Imaging: Neuroimaging Indications
- First or worst severe Migraine Headache (see below)
- New onset Migraine Headache in age over 50-55 years old
- Sudden onset Headache
- Abnormal Neurologic Examination
- Not indicated in nonacute Migraine with normal exam
- Neff (2005) Am Fam Physician 71(6):1219-22 [PubMed]
X. Diagnosis: POUND Mnemonic
- Criteria (POUND)
- Interpretation
- Migraine Headache is 92% likely if at least 4 of the following criteria are present (in primary care, LR+24)
- Migraine Headache is 64% likely when 3 criteria are present
- Migraine Headache is 17% likely when <=2 criteria are present
- References
XI. Diagnosis: Common Migraine without Aura (International Headache Society Diagnostic Criteria 3)
- Timing and general characteristics
- Five episodes or more
- Each episode (untreated or unsuccessfully treated) lasts 4 to 72 hours (>2 hours in age <18 years old)
- No evidence of Organic Headache or other more likely diagnosis
- Two of the following criteria
- One of the following criteria occur with Headache
- Nausea
- Photophobia AND Phonophobia
XII. Diagnosis: Classic Migraine with Aura (International Headache Society Diagnostic Criteria 3)
- At least 2 Headaches that fulfill the following criteria
- One or more of the following, fully-reversible aura changes:
- Motor or Brainstem disturbance (fully reversible)
- Visual aura (fully reversible)
- Scintillating scotoma or fortification spectra
- Flickering lights, spots or lines in the central Visual Field
- Photopsia
- Flashes of light
- Scintillating scotoma or fortification spectra
- Sensory aura (fully reversible)
- Paresthesia
- Numbness
- Speech disturbance (Aphasia or dysphasia)
- Other characteristics (at least 3 of the following)
- Two or more symptoms occur in succession
- At least one aura symptom is positive
- At least one aura symptom is unilateral
- At least one aura symptom spreads gradually over 5 minutes
- Each individual aura lasts 5 to 60 minutes
- Headache follows aura within 60 minutes
- Other criteria
- Not attributed to other disorder
XIII. Diagnosis: Migraine in Children
XIV. Differential Diagnosis
- See Headache Evaluation
- See Headache Causes
- See Organic Headache
-
Analgesic Rebound Headache
- Always consider for patients with frequent Headache
- Conditions that may coexist with Migraine Headache
- Myofascial cervical Neck Pain
- Not exclusive to Tension Headache
- Present in 75% of Migraine Headache patients
- Triptan medications relieve Neck Pain and Headache
- Kaniecki (2002) Neurology 58:S15-20 [PubMed]
- Sinus Headache
- Migraine Headache criteria in 90% of Sinus Headache
- Schreiber (2004) Arch Intern Med 164:1769-72 [PubMed]
- Myofascial cervical Neck Pain
- Precautions
- Occipital Headache is uncommon in prepubertal children
- May occur with Increased Intracranial Pressure and warrants additional evaluation
- Occipital Headache is uncommon in prepubertal children
XV. Evaluation: Headache with persistent neurologic deficit
- See Organic Headache
- Exclude Ischemic causes
- Exclude structural causes
- Exclude Inflammatory causes
- Exclude Metabolic cause
XVI. Evaluation: First or Worst severe Migraine Headache
- See Organic Headache
- No potent Narcotics until full evaluation
- Complete clinical and neurologic evaluation
-
CT Head (or MRI Brain)
- Not indicated in typical Migraine Headache
- Use low threshold for Organic Headache symptoms
- Neurologic changes
- New onset Headache
- Organic causes of Headache identified by CT Head
-
Lumbar Puncture
- Consider for meningeal signs, fever or ill appearance
XVII. Management
- See Migraine Management
- See Migraine Management in Children
- See Migraine in Pregnancy
XVIII. Course
- Mild episodic Headaches
- Most cases start with Migraine without Aura
- Relieved with OTC Medications
- Chronic episodic Migraine Headaches
- Unresponsive to OTC Medications
- Often presents at this stage
- Chronic progressive Migraine Headaches
- Chronic-Refractory Migraine Headaches
XIX. Complications
- Migraine with Aura is associated with a two fold increase in Cerebrovascular Accident
XX. References
- Ramdhan (2023) Crit Dec Emerg Med 37(5): 23-9
- Jackson (1998) CMEA Internal Medicine Lecture,San Diego
- Gilmore (2011) Am Fam Physician 83(3): 271-80 [PubMed]
- Ha (2019) Am Fam Physician 99(1): 17-24 [PubMed]
- Hainer (2013) Am Fam Physician 87(10): 682-7 [PubMed]
- Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
- Moore (1997) Am Fam Physician 56(8):2039-48 [PubMed]
- Noble (1997) Am Fam Physician 56(9):2279-86 [PubMed]
- Polizzotto (2002) J Fam Pract 51(2):161-7 [PubMed]
- Walling (2020) Am Fam Physician 101(7):419-28 [PubMed]
- Winner (1997) Headache 37:545-8 [PubMed]
- Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]
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Related Studies
Definition (MEDLINEPLUS) |
If you suffer from migraine headaches, you're not alone. About 12 percent of the U.S. population gets them. Migraines are recurring attacks of moderate to severe pain. The pain is throbbing or pulsing, and is often on one side of the head. During migraines, people are very sensitive to light and sound. They may also become nauseated and vomit. Migraine is three times more common in women than in men. Some people can tell when they are about to have a migraine because they see flashing lights or zigzag lines or they temporarily lose their vision. Many things can trigger a migraine. These include
Doctors used to believe migraines were linked to the opening and narrowing of blood vessels in the head. Now they believe the cause is related to genes that control the activity of some brain cells. Medicines can help prevent migraine attacks or help relieve symptoms of attacks when they happen. For many people, treatments to relieve stress can also help. NIH: National Institute of Neurological Disorders and Stroke |
Definition (NCI) | A common, severe type of vascular headache often associated with increased sympathetic activity, resulting in nausea, vomiting, and light sensitivity. |
Definition (CSP) | neural condition characterized by a severe recurrent vascular headache, usually on one side of the head, often accompanied by nausea, vomiting, and photophobia, sometimes preceded by sensory disturbances; triggers include allergic reactions, excess carbohydrates or iodine in the diet, alcohol, bright lights or loud noises. |
Definition (MSH) | A class of disabling primary headache disorders, characterized by recurrent unilateral pulsatile headaches. The two major subtypes are common migraine (without aura) and classic migraine (with aura or neurological symptoms). (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1) |
Concepts | Disease or Syndrome (T047) |
MSH | D008881 |
ICD9 | 346, 346.9 |
ICD10 | G43 , G43.9, G43.909 |
SnomedCT | 155048007, 155046006, 267699004, 193041007, 37796009 |
LNC | LA15141-7 |
English | MIGRAINE HEADACHE, Migraines, Migraine Headache, Migraine NOS, Migraine, unspecified, Migraine Disorders, MA, MIGRAINE WITH OR WITHOUT AURA, SUSCEPTIBILITY TO, 1, MGAU, MIGRAINE, MGR1, migraine headache, migraine headache (diagnosis), Migraine headache, Migraine headaches, Migraine type headaches, Migrainous headache, Headache, Migraine, Headaches, Migraine, Migraine Headaches, Migraine Disorders [Disease/Finding], migraine nos, migraines, migraine syndrome, Headache;migraine, migraine headaches, headache migraines, disorder migraine, migraine syndromes, disorders migraine, Migraine NOS (disorder), Migraine (disorder), migraine, headache; migraine, migraine; headache, migraine; syndrome, syndrome; migraine, Migraine, NOS, Migraine, Disorder, Migraine, Disorders, Migraine, Migraine Disorder |
French | MIGRAINE, Migraine SAI, Maux de tête migraineux, Migraine, non précisée, Maux de tête de type migraine, Céphalées migraineuses, Migraine, Migraines |
Portuguese | ENXAQUECA, Cefaleias tipo enxaqueca, Cefaleia tipo enxaqueca, Enxaqueca NE, Cefaleia de enxaqueca, Cefaleia Hemicrânia, Cefaleia Enxaquecosa, Síndromes de Enxaqueca, Transtornos da Enxaqueca, Síndromes Enxaquecosas, Enxaqueca, Enxaquecas, Transtornos de Enxaqueca |
German | MIGRAENE, Migraenekopfschmerz, migraeneartiger Kopfschmerz, Migraene NNB, migraeneartige Kopfschmerzen, Migraene, unspezifisch, Migraene, nicht naeher bezeichnet, Migraene, Migraenebedingte Kopfschmerzen, Kopfschmerz, Migräne-, Migräne |
Italian | Cefalee emicraniche, Cefalea emicranica, Emicrania non specificata, Cefalee tipo emicrania, Emicrania NAS, Emicrania |
Dutch | migraine hoofdpijn, migraineuze hoofdpijnen, niet-gespecificeerde migraine, migraineuze hoofdpijn, migraine NAO, hoofdpijn; migraine, migraine; hoofdpijn, migraine; syndroom, syndroom; migraine, Migraine, niet gespecificeerd, migrainehoofdpijnen, migraine, Migraine, Hoofdpijn, migraine- |
Spanish | Migraña no especificada, Dolor de cabeza migrañoso, Cefalea migrañosa, Migraña NEOM, Dolores de cabeza tipo migraña, MIGRANA, Trastornos Migrañosos, migraña, SAI (trastorno), migraña, SAI, Síndromes Jaquecosos, Jaqueca, Síndromes de Migraña, Trastornos de Migraña, Síndromes Migrañosos, Estado Jaquecoso, Trastornos Jaquecosos, Jaqueca Confusional Aguda, Síndromes de Jaqueca, Trastornos de Jaqueca, jaqueca, migraña (trastorno), migraña, Migraña, Cefaleas migrañosas, Cefalea Migrañosa |
Japanese | 片頭痛様頭痛, 片頭痛NOS, 片頭痛型頭痛, 片頭痛、詳細不明, ヘンズツウ, ヘンズツウNOS, ヘンズツウショウサイフメイ, ヘンズツウヨウズツウ, ヘンズツウガタズツウ, 片頭痛, 偏頭痛 |
Swedish | Migränsjukdomar |
Czech | migrenózní poruchy, migréna, Migrenózní bolest hlavy, Migréna, Migréna NOS, Bolesti hlavy migrenózní, Migrenózní typ bolesti hlavy, Migréna, blíže neurčená |
Finnish | Migreeni |
Russian | GEMIKRANIIA, MIGREN', MIGRENOZNYE RASSTROISTVA, ГЕМИКРАНИЯ, МИГРЕНЬ, МИГРЕНОЗНЫЕ РАССТРОЙСТВА |
Korean | 편두통, 상세불명의 편두통 |
Polish | Migrena, Stan migrenowy, Ból głowy migrenowy |
Hungarian | Migraine típusú fejfájások, Migraine, Migraine k.m.n., Migraine fejfájások, Migraine-es fejfájás, Migraines fejfájás, Migraine, nem meghatározott |
Croatian | Not Translated[Migraine Disorders] |
Norwegian | Migrenesykdommer, Migrene, Migreneforstyrrelser |
Ontology: Migraine with Aura (C0154723)
Definition (MSH) | A subtype of migraine disorder, characterized by recurrent attacks of reversible neurological symptoms (aura) that precede or accompany the headache. Aura may include a combination of sensory disturbances, such as blurred VISION; HALLUCINATIONS; VERTIGO; NUMBNESS; and difficulty in concentrating and speaking. Aura is usually followed by features of the COMMON MIGRAINE, such as PHOTOPHOBIA; PHONOPHOBIA; and NAUSEA. (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1) |
Concepts | Disease or Syndrome (T047) |
MSH | D020325 |
ICD9 | 346.0 |
ICD10 | G43.1 , G43.109 |
SnomedCT | 155047002, 4473006 |
Dutch | migraineuze aura, aura; migraine, migraine; aura, migraine met aura, Klassieke migraine, Migraine met aura, Migraine, klassieke |
French | Aura de migraine, Migraine accompagnée, Migraine avec aura |
German | Migraeneaura, Migräne mit Aura, Migraene mit Aura |
Italian | Aura da emicrania, Emicrania con aura |
Portuguese | Aura de enxaqueca, Enxaqueca Familiar Hemiplégica, Enxaqueca com aura, Enxaqueca com Aura |
Spanish | Aura migrañosa, Migraña con Aura, Jaqueca Complicada, Jaqueca Familiar Hemiplégica, Jaqueca Tipo Basilar, Jaqueca con Aura, Jaqueca Hemiplégica Familiar, Migraña Familiar Hemiplégica, migraña con aura (trastorno), migraña con aura, Migraña con aura |
Japanese | 片頭痛の前兆, ゼンチョウヲトモナウヘンズツウ, ヘンズツウノゼンチョウ, 片頭痛-古典的, 前兆を伴う片頭痛, 前兆のある片頭痛, 古典的片頭痛, 片頭痛-前兆を伴う |
Swedish | Auramigrän |
Czech | migréna s aurou, Migrenózní aura, Migréna s aurou |
Finnish | Klassinen migreeni |
Russian | BAZILIARNAIA MIGREN', GEMIPLEGICHESKAIA MIGREN' SEMEINAIA, MIGREN' KLASSICHESKAIA, MIGREN' S AUROI, БАЗИЛЯРНАЯ МИГРЕНЬ, ГЕМИПЛЕГИЧЕСКАЯ МИГРЕНЬ СЕМЕЙНАЯ, МИГРЕНЬ КЛАССИЧЕСКАЯ, МИГРЕНЬ С АУРОЙ |
English | Migraine with Aura, Migraine aura, Migraine with Auras, Migraine preceded or accompanied by transient focal neurological phenomena, Migraine with aura NOS, Migraine with Aura [Disease/Finding], aura migraine, classic migraine, migraine with aura, migraine aura, aura migraines, auras migraines, classic migraines, migraine auras, classical migraine, migraine classical, Migraine with aura, Migraine with aura (disorder), aura; migraine, migraine; aura |
Polish | Migrena z aurą, Migrena klasyczna |
Hungarian | Migraine aura, Migraine aurával |
Croatian | MIGRENA S AUROM |
Norwegian | Migrene med aura, Klassisk migrene |
Ontology: Common Migraine (C0338480)
Definition (MSH) | Recurrent unilateral pulsatile headaches, not preceded or accompanied by an aura, in attacks lasting 4-72 hours. It is characterized by PAIN of moderate to severe intensity; aggravated by physical activity; and associated with NAUSEA and / or PHOTOPHOBIA and PHONOPHOBIA. (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1) |
Concepts | Disease or Syndrome (T047) |
MSH | D020326 |
ICD9 | 346.1 |
ICD10 | G43.0 , G43.009 |
SnomedCT | 193029000, 193027003, 56097005 |
English | Common migraine NOS, Migraine without aura [common migraine], migraine without aura, common migraine (diagnosis), common migraine, Common Migraines, Migraine, Common, Migraines, Common, Migraine without aura NOS, Migraine without Aura [Disease/Finding], common migraines, Migraine;common, migraine atypical, atypical migraine, atypical migraines, sick headache, Common migraine NOS (disorder), Atypical migraine (disorder), Common migraine, Atypical migraine, Sick headache, Migraine without aura, Migraine without aura (disorder), common; migraine, migraine; common, migraine; without aura, Common Migraine, Migraine without Aura |
Dutch | gewone migraine, gewoon; migraine, migraine; gewoon, migraine; zonder aura, Migraine zonder aura [gewone migraine], migraine zonder aura, Gewone migraine, Migraine zonder aura, Migraine, gewone |
German | einfache Migraene, Migraene ohne Aura [Gewoehnliche Migraene], Migraene ohne Aura, Einfache Migräne, Migräne, einfache, Migräne ohne Aura |
Portuguese | Enxaqueca comum, Enxaqueca sem aura, Enxaqueca Comum, Enxaqueca sem Aura |
Spanish | Migraña común, Migraña sin Aura, migraña común, SAI (trastorno), migraña común, SAI, Jaqueca sin Aura, cefalea del enfermo, migraña atípica, migraña común, migraña sin aura (trastorno), migraña sin aura, Migraña sin aura, Jaqueca Común, Migraña Común |
Swedish | Vanlig migrän |
Japanese | ゼンチョウヲトモナワナイヘンズツウ, フツウガタヘンズツウ, 普通片頭痛, 普通型片頭痛, 通常型片頭痛, 前兆のない片頭痛, 片頭痛-普通型, 片頭痛-前兆を伴わない, 前兆を伴わない片頭痛 |
Czech | běžná migréna, migréna bez aury, Migréna bez aury, Prostá migréna |
Finnish | Tavallinen migreeni |
Italian | Emicrania comune, Emicrania senza aura |
Russian | MIGREN' BANAL'NAIA, MIGREN' BEZ AURY, MIGREN' OBYCHNAIA, МИГРЕНЬ БАНАЛЬНАЯ, МИГРЕНЬ БЕЗ АУРЫ, МИГРЕНЬ ОБЫЧНАЯ |
Korean | 조짐이 없는 편두통[일반 편두통] |
Polish | Migrena bez aury |
Hungarian | Migraine aura nélkül, Közönséges migraine |
Croatian | MIGRENA BEZ AURE |
Norwegian | Migrene uten aura, Vanlig migrene |
French | Migraine commune, Migraine sans aura |
Ontology: Migraine with Typical Aura (C1735856)
Concepts | Disease or Syndrome (T047) |
MSH | D020325 |
ICD10 | G43.1 |
SnomedCT | 4473006, 230462002 |
English | Migraine with aura [classical migraine], Classic Migraine, Migraine, Classic, Classical Migraine, Migraine, Classical, Migraine with Typical Aura, Classic migraine, classic migraine with typical aura, classic migraine with typical aura (diagnosis), Migraine;classical, classical migraine with aura (diagnosis), classical migraine with aura, Classical migraine, Migraine with typical aura, Migraine with typical aura (disorder), classical; migraine, migraine; classical, classical migraine |
Dutch | klassieke migraine, klassiek; migraine, migraine; klassiek, Migraine met aura [klassieke migraine] |
German | klassische Migraene, Migräne mit typischer Aura, Migraene mit Aura [Klassische Migraene] |
Portuguese | Enxaqueca clássica, Enxaqueca Clássica |
Spanish | Migraña clásica, Migraña Clásica, Jaqueca Clásica, migraña clásica, migraña con aura típica (trastorno), migraña con aura típica |
French | Migraine classique, Migraine avec aura typique |
Japanese | 古典型片頭痛, コテンガタヘンズツウ |
Czech | migréna s typickou aurou, klasická migréna, Klasická migréna |
Korean | 조짐이 있는 편두통[고전적 편두통] |
Hungarian | Klasszikus migraine |
Croatian | MIGRENA, KLASIČNA |
Norwegian | Migrene med typisk aura |
Italian | Emicrania classica, Emicrania con aura tipica |