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Migraine Headache
Aka: Migraine Headache, Migraine, Classic Migraine, Migraine with Aura, Common Migraine, Migraine without Aura, Chronic Migraine Without Aura, Migraine Headache Diagnostic Criteria
- See Also
- Headache
- Acute Recurrent Headache
- Epidemiology
- Gender
- Females more commonly affected (peak ratio 3:1)
- Prevalence
- 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
- Age 15 years: 8 to 23%
- Adults
- Prevalence: 44.5 Million U.S. in 2009
- Women: 18-26%
- Men: 6-9%
- Stokes (2011) Headache 51(7): 1058-77 [PubMed]
- 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
- Chronic Tension Headache
- Post-Traumatic Headache
- 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)
- Bigal (2002) Headache 42:575-81 [PubMed]
- 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
- Pathophysiology: Trigeminovascular activation
- CNS Platelet and Mast Cell aggregation
- Serotonin release from synaptic nerve endings
- Increase then decrease in blood brain Catecholamines
- Norepinephrine
- Epinephrine
- Alternating Vasoconstriction and Vasodilatation
- The vessel wall Stretching results in pain
- Replaces the prior theory of spasm
- Vessel Spasm
- Rebound vasodilation
- 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
- 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
- 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
- Aura (20% of patients): See diagnosis below
- Visual aura
- Scotomata (visual scintillations)
- Transient, fully reversible, colorful flashing lights or dark spots
- Atypical aura (carefully consider differential diagnosis such as Cerebrovascular Accident)
- Hemisensory aura
- Hemiparesis aura
- Dysphasia aura
- Headache Phase
- Location
- Unilateral in 50%
- Often frontal in location
- Characteristics
- Pulsating, Throbbing Headache in 50%
- Dull, ache-type Headache in 50%
- 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
- 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)
- Symptoms: Common Triggers (Patient should keep a diary)
- See Migraine Headache Triggers
- See Tyramine-Vasoactive Amines
- See Medication Causes of Headache
- 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]
- Diagnosis: POUND mnemonic
- 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
- Criteria
- Pulsatile quality of Headache
- Could also represent photophobia (but not part of mnemonic)
- One day duration
- Unilateral Location
- Nausea or Vomiting
- Disabling intensity
- References
- Ebell (2006) Am Fam Physician 74(12): 2087-88 [PubMed]
- Diagnosis: Common Migraine without Aura (International Headache Society Diagnostic Criteria)
- Timing and general characteristics
- Five episodes or more
- Each episode lasts 4 to 72 hours
- No evidence of Organic Headache
- Two of the following criteria
- Unilateral Headache pain
- Pulsating quality to Headache pain
- Symptom severity limits daily activities (moderate to severe intensity)
- Provoked by routine level of exertion (e.g. walking or climbing stairs)
- One of the following criteria occur with Headache
- Nausea
- Photophobia and Phonophobia
- Diagnosis: Classic Migraine with Aura (International Headache Society Diagnostic Criteria)
- Headache associated with Migraine aura, with NO motor weakness, and at least one of the following:
- Visual aura (fully reversible)
- Scintillating scotoma or fortification spectra
- Flickering lights, spots or lines in the central Visual Field
- Photopsia
- Flashes of light
- Sensory aura (fully reversible)
- Paresthesia
- Numbness
- Speech disturbance (Aphasia or dysphasia)
- At least 2 of the following
- Homonymous visual changes and/or unilateral sensory symptoms
- At least 1 aura symptom develops over 5 minutes (of more than one develop in succession over 5 minutes)
- Other characteristics
- Two or more attacks
- At least one aura develops over 5 or more minutes, but not longer than 60 minutes
- Headache follows aura within 60 minutes
- Not attributed to other disorder
- Diagnosis: Migraine in Children
- Five or more Headaches that last 1-72 hours
- Includes at least two Migraine characteristics
- Bilateral or unilateral temporal/frontal Headache
- Throbbing or pulsating quality
- Intensity moderate to severe
- Worse with routine exertion
- Includes at least one associated symptom
- Nausea or Vomiting
- Photophobia or Phonophobia
- Precautions
- Occipital Headache may occur with Increased Intracranial Pressure and warrants additional evaluation
- 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]
- Evaluation: Headache with persistent neurologic deficit
- See Organic Headache
- Exclude Ischemic causes
- Exclude structural causes
- Exclude Inflammatory causes
- Exclude Metabolic cause
- 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
- Subarachnoid Hemorrhage
- Intracranial Mass
- Lumbar Puncture
- Consider for meningeal signs, fever or ill appearance
- Management
- See Migraine Management
- See Migraine Management in Children
- See Migraine in Pregnancy
- 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
- Complications
- Migraine with Aura is associated with a two fold increase in Cerebrovascular Accident
- Etminan (2005) BMJ [PubMed]
- Schurks (2009) BMJ [PubMed]
- Spector (2010) Am J Med [PubMed]
- References
- 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]