Headache

Migraine Headache

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

  • Epidemiology
  1. Gender
    1. Females more commonly affected (peak ratio 3:1)
  2. Prevalence
    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. Age 15 years: 8 to 23%
    2. Adults
      1. Prevalence: 44.5 Million U.S. in 2009
      2. Women: 18-26%
      3. Men: 6-9%
      4. 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 may evolve from other Headache types
    1. Chronic Tension Headache
    2. Post-Traumatic Headache
  • Risk Factors
  1. Family History of Migraine Headaches
  2. Obesity
  3. Analgesic overuse
  4. Sleep Apnea or other sleep disturbance
  5. Head Injury
  6. Female gender
  7. Caffeine: >100 mg/day (OR: 2.9)
    1. Bigal (2002) Headache 42:575-81 [PubMed]
  • 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
  • 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
  • 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
  4. Aura (20% of patients): See diagnosis below
    1. Visual aura
      1. Scotomata (visual scintillations)
      2. Transient, fully reversible, colorful flashing lights or dark spots
    2. Atypical aura (carefully consider differential diagnosis such as Cerebrovascular Accident)
      1. Hemisensory aura
      2. Hemiparesis aura
      3. Dysphasia aura
  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)
  • Symptoms
  • Common Triggers (Patient should keep a diary)
  • 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]
  • Diagnosis
  • POUND mnemonic
  1. Migraine Headache is 92% likely if at least 4 of the following criteria are present (in primary care, LR+24)
  2. Criteria
    1. Pulsatile quality of Headache
      1. Could also represent photophobia (but not part of mnemonic)
    2. One day duration
    3. Unilateral Location
    4. Nausea or Vomiting
    5. Disabling intensity
  3. References
    1. Ebell (2006) Am Fam Physician 74(12): 2087-88 [PubMed]
  • Diagnosis
  • Migraine without Aura (International Headache Society Diagnostic Criteria)
  1. Timing and general characteristics
    1. Five episodes or more
    2. Each episode lasts 4 to 72 hours
    3. No evidence of Organic Headache
  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
    1. Nausea
    2. Photophobia and Phonophobia
  • Diagnosis
  • Migraine with Aura (International Headache Society Diagnostic Criteria)
  1. Headache associated with Migraine aura, with NO motor weakness, and at least one of the following:
    1. 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
    2. Sensory aura (fully reversible)
      1. Paresthesia
      2. Numbness
      3. Speech disturbance (Aphasia or dysphasia)
  2. At least 2 of the following
    1. Homonymous visual changes and/or unilateral sensory symptoms
    2. At least 1 aura symptom develops over 5 minutes (of more than one develop in succession over 5 minutes)
  3. Other characteristics
    1. Two or more attacks
    2. At least one aura develops over 5 or more minutes, but not longer than 60 minutes
    3. Headache follows aura within 60 minutes
    4. Not attributed to other disorder
  • Diagnosis
  • Migraine in Children
  1. Five or more Headaches that last 1-72 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
    1. Occipital Headache may occur with Increased Intracranial Pressure and warrants additional evaluation
  • 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]
  • 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
  • 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
  • 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
  • Complications