II. 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

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
  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)

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

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. Migraine Headache is 92% likely if at least 4 of the following criteria are present (in primary care, LR+24)
    1. Migraine Headache is 64% likely when 3 criteria are present
    2. Migraine Headache is 17% likely when <=2 criteria are present
  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]

XI. Diagnosis: Common 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 occur with Headache
    1. Nausea
    2. Photophobia and Phonophobia

XII. Diagnosis: Classic 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

XIII. 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

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]

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

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

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Migraine Disorders (C0149931)

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

  • Anxiety
  • Stress
  • Lack of food or sleep
  • Exposure to light
  • Hormonal changes (in women)

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
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
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
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
Korean 조짐이 없는 편두통[일반 편두통]
Polish Migrena bez aury
Hungarian Migraine aura nélkül, Közönséges migraine
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
Norwegian Migrene med typisk aura
Italian Emicrania classica, Emicrania con aura tipica

Ontology: Chronic migraine without aura (C2349476)

Concepts Disease or Syndrome (T047)
ICD9 346.7
ICD10 G43.7 , G43.709
SnomedCT 431601000124105
English Chronic migraine without aura NOS, Chronic migraine without aura (disorder), Chronic migraine without aura