• Clinical science
  • Physician

Migraine

Summary

Migraine is characterized by recurrent episodes of typically unilateral, localized headaches that are frequently accompanied by nausea, vomiting, and sensitivity to light and sound. In approximately 25% of cases, patients experience an aura preceding the headache, which involves reversible focal neurologic abnormalities, for example, visual field defects (scotomas) or paresis lasting less than an hour. Migraine is a clinical diagnosis. Treatment of attacks consists of general measures (e.g., bedrest and protection from outer stimuli) together with administration of nonsteroidal anti-inflammatory drugs (e.g., aspirin) and antiemetics (e.g., prochlorperazine) if nausea is present. In severe cases, triptans may be added. Prophylactic treatment (e.g., beta blockers) may be indicated if migraines are especially frequent or long lasting, or if abortive therapy fails or is contraindicated.

Epidemiology

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • The exact pathophysiology is unclear.
  • Genetic predisposition
  • Potential triggers
    • Emotional stress
    • Weather changes
    • Certain food and beverages: alcohol, nicotine, citrus fruits, dairy products, food containing tyramine (e.g., chocolate, red wine)
    • Poor sleeping habits
    • Hormonal changes in women: menstruation, hormone intake (oral contraceptive pills)

References:[1][2]

Pathophysiology

The pathophysiology of migraine is not fully understood. Different aspects contribute to the development and severity of migraine, such as

  • Vascular dysregulation: vasodilation appears to play a role and there is an association between migraine and disorders with generalized vasospasms
  • Dysregulation of pain sensitization in the trigeminal system
  • Cortical spreading depression: continuously spreading depolarization of neuronal cells in the cortex

References:[3]

Clinical features

Migraine is characterized by recurrent attacks and may occur with aura (∼ 25% of cases; ) or without aura (∼ 75% of cases). A typical migraine attack passes through four stages, with aura (if present) appearing before the headache. However, migraine patterns may differ and not follow the characteristic stages.

  1. Prodrome (facultative, ∼ 60% of patients): 24–48 hours before the headache starts
    • Excessive yawning
    • Difficulties writing or reading
    • Sudden hunger or lack of appetite
    • Mood changes
  2. Aura (only present in ∼25% of patients): paroxysmal reversible focal neurologic symptoms
  3. Headache
    • Localization: typically unilateral, but bilateral is possible , especially frontal, frontotemporal, retro-orbital
    • Duration: usually 4–24 hours, rarely over 72 hours
    • Course: progression of pulsating, throbbing, or pounding pain
    • Exacerbated by physical activity
    • Accompanying symptoms: photophobia, phonophobia, and nausea/vomiting
  4. Postdrome (facultative)
    • Feeling of exhaustion or euphoria
    • Muscle weakness
    • Anorexia or food cravings

The typical migraine headache is “POUND”: pulsatile, one-day duration, unilateral, nausea, disabling intensity

References:[4]

Diagnostics

  • Diagnosis can be made if there is a history of characteristic migraine attacks
    • With aura: ≥ 2 attacks
    • Without aura: ≥ 5 attacks
  • Physical exam to exclude red flag symptoms, such as :
  • Neuroimaging should be used in headaches with an unusual clinical presentation or persistent neurologic or psychopathologic abnormalities.
  • Patients diagnosed with migraines should be screened for cardiovascular disease (especially in smokers and/or if taking oral contraceptives)

Migraine is a clinical diagnosis that is based on patient history and physical examination!

References:[1][4]

Differential diagnoses

References:[9]

The differential diagnoses listed here are not exhaustive.

Treatment

Management consists of abortive and/or preventative therapy and varies according to each individual.

Abortive therapy

Triptans

Agents
Mechanism of action
Indications
Side effects
  • Temporary blood pressure increase (very common)
  • Paresthesia and sensation of cold in the extremities
  • Dizziness, malaise, flashes
  • Frequent intake (≥ 10x/month) can lead to headaches
  • Coronary ischemia (rare)
Contraindications

Prophylactic therapy

References:[1][9][10][11][12]

Acute management checklist

Migraine of any severity [13][14][15][16]

  • Consider CT/MRI brain with or without contrast if atypical presentation or red flags for headache present. [17][18]
  • Begin pharmacologic treatment within 1 hour of symptom onset, if possible.
  • Reduce excessive light/noise in the patient's environment.
  • Treat nausea/vomiting, if present.
  • Add nonspecific parenteral analgesic as needed if these measures are ineffective.
  • Avoid opioids.

Mild to moderate headache

Moderate to severe headache, or if the above treatments fail

  • Start a migraine-specific agent.
    • First-line: oral or parenteral triptans
      • If tolerating PO, consider one of the following:
      • If nausea/vomiting are present or there is a higher analgesic requirement, consider one of the following:
    • Second-line: parenteral ergotamines
      • Dihydroergotamine
  • Consider recurrence prevention with dexamethasone. [22]

Triptans and ergotamines are contraindicated in pregnancy and patients with established ischemic and vasospastic vascular disease (e.g., CAD, PVD, stroke, Prinzmetal angina), uncontrolled atherosclerotic risk factors, and accessory pathway conduction disorders.

Status migrainosus refractory to above

Do not combine triptans and ergotamines (within a 24-hour period) or with metoclopramide because of potentially dangerous drug interactions (e.g., coronary vasospasm and serotonin syndrome). [24]

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last updated 03/30/2020
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