Migraine is the most common cause of recurrent moderate to severe headache; 1-yr prevalence is 18% for women and 6% for men in the US. Migraine most commonly begins during puberty or young adulthood, waxing and waning in frequency and severity over the ensuing years; it often diminishes after age 50. Studies show familial aggregation of migraine.

Evidence based on evaluation of veterans of the Iraq and Afghanistan conflicts suggests that migraine may frequently develop after mild traumatic brain injury.

Migraine is thought to be a neurovascular pain syndrome with altered central neuronal processing (activation of brain stem nuclei, cortical hyperexcitability, and spreading cortical depression) and involvement of the trigeminovascular system (triggering neuropeptide release, which causes painful inflammation in cranial vessels and the dura mater).

Many potential migraine triggers have been identified; they include the following:

Head trauma, neck pain, or temporomandibular joint dysfunction sometimes triggers or exacerbates migraine.

Fluctuating estrogen levels are a potent migraine trigger. Many women have onset of migraine at menarche, severe attacks during menstruation (menstrual migraine), and worsening during menopause. For most women, migraines remit during pregnancy (but sometimes they worsen during the 1st or 2nd trimester); they worsen after childbirth, when estrogen levels decrease rapidly.

Oral contraceptives and other hormone therapy occasionally trigger or worsen migraine and have been associated with stroke in women who have migraine with aura.

Familial hemiplegic migraine, a rare subtype of migraine, is associated with genetic defects on chromosomes 1, 2, and 19. The role of genes in the more common forms of migraine is under study.

Often, a prodrome (a sensation that a migraine is beginning) heralds attacks. The prodrome may include mood changes, loss of appetite, nausea, or a combination.

An aura precedes attacks in about 25% of patients. Auras are temporary neurologic disturbances that can affect sensation, balance, muscle coordination, speech, or vision; they last minutes to an hour. The aura may persist after headache onset. Most commonly, auras involve visual symptoms (fortification spectra—eg, binocular flashes, arcs of scintillating lights, bright zigzags, scotomata). Paresthesias and numbness (typically starting in one hand and marching to the ipsilateral arm and face), speech disturbances, and transient brain stem dysfunction (causing, for example, ataxia, confusion, or even obtundation) are less common than visual auras. Some patients have an aura with little or no headache.

Headache varies from moderate to severe, and attacks last from 4 h to several days, typically resolving with sleep. The pain is often unilateral but may be bilateral, most often in a frontotemporal distribution, and is typically described as pulsating or throbbing.

Migraine is more than a headache. Associated symptoms such as nausea (and occasionally vomiting), photophobia, sonophobia, and osmophobia are prominent. Patients report difficulty concentrating during attacks. Routine physical activity usually aggravates migraine headache; this effect, plus the photophobia and sonophobia, encourages most patients to lie in a dark, quiet room during attacks. Severe attacks can be incapacitating, disrupting family and work life.

Attacks vary significantly in frequency and severity. Many patients have several types of headache, including milder attacks without nausea or photophobia; they may resemble tension-type headache but are a forme fruste of migraine.

Diagnosis of migraine is based on characteristic symptoms and a normal physical examination, which includes a thorough neurologic examination.

Red flag findings that suggest an alternate diagnosis (even in patients known to have migraine) include the following:

Patients with characteristic symptoms and no red flag findings do not require testing. Patients with red flag findings often require brain imaging and sometimes lumbar puncture.

Common diagnostic errors include the following:

Several unusual disorders can mimic migraine with aura:

For some patients, migraine is an infrequent, tolerable inconvenience. For others, it is a devastating disorder resulting in frequent periods of incapacity, loss of productivity, and severely impaired quality of life.

A thorough explanation of the disorder helps patients understand that although migraine cannot be cured, it can be controlled, enabling them to better participate in treatment.

Patients are urged to keep a written headache diary to document the number and timing of attacks, possible triggers, and response to treatment. Identified triggers are eliminated when possible. Patients should be encouraged to avoid triggers, and clinicians recommend behavioral interventions (biofeedback, stress management, psychotherapy) to manage migraine when stress is a major trigger or when analgesics are being overused.

Treatment of acute migraine headache is based on frequency, duration, and severity of attacks. It may include analgesics, antiemetics, triptans, and/or dihydroergotamine (1).

Daily preventive therapy is warranted when frequent migraines interfere with activity despite acute treatment. Some experts consider onabotulinumtoxinA the drug of choice.

For patients who use analgesics frequently (eg, > 2 days/wk), particularly those with medication overuse headache, preventive drugs (see Table: Drugs for Migraine and Cluster Headaches*) should be combined with a program for stopping overused analgesics. Choice of drug can be guided by coexisting disorders, as for the following: