Migraine

Migraine is the most common cause of recurrent moderate to severe headache; 1-year 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 Traumatic Brain Injury (TBI) Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more .

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:

Food triggers vary from person to person.

Head trauma Traumatic Brain Injury (TBI) Traumatic brain injury (TBI) is physical injury to brain tissue that temporarily or permanently impairs brain function. Diagnosis is suspected clinically and confirmed by imaging (primarily... read more , neck pain Evaluation of Neck and Back Pain Neck pain and back pain are among the most common reasons for physician visits. This discussion covers neck pain involving the posterior neck (not pain limited to the anterior neck) and low... read more , or temporomandibular joint dysfunction Overview of Temporomandibular Disorders (TMDs) The term temporomandibular disorders is an umbrella term for a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joint (TMJ), the masticatory muscles,... read more 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. In some families, the migraine phenotype varies considerably, causing primarily headache in some family members, vertigo in others, and hemiplegia or an aura in others. This finding suggests that migraine may actually be a more generalized disorder and not just a headache disorder.

Often, a prodrome (a sensation that a migraine is beginning) heralds attacks. The prodrome may include mood changes, neck pain, food cravings, 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 hours 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 Tension-Type Headache Tension-type headache causes mild generalized pain (usually viselike) without the incapacity, nausea, or photophobia associated with migraine. (See also Approach to the Patient With Headache... read more 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 Introduction to the Neurologic Examination The purpose of the neurologic examination is to establish whether the patient’s brain, special senses, spinal cord, peripheral nerves, and muscle and skin receptors are functioning normally... read more .

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 testing Testing Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the most common reasons patients seek medical... read more , including MRI and sometimes lumbar puncture.

Common diagnostic errors include the following:

Several unusual disorders can mimic migraine with aura:

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. However, elimination of triggers can be overdone.

Choice of medications used to treat acute migraine headache is based on frequency, duration, and severity of attacks. Analgesics, antiemetics, triptans, lasmiditan, gepants (small-molecule calcitonin gene–related peptide [CGRP] receptor antagonists), or dihydroergotamine may be used (1 Treatment references Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 hours and may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms... read more ). If patients wish to avoid medications or if medications have been ineffective, neuromodulatory treatments Neuromodulatory treatments Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 hours and may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms... read more can sometimes be used for acute attacks and/or prevention.

Patients who frequently (eg, > 2 days/week) use medications to treat their acute migraine attacks (particularly analgesics that contain butalbital, triptans, ergotamine, or opioids) should be treated with preventive migraine drugs combined with a program for stopping overused analgesics.

Clinicians sometimes recommend behavioral interventions (biofeedback, stress management, psychotherapy) to manage migraine, especially when stress is a major trigger or when analgesics are being overused.

Yoga can reduce headache frequency and intensity; it enhances vagal tone and decreases sympathetic drive, thus improving cardiac autonomic balance. Relaxation techniques can reduce sympathetic nervous system activity, ease muscle tension, and alter brain wave activity.

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.

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/week), particularly those with medication overuse headache, preventive drugs should be combined with a program for stopping overused analgesics. Choice of medication can be guided by coexisting disorders, as for the following:

Monoclonal antibodies and gepants that are used to prevent migraines block the activation of calcitonin gene-related peptide (CGRP), which can precipitate migraines (1 Prevention references Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 hours and may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms... read more ).

Neuromodulatory treatments can also help. Transcutaneous supraorbital nerve stimulation, using a device applied to the forehead, can reduce the frequency of migraines (2 Prevention references Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 hours and may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms... read more ). Transcranial magnetic stimulation, using by a device applied to the back of the skull, is indicated for the acute and prophylactic treatment of migraine headache in adolescents (≥ 12) and adults.