Headache, Migraine

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Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Typical characteristics are unilateral location, pulsating quality, moderate or severe intensity, aggravation by physical activity, and association with nausea and/or photophobia and phonophobia (1).

  • Most frequent subtypes of migraine (1):
    • Without aura (common migraine): defining >80% of attacks, often associated with nausea, vomiting, photophobia, and/or phonophobia
    • With aura (classic migraine): visual or other types of fully reversible neurologic phenomenon lasting 5 to 60 minutes
    • Chronic (transformed) migraine: chronic headache pattern evolving from episodic migraine. Migraine-like attacks are superimposed on a daily or near-daily headache pattern (e.g., tension headaches) >15 headache days/month for at least 3 months.
    • Menstrual-related (molimina) migraine: associated with onset of menstrual period
  • Rare but important subtypes (1):
    • Status migrainosus: debilitating migraine lasting >72 hours
    • With brainstem aura (basilar migraine): brainstem symptoms—dysarthria, vertigo, tinnitus, or ataxia, which are fully reversible, lasting 5 to 60 minutes
    • Hemiplegic migraine: aura consisting of fully reversible hemiplegia and/or hemiparesis
    • Recurrent painful ophthalmoplegic neuropathy (ophthalmoplegic migraine): neuralgia accompanied by paresis of an ocular cranial nerve with ipsilateral headache
    • Retinal: repeated attacks of monocular visual disturbance, including scintillations, scotomata, or blindness, associated with migraine headache


Female > male (3:1)

  • Affects >28 million Americans
  • Adults: women 18%; men 6%

Etiology and Pathophysiology

Trigeminovascular hypothesis: Hyperexcitable trigeminal sensory neurons in brainstem are stimulated and release neuropeptides, such as substance P and calcitonin gene-related peptide (CGRP), leading to vasodilation and neurogenic inflammation.

  • >80% of patients have a positive family history.
  • Familial hemiplegic migraine has been shown to be linked to chromosomes 1, 2, and 19 (1).

Risk Factors

  • Family history of migraine
  • Female gender
  • Stress
  • Menstrual cycle, hormones
  • Sleep pattern disruption
  • Diet: skipped meals (48%), alcohol (32%), chocolate (20%), cheese (13%), caffeine overuse (14%), monosodium glutamate (MSG) (12%), and artificial sweeteners (e.g., aspartame, sucralose)
  • Medications: estrogens, vasodilators

General Prevention

  • Avoid precipitants of attacks.
  • Lifestyle modifications are the cornerstone of prevention: sleep hygiene, stress management, healthy diet, and regular exercise.
  • Biofeedback, education, and psychological intervention
  • Prophylactic medication if attacks are frequent, severely debilitating, or not controlled by acute interventions

Commonly Associated Conditions

  • Depression, psychiatric disorders
  • Sleep disturbance (e.g., sleep apnea)
  • Cerebral vascular disease
  • Peripheral vascular disease
  • Seizure disorders
  • Irritable bowel syndrome
  • Obesity
  • Medication overuse headache (MOH)

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