Description

Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Typical characteristics are unilateral location, pulsating quality, moderate to 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 (motor, sensory or brainstem symptoms, including previously known as basilar or hemiplegic migraine) of fully reversible neurologic phenomenon develops gradually over 5 minutes and lasts up to 60 minutes
  • Chronic migraine: Migraine attacks are >15 headache days/month, >4 hours/day, for at least 3 months.
  • Menstrual-related migraine: associated with onset of menstrual period
• Rare but important subtypes (1):
  • Status migrainosus: debilitating migraine lasting >72 hours
  • Prolonged aura: aura symptoms lasting more than 60 minutes (can last up to 7 days)
  • Retinal: repeated attacks of monocular visual disturbance, including scintillations, scotomata, or blindness, associated with migraine headache
  • Acephalagic migraine (migraine aura without headache): typical aura symptoms not followed by a migraine headache

Epidemiology

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.
• Cortical spreading depression: Mainly accepted hypotheses for migraine with aura; change in electrical activity with reduction of blood flow, leading to aura

• >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, adequate hydration, 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, anxiety, posttraumatic stress disorder
• Sleep disturbance (e.g., sleep apnea)
• Cerebral vascular disease
• Seizure disorders
• Irritable bowel syndrome
• Obesity
• Medication overuse headache (MOH)
• Childhood trauma