Headache, Migraine

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Basics

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)

Prevalence
  • 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

Genetics
  • >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

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Basics

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)

Prevalence
  • 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

Genetics
  • >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

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