Headache, Migraine

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Basics

Description

Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Typically: unilateral location, pulsating quality, moderate to severe intensity, and associated nausea and/or photophobia and phonophobia (1)

  • Most frequent subtypes of migraine (1):
    • Without aura: defines >80% of migraines, vomiting, photophobia, and/or phonophobia
    • With aura: visual or other (motor, sensory or brainstem symptoms, including previously known as basilar or hemiplegic migraine); fully reversible neurologic phenomenon, develop gradually over 5 minutes and last up to 60 minutes
    • Chronic migraine: >15 migraine days/month, >4 hours/attack, for ≥3 months
    • Menstrual migraine: migraine attacks in a menstruating person, onset 1 to 2 days prior to menses or up to day 3 of menstruation, occurring in 2 of 3 menstrual cycles and at no other time during cycle
    • Menstrually related migraine: menstrual migraine plus migraine attacks at other times during cycle
  • Rare but important subtypes (1):
    • Status migrainosus: debilitating migraine lasting >72 hours
    • Prolonged aura: aura symptoms >60 minutes (can last up to 7 days), should prompt consideration of secondary causes
    • Ocular: repeated attacks of monocular visual disturbance, including scintillations, scotomata, or blindness, with migraine
    • Vertiginous: migraine with vertigo or dizziness
    • Acephalgic migraine (migraine aura without headache): typical aura symptoms not followed by a migraine headache

Epidemiology

  • Female > male (3:1)
  • Affects >28 million Americans

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 family history

Risk Factors

  • Female sex (menstrual cycle)
  • Sleep pattern disruption
  • Diet: skipped meals (48%), alcohol (32%), chocolate (20%), cheese (13%), caffeine overuse (14%), monosodium glutamate (MSG) (12%), and artificial sweeteners
  • Medications: estrogens, vasodilators

General Prevention

  • Lifestyle modifications are the cornerstone: sleep hygiene, stress management, healthy diet, adequate hydration, and regular exercise.
  • Prophylactic medication for frequent attacks

Commonly Associated Conditions

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

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Basics

Description

Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Typically: unilateral location, pulsating quality, moderate to severe intensity, and associated nausea and/or photophobia and phonophobia (1)

  • Most frequent subtypes of migraine (1):
    • Without aura: defines >80% of migraines, vomiting, photophobia, and/or phonophobia
    • With aura: visual or other (motor, sensory or brainstem symptoms, including previously known as basilar or hemiplegic migraine); fully reversible neurologic phenomenon, develop gradually over 5 minutes and last up to 60 minutes
    • Chronic migraine: >15 migraine days/month, >4 hours/attack, for ≥3 months
    • Menstrual migraine: migraine attacks in a menstruating person, onset 1 to 2 days prior to menses or up to day 3 of menstruation, occurring in 2 of 3 menstrual cycles and at no other time during cycle
    • Menstrually related migraine: menstrual migraine plus migraine attacks at other times during cycle
  • Rare but important subtypes (1):
    • Status migrainosus: debilitating migraine lasting >72 hours
    • Prolonged aura: aura symptoms >60 minutes (can last up to 7 days), should prompt consideration of secondary causes
    • Ocular: repeated attacks of monocular visual disturbance, including scintillations, scotomata, or blindness, with migraine
    • Vertiginous: migraine with vertigo or dizziness
    • Acephalgic migraine (migraine aura without headache): typical aura symptoms not followed by a migraine headache

Epidemiology

  • Female > male (3:1)
  • Affects >28 million Americans

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 family history

Risk Factors

  • Female sex (menstrual cycle)
  • Sleep pattern disruption
  • Diet: skipped meals (48%), alcohol (32%), chocolate (20%), cheese (13%), caffeine overuse (14%), monosodium glutamate (MSG) (12%), and artificial sweeteners
  • Medications: estrogens, vasodilators

General Prevention

  • Lifestyle modifications are the cornerstone: sleep hygiene, stress management, healthy diet, adequate hydration, and regular exercise.
  • Prophylactic medication for frequent attacks

Commonly Associated Conditions

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

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