Headache, Migraine

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Description

Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours; typically: unilateral, pulsating, moderate to severe intensity, and associated nausea and/or photo/phonophobia (1)

  • Most frequent subtypes of migraine (1):
    • Without aura: >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: migraine lasting >72 hours
    • Prolonged aura: aura symptoms >60 minutes (can last up to 7 days); should consider secondary causes
    • Ocular: repeated attacks of monocular visual disturbance, 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

  • Neurogenic theory: Activation of hypothalamus and brainstem nuclei; trigeminal vascular system activation and release of neuropeptides (CGRP, PACAP)
  • Cortical spreading depression: main hypotheses for migraine with aura; change in electrical activity with reduced blood flow, leading to aura

Genetics

>80% have a family history

Risk Factors

  • Female sex (menstrual cycle)
  • Family history of migraine
  • Triggers include sleep disruption and diet influences (skipped meals, alcohol, chocolate, cheese, caffeine overuse, monosodium glutamate [MSG], and artificial sweeteners)

General Prevention

  • Lifestyle modifications are 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 (sleep apnea)
  • IBS
  • Other pain syndromes (cervical spine disease, endometriosis)

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