Jaclyn Laine, DO
Ann Pakalnis, MD
DESCRIPTION 
Migraine is an episodic primary headache disorder characterized by at least 5 episodes lasting 4–72 hours. Patients experience throbbing, moderate-to-severe pain which may be unilateral in location. Complaints of nausea, vomiting, photophobia, and phonophobia are common. Migraine aura manifests as characteristic reversible, focal neurologic symptoms. This will gradually develop from 5 to 20 minutes, but should last less than 1 hour.
- Migraine classification according to the International Headache Society IHS ICHD-II includes these migraine variants:
- Migraine without aura
- Migraine with aura
- Typical aura with migraine
- Typical aura with non-migraine headache
- Typical aura without headache
- Familial/sporadic hemiplegic migraine
- Basilar migraine
- Retinal migraine
- Chronic migraine headache ≥15 days/month, no medication overuse
- Medication overuse occurring in migraine:
- Headache present ≥15 days/month
- Regular overuse for >3 months
EPIDEMIOLOGY
Incidence
- 20–29-year-old population most at risk to develop migraine.
- Occurs more often in males prior to puberty, more common in females after menarche.
Prevalence
- Occurs in 12% of the US population affecting 17% women and 6% of men.
- The World Health Organization (WHO) estimates a worldwide prevalence of current migraine of 10% and a lifetime prevalence of 14%.
- Female-to-male ratio 2.8:1 at puberty and 3.5:1 at 40 years old.
- Lower among African Americans and Asian Americans than whites.
RISK FACTORS
Migraine family history, highest risk if first-degree relative with migraine with aura.
Pregnancy Considerations
- Migraine improves for half of women during pregnancy.
- Low estradiol levels trigger migraine during menstruation and high levels may be protective during pregnancy.
- Migraine during pregnancy increases the risk of stroke, thrombosis, and other vascular diseases.
Genetics
- Migraine develops from a combination of polygenic and environmental factors.
- Hemiplegic migraine—50% sporadic.
- Familial hemiplegic migraine (FHM1) – autosomal dominant mapped to the CACNA1 gene coding for voltage-gated P/Q calcium channel on chromosome 19.
- FHM2 is associated with the gene ATP1A2 on chromosome 1 encoding for the alpha 2 subunit of the Na+/K+ pump.
GENERAL PREVENTION
Maintain a regular sleep schedule, avoid triggers, do not skip meals, maintain adequate hydration, regular exercise.
PATHOPHYSIOLOGY
- Migraine is a neurovascular headache, involving a cortical spreading depression of activity in migraine with aura. There is an abnormal afferent activation of the trigeminocervical complex on dural blood vessels, associated with vasodilation and pain signal.
- Serotonin receptors (5HT) in the trigeminal sensory neurons aid regulating neuropeptide release, producing neurogenic inflammation and secondary vessel dilation.
ETIOLOGY
Combination of genetic predisposition and environmental factors contributes to development.
COMMONLY ASSOCIATED CONDITIONS
Depression, anxiety, ischemic stroke, irritable bowel syndrome, epilepsy, hypertension.
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HISTORY
To distinguish migraine from other headache disorders consider:
- Gradual onset throbbing pain, more often unilateral although bilateral location is common
- Associated nausea, vomiting, lightheadedness, and blurred vision
- Photophobia, phonophobia and pain aggravated by activity
- Spreading sensory/motor symptoms between locations on body over minutes
PHYSICAL EXAM
Normal neurologic and fundus exam.
DIAGNOSTIC TESTS AND INTERPRETATION
Lab
Initial Lab Tests
No specific tests are indicated routinely.
Follow-Up & Special Considerations
Additional testing may be needed to exclude secondary headache disorders.
Imaging
Initial Approach
Imaging is not needed in patients with non-focal exam, with characteristic symptoms and normal exam (4)[B].
Follow-Up & Special Considerations
- Brain imaging is recommended:
- Change in headache pattern (4)[C]
- Abnormal or changed neurologic exam (4)[B]
- Atypical aura or duration longer than 60 minutes (4)[C]
- White-matter abnormalities are more common in migraineurs. Subclinical posterior circulation infarcts are more common in migraine with aura.
Diagnostic Procedures/Other
Lumbar puncture to measure opening pressure and exclude vascular, inflammatory, and infectious etiologies.
Pathological Findings
No abnormal findings.
DIFFERENTIAL DIAGNOSIS
Tension-type headache, cluster headache, temporomandibular joint dysfunction, trigeminal neuralgia, vasculitis, tumor, infection, idiopathic intracranial hypertension, arteriovenous malformation, arterial dissection, venous sinus thrombosis.
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MEDICATION
First Line
Abortive
NSAIDs
Combination analgesics
Triptans
- Sumatriptan 50 mg, 100 mg oral, nasal spray, subcutaneous injection (4)[A]
- Rizatriptan, zolmitriptan, faster acting
- Naratriptan, frovatriptan, longer half life
- Treximet® (sumatriptan 85 mg/naproxen 500 mg) (4)[A], triptans contraindicated in vascular disease, basilar and hemiplegic migraine
Prophylaxis
Antiepileptics
Antihypertensives
Tricyclic antidepressants
- Amitriptyline 30–150 mg/day, can cause arrhythmia, drowsiness, anticholinergic effects (3)[A]
- Nortriptyline, better tolerated than amitriptyline (3)[C]
Second Line
Abortive
Combination treatment
Ergot derivatives
Prophylaxis
Calcium channel blockers
Selective serotonin reuptake inhibitor
Other
- Cyproheptadine, used more in pediatric migraine, can cause weight gain (3)[C]
- Butterbur 100–150 mg/day, reflux and burping
Nausea associated with migraine
Treatment in pregnancy
Acute attack:
- Acetaminophen (preg B) (4)[B]
- Prochlorperazine (preg C) (4)[B]
- Prednisone (preg B) refractory cases (4)[B]
Prophylaxis: Reserved for refractory cases
- Magnesium (preg B) 400–600 mg/day (3)[B]
- Riboflavin (vitamin B2) (preg B) up to 400 mg/day (3)[B]
- Propranolol (preg C) <160 mg/day
ADDITIONAL TREATMENT
General Measures
Indications for prophylaxis: 4 or more headaches per month, abortive therapy fails or used more than twice per week, headache lasting more than 24 hours, symptoms causing significant disability.
Issues for Referral
Neurosurgery for possible surgical intervention and neuro-ophthalmology for concerning visual field testing or fundus exam.
Additional Therapies
Cognitive behavioral therapy, physical therapy, relaxation therapy.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Biofeedback, massage, acupuncture.
SURGERY/OTHER PROCEDURES
Onabotulinum toxin (Botox type A) – FDA-approved treatment for chronic migraine.
IN-PATIENT CONSIDERATIONS
Initial Stabilization
Ensure patient environment is quiet, dark, with little disruption.
Admission Criteria
Intractable headache that fails to respond to appropriate outpatient or emergency department measures, failed outpatient detoxification, effective treatment of dehydration due to intractable vomiting (1)[C].
Nursing
Education for: Dietary management, stress management, exercise programs.
Discharge Criteria
Significant improvement of pain level and associated nausea and vomiting, detoxification, and transition to alternative prophylaxis.
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FOLLOW-UP RECOMMENDATIONS
Patients should keep a headache journal for accurate account of headaches.
DIET
- Adequate hydration, avoid triggers: Chocolate, alcohol, aspartame, monosodium glutamate, and tyramine-containing foods.
- Caffeine: Wean off one cup per week for chronic migraineurs.
PATIENT EDUCATION
Appropriate timing in self-administered abortive treatment, reinforcing lifestyle changes.
PROGNOSIS
Migraine is a chronic condition, but frequency and severity decreases with age.
COMPLICATIONS
- Migrainous infarction may occur as a serious complication of migraine. This risk is highest in patients with migraine with aura, are female, smokers, and with estrogen use.
- Status migrainous, persistent aura without infarction, migraine-triggered seizure.
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