A benign, episodic syndrome of headache associated with other symptoms of neurologic dysfunction in varying admixtures. Second to tension-type as most common cause of headache; afflicts ~15% of women and 6% of men annually. Diagnostic criteria are listed in Table 49-3. Onset usually in childhood, adolescence, or early adulthood; however, initial attack may occur at any age. Family history is often present. Women may have increased sensitivity to attacks during menstrual cycle. Classic triad: premonitory visual (scotoma or scintillations), sensory, or motor symptoms; unilateral throbbing headache; and nausea and vomiting. Most pts do not have visual aura or other premonitory symptoms. Photo- and phonophobia common. Vertigo may occur. Focal neurologic disturbances without headache or vomiting (migraine equivalents) may also occur. An attack lasting 4-72 h is typical, as is relief after sleep. Attacks may be triggered by glare, bright lights, sounds, hunger, stress, physical exertion, hormonal fluctuations, lack of sleep, alcohol, or other chemical stimulation.
Treatment: Migraine - Three approaches to migraine treatment: nonpharmacologic (such as the avoidance of pt-specific triggers; information for pts is available at www.achenet.org); drug treatment of acute attacks (Tables 49-4 and 49-5); and prophylaxis (Table 49-6).
- Drug treatment necessary for most migraine pts, but avoidance or management of environmental triggers alone is sufficient for some.
- General principles of pharmacologic treatment:
- - Response rates vary from 50% to 70%.
- - Initial drug choice is empirical and individualized—influenced by age, coexisting illnesses, and side effect profile.
- - Efficacy of prophylactic treatment may take several months to assess with each drug.
- - When an acute attack requires additional medication 60 min after the first dose, then the initial drug dose should be increased for subsequent attacks or another class of drug tried.
- Mild to moderate acute migraine attacks often respond to over-the-counter (OTC) NSAIDs when taken early.
- Triptans are widely used and have many formulations.
- There is likely less frequent headache recurrence when using ergots, but more frequent nausea.
- For prophylaxis, tricyclic antidepressants are a good first choice for young people with difficulty falling asleep; verapamil is often a first choice for prophylaxis in the elderly.
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