Typically unilateral (although it may occur behind both eyes or across the entire front of the head), throbbing or boring head pain accompanied at times by nausea, vomiting, mood changes, fatigue, photophobia, or phonophobia. An aura with visual disturbances, including flashing (zig-zagging or kaleidoscopic) lights, blurred vision, or a visual field defect lasting 15 to 50 minutes, may precede the migraine. May experience temporary or rarely permanent neurologic deficits, such as paralysis, numbness, tingling, or others. A family history is common. Motion sickness or cyclic vomiting as a child is also common. Migraine in children may be seen as recurrent abdominal pain and malaise. Of these patients, 60% to 70% are girls.

Migraine prevalence is highest between ages 30 and 39 years and progressively declines after age 40. Migraine attacks may be shorter and less typical with advancing age. New-onset migraines are uncommon after the age of 50, and these patients should be worked up for secondary causes such as vascular lesions, intracranial hemorrhages, infarcts, masses, or GCA.

NOTE:

Most unilateral migraine headaches at some point change sides of the head. Headaches always on the same side of the head may have another cause of headache (e.g., intracranial structural lesions).

Determine if headache precedes visual symptoms, which is more common with arteriovenous malformations, mass lesions with cerebral edema, or seizure foci.

Usually none. Complicated migraines may have a permanent neurologic or ocular deficit (see the following discussion).

See 10.26, HEADACHE.

International Classification

Consult International Classification of Headache Disorders, 3rd edition, for further information.

• Migraine without aura (common migraine; 80%): Lasts 4 to 72 hours. Unilateral location, pulsating quality, moderate-to-severe pain, and/or aggravation by physical activity. Nausea, vomiting, photophobia, and/or phonophobia are the characteristics.
• Migraine with typical aura (classic migraine; 10%): Fully reversible binocular visual symptoms that may be perceived as monocular (e.g., flickering lights, spots, lines, loss of vision) or fully reversible unilateral sensory symptoms (e.g., numbness, “pins and needles”). Symptoms gradually develop over 5 minutes and last between 5 and 60 minutes. No motor symptoms are present.
• Typical aura without headache (acephalgic migraine): Visual or sensory symptoms as above without accompanying or subsequent headache.
• Familial hemiplegic and sporadic hemiplegic migraine: Migraine with aura as above with accompanying motor weakness with (familial) or without (sporadic) history in a first-degree or second-degree relative. Sporadic cases always require neuroimaging.
• Retinal migraine: Fully reversible monocular visual phenomenon (e.g., scintillations, scotoma, blindness) accompanied by headache fulfilling migraine definition. Appropriate investigations to exclude other causes of transient monocular blindness should be completed. Existence of retinal migraine is controversial.
• Basilar-type migraine: Aura symptoms mimic vertebrobasilar artery insufficiency in a patient with migraine. See 10.23, VERTEBROBASILAR ARTERY INSUFFICIENCY.
• Ophthalmoplegic migraine: Onset in childhood. Headache with third cranial nerve palsy. Likely an inflammation, rather than migraine, as MRI shows enhancement of CNIII.

Associations or Precipitating Factors

Birth control or other hormonal pills, puberty, pregnancy, menopause, foods containing tyramine or phenylalanine (e.g., aged cheeses, wines, chocolate, cashew nuts), nitrates or nitrites, monosodium glutamate, alcohol, aspartame, caffeine withdrawal, weather changes, fatigue, emotional stress, or bright lights.

1. Avoid agents that precipitate the headaches (e.g., stop using birth control pills; avoid alcohol and any foods that may precipitate attacks; reduce stress).
2. Referral to neurologist or internist for pharmacologic management.
   1. Abortive therapy: Medications used at onset of the headache. Best for infrequent headaches.
      1. Initial therapy: Aspirin or nonsteroidal anti-inflammatory agents.
      2. More potent therapy (when initial therapy fails): Ergotamines or selective serotonin receptor agonists (triptans). More recently FDA-approved medications include rimegepant and ubrogepant (calcitonin gene–related peptide [CGRP] antagonists) and lasmiditan (selective serotonin agonist without vasoconstrictor activity). Check contraindications for specific agents.
   2. Prophylactic therapy: Used in patients with frequent or severe headache attacks (e.g., two or more headaches per month) or those with neurologic changes. Includes beta-blockers, calcium channel blockers, antidepressants, anti-CGRP monoclonal antibodies, and others.
   3. Antinausea medication as needed during an acute episode.

NOTE:

Opioid drugs should be avoided.

Reevaluate in 4 to 6 weeks to assess the efficacy of the therapy.