Migraine Headache health

Practice Essentials

Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with visual or sensory symptoms—collectively known as an aura—that arise most often before the head pain but that may occur during or afterward. Migraine is most common in women and has a strong genetic component.

Essential update: 

Study

 finds benefit from longer botulinum toxin treatmentfor chronic migraine

A retrospective study of patients who received onabotulinumtoxinA (Botox) injections for prophylaxis of chronic migraine found that extending treatment for up 9 treatment cycles resulted in progressive improvement over multiple treatment cycles, with excellent tolerability. In earlier studies, patients received 5 cycles, or 56 weeks, of onabotulinumtoxinA treatment. Of the 33 patients in this review, 17 received 8 cycles of onabotulinumtoxinA treatment; 10 patients received 9 cycles given 12 weeks apart, for a total of 108 weeks.^[1]

Signs and symptoms

Typical symptoms of migraine include the following:

• Throbbing or pulsatile headache, with moderate to severe pain that intensifies with movement or physical activity
• Unilateral and localized pain in the frontotemporal and ocular area, but the pain may be felt anywhere around the head or neck
• Pain builds up over a period of 1-2 hours, progressing posteriorly and becoming diffuse
• Headache lasts 4-72 hours
• Nausea (80%) and vomiting (50%), including anorexia and food intolerance, and light-headedness
• Sensitivity to light and sound

Features of migraine aura are as follows:

• May precede or accompany the headache phase or may occur in isolation
• Usually develops over 5-20 minutes and lasts less than 60 minutes
• Most commonly visual but can be sensory, motor, or any combination of these
• Visual symptoms may be positive or negative
• The most common positive visual phenomenon is the scintillating scotoma, an arc or band of absent vision with a shimmering or glittering zigzag border

Physical findings during a migraine headache may include the following:

• Cranial/cervical muscle tenderness
• Horner syndrome (ie, relative miosis with 1-2 mm of ptosis on the same side as the headache)
• Conjunctival injection
• Tachycardia or bradycardia
• Hypertension or hypotension
• Hemisensory or hemiparetic neurologic deficits (ie, complicated migraine)
• Adie-type pupil (ie, poor light reactivity, with near dissociation from light)

See Clinical Presentation for more detail.

Diagnosis

The diagnosis of migraine is based on patient history. International Headache Society diagnostic criteria are that patients must have had at least 5 headache attacks that lasted 4-72 hours (untreated or unsuccessfully treated) and that the headache must have had at least 2 of the following characteristics^[2] :

• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

In addition, during the headache the patient must have had at least 1 of the following:

• Nausea and/or vomiting
• Photophobia and phonophobia

Finally, these features must not have been attributable to another disorder. Classification of migraine is as follows:

• Migraine without aura (formerly, common migraine)
• Probable migraine without aura
• Migraine with aura (formerly, classic migraine)
• Probable migraine with aura
• Chronic migraine
• Chronic migraine associated with analgesic overuse
• Childhood periodic syndromes that may not be precursors to or associated with migraine
• Complications of migraine
• Migrainous disorder not fulfilling above criteria

Migraine variants include the following:

• Childhood periodic syndromes
• Late-life migrainous accompaniments
• Basilar-type migraine
• Hemiplegic migraine
• Status migrainosus
• Ophthalmoplegic migraine
• Retinal migraine

A migraine variant may be suggested by focal neurologic findings, such as the following, that occur with the headache and persist temporarily after the pain resolves:

• Unilateral paralysis or weakness - Hemiplegic migraine
• Aphasia, syncope, and balance problems - Basilar-type migraine
• Third nerve palsy with ocular muscle paralysis and ptosis, including or sparing the pupillary response - Ophthalmoplegic migraine

Testing and imaging studies

Selection of laboratory and/or imaging studies to rule out conditions other than migraine headache is determined by the individual presentation (eg, erythrocyte sedimentation rate and C-reactive protein levels may be appropriate to exclude temporal/giant cell arteritis). Neuroimaging is not necessary in patients with a history of recurrent migraine headaches and a normal neurologic examination.

The American Headache Society released a list of 5 commonly performed tests or procedures that are not always necessary in the treatment of migraine and headache, as part of the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign. The recommendations include^{[3, 4]} :

• Don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.
• Don't perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings.
• Don't recommend surgical deactivation of migraine trigger points outside of a clinical trial.
• Don't prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.
• Don't recommend prolonged or frequent use of over-the-counter pain medications for headache.

See Workup for more detail.

Management

Pharmacologic agents used for the treatment of migraine can be classified as abortive (ie, for alleviating the acute phase) or prophylactic (ie, preventive).

Acute/abortive medications

Acute treatment aims to reverse, or at least stop the progression of, a headache. It is most effective when given within 15 minutes of pain onset and when pain is mild.^[5]

Abortive medications include the following:

• Selective serotonin receptor (5-hydroxytryptamine–1, or 5-HT1) agonists (triptans)
• Ergot alkaloids (eg, ergotamine, dihydroergotamine [DHE])
• Analgesics
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Combination products
• Antiemetics

Preventive/prophylactic medications

The following may be considered indications for prophylactic migraine therapy:

• Frequency of migraine attacks is greater than 2 per month
• Duration of individual attacks is longer than 24 hours
• The headaches cause major disruptions in the patient's lifestyle, with significant disability that lasts 3 or more days
• Abortive therapy fails or is overused
• Symptomatic medications are contraindicated or ineffective
• Use of abortive medications more than twice a week
• Migraine variants such as hemiplegic migraine or rare headache attacks producing profound disruption or risk of permanent neurologic injury^[6]

Prophylactic medications include the following:

• Antiepileptic drugs
• Beta blockers
• Tricyclic antidepressants
• Calcium channel blockers
• Selective serotonin reuptake inhibitors (SSRIs)
• NSAIDs
• Serotonin antagonists
• Botulinum toxin