Headache, Migraine

DESCRIPTION

Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours; typically: unilateral, pulsating, moderate to severe intensity, and associated nausea and/or photophobia or 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 of 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 of >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

• Trigeminovascular hypothesis: Hyperexcitable trigeminal brainstem sensory neurons are stimulated and release neuropeptides (substance P and CGRP), leading to vasodilation and neurogenic inflammation.
• Cortical spreading depression: main hypotheses for migraine with aura; change in electrical activity with reduced blood flow, leading to aura

RISK FACTORS

• Female sex (menstrual cycle)
• Family history of migraine
• Triggers:
  • Sleep pattern disruption
  • Diet: skipped meals (48%), alcohol (32%), chocolate (20%), cheese (13%), caffeine overuse (14%), monosodium glutamate (MSG) (12%), and artificial sweeteners
  • Medications: estrogens, vasodilators

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)
• Cerebral vascular disease
• IBS
• Other pain syndromes (cervical spine disease, endometriosis)