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Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours. Typical characteristics are unilateral location, pulsating quality, moderate or severe intensity, aggravation by physical activity, and association with nausea and/or photophobia and phonophobia (1).
- Most frequent subtypes of migraine (1):
- Without aura (common migraine): defining >80% of attacks, often associated with nausea, vomiting, photophobia, and/or phonophobia
- With aura (classic migraine): visual or other types of fully reversible neurologic phenomenon lasting 5 to 60 minutes
- Chronic (transformed) migraine: chronic headache pattern evolving from episodic migraine. Migraine-like attacks are superimposed on a daily or near-daily headache pattern (e.g., tension headaches) >15 headache days/month for at least 3 months.
- Menstrual-related (molimina) migraine: associated with onset of menstrual period
- Rare but important subtypes (1):
- Status migrainosus: debilitating migraine lasting >72 hours
- With brainstem aura (basilar migraine): brainstem symptoms—dysarthria, vertigo, tinnitus, or ataxia, which are fully reversible, lasting 5 to 60 minutes
- Hemiplegic migraine: aura consisting of fully reversible hemiplegia and/or hemiparesis
- Recurrent painful ophthalmoplegic neuropathy (ophthalmoplegic migraine): neuralgia accompanied by paresis of an ocular cranial nerve with ipsilateral headache
- Retinal: repeated attacks of monocular visual disturbance, including scintillations, scotomata, or blindness, associated with migraine headache
Female > male (3:1)Prevalence
- Affects >28 million Americans
- Adults: women 18%; men 6%
Etiology and Pathophysiology
Trigeminovascular hypothesis: Hyperexcitable trigeminal sensory neurons in brainstem are stimulated and release neuropeptides, such as substance P and calcitonin gene-related peptide (CGRP), leading to vasodilation and neurogenic inflammation.Genetics
- >80% of patients have a positive family history.
- Familial hemiplegic migraine has been shown to be linked to chromosomes 1, 2, and 19 (1).
- Family history of migraine
- Female gender
- Menstrual cycle, hormones
- Sleep pattern disruption
- Diet: skipped meals (48%), alcohol (32%), chocolate (20%), cheese (13%), caffeine overuse (14%), monosodium glutamate (MSG) (12%), and artificial sweeteners (e.g., aspartame, sucralose)
- Medications: estrogens, vasodilators
- Avoid precipitants of attacks.
- Lifestyle modifications are the cornerstone of prevention: sleep hygiene, stress management, healthy diet, and regular exercise.
- Biofeedback, education, and psychological intervention
- Prophylactic medication if attacks are frequent, severely debilitating, or not controlled by acute interventions
Commonly Associated Conditions
- Depression, psychiatric disorders
- Sleep disturbance (e.g., sleep apnea)
- Cerebral vascular disease
- Peripheral vascular disease
- Seizure disorders
- Irritable bowel syndrome
- Medication overuse headache (MOH)