Description

Recurrent headache disorder manifesting in attacks lasting 4 to 72 hours; typically: unilateral location, pulsating quality, moderate to severe intensity, and associated nausea and/or photophobia and phonophobia (1)

• Most frequent subtypes of migraine (1):
  • Without aura: defines >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: debilitating migraine lasting >72 hours
  • Prolonged aura: Aura symptoms of >60 minutes (can last up to 7 days) should prompt consideration of secondary causes.
  • Ocular: repeated attacks of monocular visual disturbance, including 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 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.
• Cortical spreading depression: mainly accepted hypotheses for migraine with aura; change in electrical activity with reduction of blood flow, leading to aura

Genetics
>80% of patients have a family history.

Risk Factors

• Female sex (menstrual cycle)
• Positive 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 the 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 (e.g., sleep apnea)
• Cerebral vascular disease
• Seizure disorders
• Irritable bowel syndrome
• Other pain syndromes (cervical spine disease, endometriosis)