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KEY POINTS
■ Migraine headache is often characterized by moderate to severe unilateral, throbbing pain and accompanied by nausea or vomiting, with sensitivities to lights and sounds.
■ The three most common triggers for migraine headaches are poorly managed stress, hormonal changes, and poor sleep patterns.
■ While numerous preventive treatments are available, the treating clinician should become comfortable with using two to three medications and be aware of other options that are available if needed.
■ The triptans treat associated migraine symptoms as well as the migraine pain.
Migraine headache is a chronic, genetic, neurologic disorder involving abnormal sensory processing. Migraines are often disabling, leading to dramatic lifestyle changes and limitations for the migraineur. Clinicians must be confident in their diagnosis and treatment of migraine headaches if patient outcomes are to improve.
The pathophysiology of migraine headache has not been clearly elucidated. Early theories positing that migraine and migraine aura were solely due to vasodilation and vasoconstriction of cranial vasculature have been largely disproven. Recent theories emphasize the importance of close interactions between meningeal/cranial vessels and nerves; neuropeptides; and CNS structures, especially the trigeminal neurovascular unit and the brainstem.1,2 The migraineur's brain most likely has dysfunctional descending pain inhibition, is hyperexcitable, and has a decreased pain threshold. Several authors have discussed the pathophysiology of migraine.1,2
DIAGNOSTIC CRITERIA
The diagnosis of migraine headache is straightforward and follows the guidelines established by the International Headache Society (IHS) in its second edition of the International Headache Classification (IHCD-2)3 (Table 1). Migraine headache is often characterized by moderate to severe unilateral throbbing pain and accompanied by nausea or vomiting, with sensitivities to lights and sounds. Note, however, that not all these elements need be present for a diagnosis of migraine.
Migraine aura can occur in up to 30% of persons with migraine headache.4 An aura is a stereotypical, reversible neurologic event that may occur either prior to or during a migraine headache. The aura can be visual, auditory, sensory, motor, or a combination of these. The most common aura is visual; the second most common is sensory. Visual auras include seeing light or dark spots, unformed flashes of light, or expanding zigzag lines, or they can manifest as tunnel vision. First-time visual loss or monocular visual loss warrants further investigation to rule out other neurologic problems, such as amaurosis fugax in the setting of a transient ischemic attack (TIA). Sensory auras are typically experienced either as tingling or numbness in the face or extremities or as a "sensory march," which begins with sensory symptoms in the hand that may then progress upward along the arm or shoulder. A motor aura causes weakness, usually in an extremity, and may need further evaluation during a first-time event.
In addition to migraine with and without aura, there are four other subclassifications of migraine: childhood periodic syndromes that are commonly precursors of migraine, retinal migraine, complications of migraine, and probable migraine. Migraine with aura includes the following subtypes: typical aura with migraine headache, typical aura with nonmigraine headache, typical aura without headache, basilar-type migraine, familial hemiplegic migraine, and sporadic hemiplegic migraine.3 The complications of migraine subclassification include chronic migraine and status migrainosus. Chronic migraine headache is a migraine headache that occurs on 15 or more days per month for at least 3 months.
Migraine headaches are often misdiagnosed. Migraineurs are frequently told they have sinus headache, toothache, "allergy headache," or tension headache. By applying IHS-ICHD-2 migraine criteria, performing a thorough examination, and bearing in mind the cranial and cervical anatomy (particularly the three divisions of the trigeminal nerve), the clinician can correctly diagnose migraine.
SECONDARY HEADACHES
In most patients, the diagnosis of migraine is straightforward and additional testing or imaging is not needed. However, certain headache patterns or features are more ominous and may reflect serious underlying abnormalities requiring immediate attention. Some of these red-flag patterns include headache with rapid onset and peak (seconds to minutes); a first or worst headache; headache with abnormal neurologic symptoms or signs; headache accompanied by a change in level of consciousness; headache associated with fever/chills or a stiff neck; headache following trauma (particularly head trauma); new-onset headache in a patient older than 50 years; headaches in patients who are immunosuppressed, have a malignancy, or are HIV-positive; headache during pregnancy or postpartum; and headache caused by exertion, sexual intercourse, or Valsalva maneuver.5,6
Various medical conditions are frequently accompanied by headaches, and it is important to remember that patients may have more than one headache disorder. Taking into consideration systemic symptoms, neurologic symptoms, onset timing, onset after age 50 years, and pattern change in the patient with a history of headaches will help identify the cause of secondary headaches (Table 2). The mnemonic SNOOP4 is a helpful tool for this purpose.
The evaluation of a secondary headache disorder depends on the clinical presentation. The diagnostic evaluation may include brain imaging (CT, MRI, magnetic resonance angiography [MRA], magnetic resonance venography [MRV]) with or without IV contrast enhancement; lumbar puncture; serum testing, including ESR; and assessment for malignancies or an immunosuppressed state. Not all testing is needed for all patients.