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Migraine HeadacheAka: Migraine, Classic Migraine, Migraine with Aura, Common Migraine, Migraine without Aura

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  1. See Also
    1. Headache
    2. Acute Recurrent Headache
  2. Epidemiology
    1. Female gender more commonly affected
    2. Prevalence
      1. New data suggests as high as 25% of U.S. population
      2. Children
        1. Age 3 to 7 years: 1.2 to 3.2%
        2. Age 7 to 11 years: 4 to 11%
        3. Age 15 years: 8 to 23%
      3. Adults
        1. Women: 18%
        2. Men: 6%
    3. More common if Family History of Migraine Headaches
    4. Most Migraine Headaches are undiagnosed
      1. Women: 59% are undiagnosed
      2. Men: 71% are undiagnosed
      3. Migraine Headaches account for 95% of presentations
        1. Increases to 99% if patients say they have migraine
    5. Chronic migraine may evolve from other Headache types
      1. Chronic Tension Headache
      2. Post-Traumatic Headache
  3. Risk Factors
    1. Caffeine: >100 mg/day (OR: 2.9)
      1. Bigal (2002) {a 14316} 42:575
    2. Obesity
    3. Analgesic overuse
    4. Sleep Apnea or other sleep disturbance
    5. Head Injury
    6. Female gender
  4. Pathophysiology: Trigeminovascular activation
    1. CNS Platelet and mast cell aggregation
    2. Serotonin release from synaptic nerve endings
    3. Increase then decrease in blood brain Catecholamines
      1. Norepinephrine
      2. Epinephrine
    4. Alternating Vasoconstriction and Vasodilatation
      1. The vessel wall Stretching results in pain
    5. Replaces the prior theory of spasm
      1. Vessel Spasm
      2. Rebound vasodilation
  5. Types
    1. Common Migraine
      1. Migraine without aura
    2. Classic Migraine
      1. Migraine with aura
    3. Complicated Migraine
      1. Migraine with prominent neurologic Signs
    4. Basilar Migraine
    5. Hemiplegic Migraine
    6. Ophthalmoplegic Migraine
    7. Menstrual Migraine
    8. Migrainous Carotidynia
  6. Symptoms
    1. Timing
      1. Episodic Headache
      2. Occurs 1-2 times per month
    2. Prodrome (30% of patients)
      1. Precedes Headache by up to 24 hours
      2. Excitability and Irritability
      3. Increased appetite and cravings (especially sweets)
      4. Depression
      5. Sleepiness and Fatigue
      6. Yawning
      7. Heightened perception to external stimuli
    3. Severity
      1. Disability is the marker of migraine
    4. Aura (20% of patients): See diagnosis below
      1. Visual aura
      2. Hemisensory aura
      3. Hemiparesis aura
      4. Dysphasia aura
    5. Headache Phase
      1. Persists for 4 to 72 hours
      2. Location
        1. Unilateral in 50%
        2. Often frontal in location
      3. Characteristics
        1. Pulsating, Throbbing Headache in 50%
        2. Dull, ache-type Headache in 50%
      4. Relieved with sleep
      5. Symptoms strongly correlated with migraine Headache
        1. Nausea or Vomiting
          1. Positive Predictive Value: 56% (m) 82% (f)
          2. Negative Predictive Value: 1.2% (m) 4.2% (f)
        2. Photophobia or Phonophobia
          1. Positive Predictive Value: 25% (m) 53% (f)
          2. Negative Predictive Value: 2.4% (m) 7.7% (f)
  7. Common Triggers (Patient should keep a diary)
    1. See Migraine Headache Triggers
    2. See Tyramine-Vasoactive Amines
    3. See Medication Causes of Headache
  8. Radiology: Neuroimaging Indications
    1. First or worst severe migraine Headache (see below)
    2. Abnormal Neurologic Examination
    3. Not indicated in nonacute migraine with normal exam
    4. Neff (2005) Am Fam Physician 71(6):1219
  9. Diagnosis: Migraine without aura
    1. Timing and general characteristics
      1. Five episodes or more
      2. Each episode lasts 4 to 72 hours
      3. No evidence of Organic Headache
    2. Two of the following criteria
      1. Unilateral Headache pain
      2. Pulsating quality to Headache pain
      3. Symptom severity limits daily activities
      4. Provoked by routine level of exertion
    3. One of the following criteria
      1. Nausea
      2. Photophobia and Phonophobia
  10. Diagnosis: Migraine with aura
    1. Two or more attacks
    2. Headache associated with migraine aura
      1. Visual aura
        1. Scintillating scotoma
        2. Fortification spectra
        3. Photopsia
      2. Sensory aura
        1. Paresthesia
        2. Numbness
        3. Unilateral weakness
        4. Speech disturbance (Aphasia)
    3. Three or more of the following characteristics
      1. One or more completely reversible aura symptom
      2. At least one aura develops over 4 or more minutes
      3. Aura duration 60 minutes or less
      4. Headache follows aura within 60 minutes
  11. Diagnosis: Migraine in Children
    1. Five or more Headaches that last 1-48 hours
    2. Includes at least two migraine characteristics
      1. Bilateral or unilateral temporal/frontal Headache
      2. Pulsating quality
      3. Intensity moderate to severe
      4. Worse with routine exertion
    3. Includes at least one associated symptom
      1. Nausea or Vomiting
      2. Photophobia or Phonophobia
  12. Differential Diagnosis
    1. See Headache Evaluation
    2. See Organic Headache
    3. Analgesic Rebound Headache
      1. Always consider for patients with frequent Headache
    4. Conditions that may coexist with migraine Headache
      1. Myofascial cervical neck pain
        1. Not exclusive to Tension Headache
        2. Present in 75% of migraine Headache patients
        3. Triptan medications relieve neck pain and Headache
        4. Kaniecki (2002) Neurology 58:S15
      2. Sinus Headache
        1. Migraine Headache criteria in 90% of Sinus Headache
        2. Schreiber (2004) Arch Intern Med 164:1769
  13. Evaluation: Headache with persistent neurologic deficit
    1. See Organic Headache
    2. Exclude Ischemic causes
    3. Exclude structural causes
    4. Exclude Inflammatory causes
    5. Exclude Metabolic cause
  14. Evaluation: First or Worst severe migraine Headache
    1. See Organic Headache
    2. No potent Narcotics until full evaluation
    3. Complete clinical and neurologic evaluation
    4. CT Head
      1. Not indicated in typical migraine Headache
      2. Use low threshold for Organic Headache symptoms
        1. Neurologic changes
        2. New onset Headache
      3. Organic causes of Headache identified by CT Head
        1. Subarachnoid Hemorrhage
        2. Intracranial mass
    5. Lumbar Puncture
      1. Consider for meningeal signs, fever or ill appearance
  15. Management
    1. See Migraine Management
    2. See Migraine Management in Children
  16. Course
    1. Mild episodic Headaches
      1. Most cases start with Migraine without Aura
      2. Relieved with OTC medications
    2. Chronic episodic migraine Headaches
      1. Unresponsive to OTC medications
      2. Often presents at this stage
    3. Chronic progressive migraine Headaches
    4. Chronic-Refractory migraine Headaches
  17. References
    1. Jackson (1998) CMEA Internal Medicine Lecture,San Diego
    2. Moore (1997) Am Fam Physician 56(8):2039
    3. Noble (1997) Am Fam Physician 56(9):2279
    4. Polizzotto (2002) J Fam Pract 51(2):161
    5. Winner (1997) {a 14316} 37:545

Migraine Disorders (C0149931)

Definition (CSP)neural condition characterized by a severe recurrent vascular headache, usually on one side of the head, often accompanied by nausea, vomiting, and photophobia, sometimes preceded by sensory disturbances; triggers include allergic reactions, excess carbohydrates or iodine in the diet, alcohol, bright lights or loud noises.
Definition (MSH)A class of disabling primary headache disorders, characterized by recurrent unilateral pulsatile headaches. The two major subtypes are common migraine (without aura) and classic migraine (with aura or neurological symptoms). (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1)
ConceptsDisease or Syndrome (T047)
ICD9346, 346.9
BasqueMIGRAINA
DanishMigraene
DutchMigraine
EnglishMA, MGAU, MGR1, Migraine, Migraine Disorder, Migraine Disorders, Migraine Headache, Migraine Headaches, MIGRAINE SYNDROME, Migraines
FinnishMIGREENI
FrenchMigraine
GermanMigraene
Hebrewtzilxa
Hungarianmigraine
ItalianEmicrania
NorwegianMIGRENE
PortugueseEnxaqueca
Spanishjaqueca, migraña, migrana
SwedishMIGRAN
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Common Migraine (C0338480)

Definition (MSH)Recurrent unilateral pulsatile headaches, not preceded or accompanied by an aura, in attacks lasting 4-72 hours. It is characterized by PAIN of moderate to severe intensity; aggravated by physical activity; and associated with NAUSEA and / or PHOTOPHOBIA and PHONOPHOBIA. (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1)
ConceptsDisease or Syndrome (T047)
ICD9346.1
EnglishAtypical migraine, Common Migraine, Common Migraines, Migraine without Aura, Sick headache
Spanishcefalea del enfermo, migraña atípica, migraña común, migraña sin aura, migrana atipica, migrana comun, migrana sin aura
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Migraine with Typical Aura (C1735856)

ConceptsDisease or Syndrome (T047)
ICD9346.0
EnglishClassic Migraine, Classical Migraine, Migraine with Typical Aura
Spanishmigraña clásica, migraña con aura típica, migrana clasica, migrana con aura tipica
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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