Migraine Headache Clinical Presentation

  • Author: Jasvinder Chawla, MBBS, MD, MBA; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: May 25, 2011
 

History

Migraine attacks commonly occur when the person is awake, although it may have already started upon awakening. Less commonly, it may awaken the patient at night.

The typical headache of migraine is throbbing or pulsatile. (However, more than 50% of people who suffer from migraines report nonthrobbing pain at some time during the attack.)

The headache is initially unilateral and localized in the frontotemporal and ocular area, but pain can be felt anywhere around the head or neck. The pain typically builds up over a period of 1-2 hours, progressing posteriorly and becoming diffuse.

The headache typically lasts from 4-72 hours. Among females, more than two thirds of patients report attacks lasting longer than 24 hours.

Pain intensity is moderate to severe and intensifies with movement or physical activity. Many patients prefer to lie quietly in a dark room. The pain usually subsides gradually within a day and after a period of sleep; a majority of patients report feeling tired and weak afterwards.

Other symptoms

Nausea and vomiting usually occur later in the attack in about 80% and 50% of patients, respectively, along with anorexia and food intolerance. Some patients have been noted to be pale and clammy, especially if nausea develops. Photophobia and/or phonophobia also commonly are associated with the headache. Light-headedness is frequent. See Migraine-Associated Vertigo for more information on migraine-related vestibulopathy.

Other neurological symptoms that may be observed include hemiparesis (this symptom defines hemiplegic migraine), aphasia, confusion, and paresthesias or true numbness.

Prodrome

About 60% of people who experience migraines report premonitory symptoms that occur hours to days before headache onset. Although the prodromal features vary, they tend to be consistent for a given individual and may include the following:

  • Heightened sensitivity to light, sound, and odors
  • Lethargy or uncontrollable yawning
  • Food cravings
  • Mental and mood changes (eg, depression, anger, euphoria)
  • Excessive thirst and polyuria
  • Fluid retention
  • Anorexia
  • Constipation or diarrhea

These symptoms may be difficult to diagnose as part of the migraine complex if they occur in isolation from the headache or if they are mild. The prodrome of migraine has yet to receive significant investigational attention.

Aura

The migraine aura is a complex of neurologic symptoms that may precede or accompany the headache phase or may occur in isolation. It usually develops over 5-20 minutes and lasts less than 60 minutes. The aura can be visual, sensory, motor, or any combination of these.

Auras most commonly consist of visual symptoms, which may be negative or positive. Negative symptoms include negative scotomata or negative visual phenomena, such as homonymous hemianopic or quadrantic field defects, central scotomas, tunnel vision, altitudinal visual defects, or even complete blindness (see the image below).

Migraine headache. Frank visual field loss can alsMigraine headache. Frank visual field loss can also occur associated with migraine. This example shows loss of the entire right visual field as described by a person who experiences migraines.

The most common positive visual phenomenon is the scintillating scotoma. This consists of an arc or band of absent vision with a shimmering or glittering zigzag border. The disturbance begins in the paracentral area, and gradually enlarges and moves across the hemifield, eventually breaking up and resolving. It is often combined with photopsias or visual hallucinations, which may take various shapes (see the images below).

Migraine headache. Example of a visual migraine auMigraine headache. Example of a visual migraine aura as described by a person who experiences migraines. This patient reported that these visual auras preceded her headache by 20-30 minutes. Migraine headache. Example of a central scotoma asMigraine headache. Example of a central scotoma as described by a person who experiences migraines. Note the visual loss in the center of vision. Migraine headache. Example of a central scotoma asMigraine headache. Example of a central scotoma as described by a person who experiences migraine headaches. Again note the visual loss in the center of vision. Migraine headache. Example of visual changes durinMigraine headache. Example of visual changes during migraine. Multiple spotty scotomata are described by a person who experiences migraines.

Scintillating scotoma is a highly characteristic syndrome that always occurs prior to the headache phase of an attack and is pathognomonic of a classic migraine. It is sometimes called a "fortification spectrum" because the serrated edges of the hallucinated "C" resemble a "fortified town with bastions around it."

Other positive visual phenomena include photopsia (uniform flashes of light) or simple forms of visual hallucinations. Heat waves, fractured vision, macropsia, micropsia, and achromatopsia may also occur.

Paresthesias, occurring in 40% of cases, constitute the next most common aura; they are often cheiro-oral with numbness starting in the hand, migrating to the arm, and then jumping to involve the face, lips, and tongue. As with visual auras, positive symptoms typically are followed by negative symptoms; paresthesias may be followed by numbness.

Sensory aura rarely occurs in isolation and usually follows visual aura. The rate of spread of sensory aura is helpful in distinguishing it from transient ischemic attack (TIA) or a sensory seizure. Just as a visual aura spreads across the visual field slowly, paresthesias may take 10-20 minutes to spread, which is slower than the spread of sensory symptoms of TIA.

Motor symptoms may occur in 18% of patients and usually are associated with sensory symptoms. Motor symptoms often are described as a sense of heaviness of the limbs before a headache but without any true weakness.

Speech and language disturbances have been reported in 17-20% of patients. These disturbances are commonly associated with upper extremity heaviness or weakness.

The migrainous aura generally resolves within a few minutes and then is followed by a latent period before the onset of headache, although merging of the 2 also is reported.

Whether migraine with and without aura (prevalences, 36% and 55%, respectively) represent 2 distinct processes remains debatable; however, the similarities of the prodrome, headache, and resolution phases of the attacks, as well as the similarity in therapeutic response and the fact that 9% of patients experience both, suggest that they are the same entity.

When an aura is not followed by a headache, it is called a migraine equivalent or acephalic migraine. This is reported most commonly in patients older than 40 years who have a history of recurrent headache.

Scintillating scotoma has been considered to be diagnostic of migraine even in the absence of a headache; however, paresthesias, weakness, and other transient neurologic symptoms are not. In the absence of a prior history of recurrent headache and first occurrence after age 45 years, TIA should be considered and must be investigated fully.

Postdromal symptoms

Postdromal symptoms may persist for 24 hours after the headache. They may include the following:

  • Feeling tired, ‘washed out’, or irritable
  • Feeling unusually refreshed or euphoric
  • Muscle weakness or myalgias
  • Anorexia or food cravings

Migraine triggers

A history of migraine triggers may be elicited. Common triggers include the following:

  • Certain foods (eg, chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate [MSG], aspartame, red wine, alcohol)
  • Hormonal changes (eg, menstruation, ovulation, oral contraceptives, hormone replacement)
  • Head trauma
  • Physical exertion
  • Fatigue
  • Medications (eg, nitroglycerin, histamine, reserpine, hydralazine, ranitidine, estrogen)
  • Stress

Family history

Approximately 70% of patients have a first-degree relative with a history of migraine. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura.[24] Although no genetic basis has been identified for common migraine, it generally demonstrates a maternal inheritance pattern.

Disability assessment

Simple questionnaires, such as the Migraine Disability Assessment Scale (MIDAS), can be used to quantify the extent of disability on the first visit. These questionnaires can also be used for follow-up evaluations.

Next

Physical Examination

Although a thorough screening neurologic examination is essential, the results will be normal in most patients with headache.

Evidence of autonomic nervous system involvement can be helpful, although most patients with migraine exhibit few or no findings. Serial neurologic examinations are recommended.

Possible findings during a migraine include the following:

  • Cranial/cervical muscle tenderness
  • Horner syndrome (ie, relative miosis with 1-2 mm of ptosis on the same side as the headache)
  • Conjunctival injection
  • Tachycardia/bradycardia
  • Hypertension/hypotension
  • Hemisensory or hemiparetic neurological deficits (ie, complicated migraine)
  • Adie type pupil (ie, poor light reactivity with light-near dissociation)

Pertinent physical examination findings that suggest a headache diagnosis other than migraine include the following:

  • Dim scotoma lasting a few seconds to several minutes (ie, amaurosis)
  • Temporal artery tenderness in the elderly
  • Meningismus
  • Increased lethargy (unrelated to medication use)
  • Mental status changes

Physical examination findings suggesting a more serious cause of headache include systemic symptoms (eg, myalgia, fever, malaise, weight loss, scalp tenderness, jaw claudication) and focal neurologic abnormalities or confusion, seizures, or any impairment of level of consciousness. On the other hand, focal neurologic findings that occur with the headache and persist temporarily after the pain resolves suggest a migraine variant, as follows:

  • Unilateral paralysis or weakness: hemiplegic migraine
  • Aphasia, syncope, and balance problems: basilar migraines
  • Third nerve palsy, with ocular muscle paralysis and ptosis, including or sparing the pupillary response: ophthalmoplegic migraine

Ophthalmic migraines cause a visual disturbance (usually lateral field deficit). This diagnosis is more common in children, with the abnormal motor findings lasting hours to days after the headache.

Previous
Next

Diagnostic Criteria

The diagnosis of migraine is based on the history. Diagnostic criteria have been established by the International Headache Society (IHS). (See the image below.)

Overview of migraine treatment. Five steps. Overview of migraine treatment. Five steps.
Previous
Next

Migraine Variants

Migraine variants include the following:

  • Childhood periodic syndromes
  • Late-life migrainous accompaniments
  • Vertebrobasilar migraine
  • Hemiplegic migraine
  • Status migrainosus
  • Ophthalmoplegic migraine
  • Retinal migraine

See Migraine Variants for more information on these topics.

Childhood periodic syndromes

Childhood periodic syndromes evolve into migraine in adulthood. These syndromes include cyclic vomiting, abdominal migraine, and benign paroxysmal vertigo of childhood.

In cyclic vomiting, the child has at least 5 attacks of intense nausea and vomiting ranging from 1 hour to 5 days. Abdominal migraine consists of episodic midline abdominal pain lasting 1-72 hours with at least 2 of 4 other symptoms (ie, nausea, vomiting, anorexia, and/or pallor). Benign paroxysmal vertigo of childhood involves recurrent attacks of vertigo, often associated with vomiting or nystagmus.

See Migraine in Children for more information on these topics.

Late-life migrainous accompaniments

In elderly persons, a stereotypical series of prodromelike symptoms may entirely replace the migrainous episode; this is termed late-life migrainous accompaniments. If the headache is always on one side, a structural lesion needs to be excluded using imaging studies.

Eliciting a history of recurrent typical attacks and determining the provoking agent are important because a secondary headache can mimic migraine. A new headache, even if it appears typical on the basis of its history, should always suggest a broad differential diagnosis and the possibility of a secondary headache.

Vertebrobasilar migraine

Patients with vertebrobasilar migraine can present without headaches but with vertebrobasilar symptoms such as vertigo, dizziness, confusion, dysarthria, tingling of extremities, and incoordination.

Hemiplegic migraine

Hemiplegic migraine is a very rare migraine variant in which headaches are associated with temporary unilateral hemiparesis or hemiplegia, at times accompanied by ipsilateral numbness or tingling, with or without a speech disturbance.

The focal neurologic deficit may precede or accompany the headache, which is usually less dramatic than the motor deficit. Other migraine symptoms may variably be present. Patients may also experience disturbance of consciousness, and rarely coma

Ophthalmoplegic migraine

This variant has recently been reclassified by the IHS as a neuralgia. It is associated with transient palsies of the extraocular muscle with dilated pupils and eye pain. It is thought to be due to idiopathic inflammatory neuritis. In the acute phase, enhancement of the cisternal segment of the third cranial nerve occurs.

Retinal migraine

Occasionally, patients develop retinal and optic nerve ischemia and present with monocular blindness, papilledema, and retinal hemorrhages; this variant is called retinal migraine or ocular migraine.

Status migrainosus

This occurs when the migraine attack persists for more than 72 hours. Status migrainosus may result in complications such as dehydration.

Chronic migraine

Chronic migraine is defined as migraine headache that occurs for more than 15 days a month for greater than 3 months. Most of these patients have a history of migraine headaches since a young age. Associated symptoms of nausea, vomiting, photophobia, and phonophobia may be less frequent.

Previous
Next

Comorbidities of Migraine

Migraine is associated with the following:

Epilepsy increases the relative risk of migraine by 2.4.

A Danish study found that migraine occurs in 20-30% of patients with several medical conditions, including kidney stone, psoriasis, rheumatoid arthritis, and fibromyalgia.[48] Migraine with aura had more comorbidities than migraine without aura.

Previous
Next

Complications of Migraine

Complications of migraine include chronic migraine, migraine-triggered seizures, migrainous infarction (stroke with migraine), and persistent aura (eg, 30-60 minutes) without infarction. Ischemic stroke may occur as a rare but serious complication of migraine.[49] In migraines with aura, the risk for hemorrhagic stroke may be possible, but rare.[50] Risk factors for stroke include migraine with aura, female sex, cigarette smoking, and estrogen use.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Jasvinder Chawla, MBBS, MD, MBA  Chief of Neurology, Hines Veterans Affairs Hospital; Associate Professor and Director, Neurology Residency Training Program, Loyola University Medical Center

Jasvinder Chawla, MBBS, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Blanda, MD  Chair, Department of Emergency Medicine, Summa Health System Akron City/St. Thomas Hospital; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

Michelle Blanda, MD, is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ronald Braswell, MD  Associate Professor, Department of Ophthalmology, University of Alabama-Birmingham

Ronald Braswell, MD is a member of the following medical societies: American Academy of Ophthalmology and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Joseph Carcione Jr, DO, MBA  Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans

Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Jane W Chan, MD  Professor of Neurology/Neuro-ophthalmology, Department of Medicine, Division of Neurology, University of Nevada School of Medicine

Jane W Chan, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Medical Association, North American Neuro-Ophthalmology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Eric R Eggenberger, DO, MS, FAAN  Professor, Vice-Chairman, Department of Neurology and Ophthalmology, Colleges of Osteopathic Medicine and Human Medicine, Michigan State University; Director of Michigan State University Ocular Motility Laboratory; Director of National Multiple Sclerosis Society Clinic, Michigan State University

Eric R Eggenberger, DO, MS, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Osteopathic Association, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Jacqueline Freudenthal, MD  Co-Investigator, Ophthalmic Consultants Centre, Toronto

Jacqueline Freudenthal, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, and Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Deborah I Friedman, MD, MPH  Professor of Ophthalmology and Neurology, University of Rochester School of Medicine and Dentistry; Consulting Staff, Strong Memorial Hospital

Deborah I Friedman, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Headache Society, American Neurological Association, Association for Research in Vision and Ophthalmology, North American Neuro-Ophthalmology Society, Society for Neuroscience, and United Council of Neurologic Subspecialties, Certification in Headache Medicine

Disclosure: MAP Pharmaceuticals Grant/research funds Site PI (through university); AGA Medical Grant/research funds Site PI (through university); Teva Grant/research funds Site PI (through university); Pfizer Grant/research funds Site PI; Neurology Reviews Honoraria Editorial board; Merck Grant/research funds Site PI

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edsel Ing, MD, FRCSC  Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Toronto East General Hospital, Canada

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

David Y Ko, MD  Associate Professor of Clinical Neurology, Associate Director, USC Adult Epilepsy Program, Keck School of Medicine of the University of Southern California

David Y Ko, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Headache Society

Disclosure: GSK Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Lundbeck Consulting fee Consulting; Westward Consulting fee Consulting

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Soma Sahai-Srivastava, MD  Director of Neurology Ambulatory Care Services, LAC and USC Medical Center; Assistant Professor, Department of Neurology, Keck School of Medicine of the University of Southern California

Soma Sahai-Srivastava, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, and American Medical Association

Disclosure: Nothing to disclose.

Jeff T Wright, MD  Instructor, Department of Emergency Medicine, Summa Health System; Corporation President and Consulting Staff, Summa Emergency Associates, Inc

Jeff T Wright, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Brian R Younge, MD  Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Robert A Egan, MD  Director of Neuro-Ophthalmology, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

References

  1. [Guideline] The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160. [Medline].

  2. [Guideline] Matchar DB, Young WB, Rosenberg JA, et al. Evidence-based guidelines for migraine headache in the primary care setting: Pharmacological management of acute attacks. American Academy of Neurology. Accessed February 10, 2011. [Full Text].

  3. [Guideline] Solomon GD, Cady RK, Klapper JA, Ryan RE Jr. Standards of care for treating headache in primary care practice. National Headache Foundation. Cleve Clin J Med. Jul-Aug 1997;64(7):373-83. [Medline].

  4. [Guideline] Ducharme J. Canadian Association of Emergency Physicians Guidelines for the acute management of migraine headache. J Emerg Med. Jan-Feb 1999;17(1):137-44. [Medline].

  5. Perciaccante A. Migraine is characterized by a cardiac autonomic dysfunction. Headache. Jun 2008;48(6):973. [Medline].

  6. May A, Goadsby PJ. The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation. J Cereb Blood Flow Metab. Feb 1999;19(2):115-27. [Medline].

  7. Cutrer FM, Charles A. The neurogenic basis of migraine. Headache. Oct 2008;48(9):1411-4. [Medline].

  8. Waeber C, Moskowitz MA. Therapeutic implications of central and peripheral neurologic mechanisms in migraine. Neurology. Oct 28 2003;61(8 Suppl 4):S9-20. [Medline].

  9. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology. Oct 28 2003;61(8 Suppl 4):S2-8. [Medline].

  10. Hauge AW, Asghar MS, Schytz HW, Christensen K, Olesen J. Effects of tonabersat on migraine with aura: a randomised, double-blind, placebo-controlled crossover study. Lancet Neurol. Aug 2009;8(8):718-23. [Medline].

  11. Moulton EA, Burstein R, Tully S, Hargreaves R, Becerra L, Borsook D. Interictal dysfunction of a brainstem descending modulatory center in migraine patients. PLoS One. 2008;3(11):e3799. [Medline]. [Full Text].

  12. Richter F, Lehmenkühler A. [Cortical spreading depression (CSD): a neurophysiological correlate of migraine aura]. Schmerz. Oct 2008;22(5):544-6, 548-50. [Medline].

  13. Martins-Oliveira A, Speciali JG, Dach F, Marcaccini AM, Gonçalves FM, Gerlach RF, et al. Different circulating metalloproteinases profiles in women with migraine with and without aura. Clin Chim Acta. Oct 2009;408(1-2):60-4. [Medline].

  14. Imamura K, Takeshima T, Fusayasu E, Nakashima K. Increased plasma matrix metalloproteinase-9 levels in migraineurs. Headache. Jan 2008;48(1):135-9. [Medline].

  15. Piilgaard H, Lauritzen M. Persistent increase in oxygen consumption and impaired neurovascular coupling after spreading depression in rat neocortex. J Cereb Blood Flow Metab. Sep 2009;29(9):1517-27. [Medline].

  16. Burstein R, Yarnitsky D, Goor-Aryeh I, Ransil BJ, Bajwa ZH. An association between migraine and cutaneous allodynia. Ann Neurol. May 2000;47(5):614-24. [Medline].

  17. Peroutka SJ. Dopamine and migraine. Neurology. Sep 1997;49(3):650-6. [Medline].

  18. Napoli R, Guardasole V, Zarra E, Matarazzo M, D'Anna C, Saccà F, et al. Vascular smooth muscle cell dysfunction in patients with migraine. Neurology. Jun 16 2009;72(24):2111-4. [Medline].

  19. Gruber HJ, Bernecker C, Lechner A, Weiss S, Wallner-Blazek M, Meinitzer A, et al. Increased nitric oxide stress is associated with migraine. Cephalalgia. Apr 2010;30(4):486-92. [Medline].

  20. Tietjen GE, Herial NA, White L, Utley C, Kosmyna JM, Khuder SA. Migraine and biomarkers of endothelial activation in young women. Stroke. Sep 2009;40(9):2977-82. [Medline].

  21. Minson CT, Green DJ. Measures of vascular reactivity: prognostic crystal ball or Pandora's box?. J Appl Physiol. Aug 2008;105(2):398-9. [Medline].

  22. Hamed SA. The vascular risk associations with migraine: relation to migraine susceptibility and progression. Atherosclerosis. Jul 2009;205(1):15-22. [Medline].

  23. Bigal ME, Lipton RB. Excessive acute migraine medication use and migraine progression. Neurology. Nov 25 2008;71(22):1821-8. [Medline].

  24. Kors EE, Haan J, Ferrari MD. Genetics of primary headaches. Curr Opin Neurol. Jun 1999;12(3):249-54. [Medline].

  25. Ferrari MD. Heritability of migraine. Neurology. 2003;60(7):S15-20.

  26. Kahlig KM, Rhodes TH, Pusch M, Freilinger T, Pereira-Monteiro JM, Ferrari MD, et al. Divergent sodium channel defects in familial hemiplegic migraine. Proc Natl Acad Sci U S A. Jul 15 2008;105(28):9799-804. [Medline]. [Full Text].

  27. Stam AH, Haan J, van den Maagdenberg AM, Ferrari MD, Terwindt GM. Migraine and genetic and acquired vasculopathies. Cephalalgia. Sep 2009;29(9):1006-17. [Medline].

  28. Allais G, Gabellari IC, De Lorenzo C, Mana O, Benedetto C. Oral contraceptives in migraine. Expert Rev Neurother. Mar 2009;9(3):381-93. [Medline].

  29. MacGregor EA. Menstrual migraine. Curr Opin Neurol. Jun 2008;21(3):309-15. [Medline].

  30. Klein E, Spencer D. Migraine frequency and risk of cardiovascular disease in women. Neurology. Aug 25 2009;73(8):e42-3. [Medline].

  31. Woodward M. Migraine and the risk of coronary heart disease and ischemic stroke in women. Womens Health (Lond Engl). Jan 2009;5(1):69-77. [Medline].

  32. Bushnell CD, Jamison M, James AH. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study. BMJ. Mar 10 2009;338:b664. [Medline]. [Full Text].

  33. Scher AI, Gudmundsson LS, Sigurdsson S, Ghambaryan A, Aspelund T, Eiriksdottir G, et al. Migraine headache in middle age and late-life brain infarcts. JAMA. Jun 24 2009;301(24):2563-70. [Medline].

  34. Kruit MC, Launer LJ, Overbosch J, van Buchem MA, Ferrari MD. Iron accumulation in deep brain nuclei in migraine: a population-based magnetic resonance imaging study. Cephalalgia. Mar 2009;29(3):351-9. [Medline].

  35. Welch KM. Iron in the migraine brain; a resilient hypothesis. Cephalalgia. Mar 2009;29(3):283-5. [Medline].

  36. Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology. Mar 26 2002;58(6):885-94. [Medline].

  37. Stewart WF, Linet MS, Celentano DD, Van Natta M, Ziegler D. Age- and sex-specific incidence rates of migraine with and without visual aura. Am J Epidemiol. Nov 15 1991;134(10):1111-20. [Medline].

  38. Hsu LC, Wang SJ, Fuh JL. Prevalence and impact of migrainous vertigo in mid-life women: a community-based study. Cephalalgia. Jan 2011;31(1):77-83. [Medline].

  39. Wilper A, Woolhandler S, Himmelstein D, Nardin R. Impact of insurance status on migraine care in the United States: a population-based study. Neurology. Apr 13 2010;74(15):1178-83. [Medline].

  40. Burton WN, Landy SH, Downs KE, Runken MC. The impact of migraine and the effect of migraine treatment on workplace productivity in the United States and suggestions for future research. Mayo Clin Proc. May 2009;84(5):436-45. [Medline]. [Full Text].

  41. Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology. Nov 27 2001;57(10):1805-11. [Medline].

  42. Kruit MC, Launer LJ, Ferrari MD, van Buchem MA. Infarcts in the posterior circulation territory in migraine. The population-based MRI CAMERA study. Brain. Sep 2005;128:2068-77. [Medline].

  43. Bigal ME, Kurth T, Hu H, Santanello N, Lipton RB. Migraine and cardiovascular disease: possible mechanisms of interaction. Neurology. May 26 2009;72(21):1864-71. [Medline]. [Full Text].

  44. Scher AI, Terwindt GM, Picavet HS, Verschuren WM, Ferrari MD, Launer LJ. Cardiovascular risk factors and migraine: the GEM population-based study. Neurology. Feb 22 2005;64(4):614-20. [Medline].

  45. Kurth T, Schürks M, Logroscino G, Buring JE. Migraine frequency and risk of cardiovascular disease in women. Neurology. Aug 25 2009;73(8):581-8. [Medline]. [Full Text].

  46. Bigal ME, Kurth T, Santanello N, Buse D, Golden W, Robbins M, et al. Migraine and cardiovascular disease: a population-based study. Neurology. Feb 23 2010;74(8):628-35. [Medline].

  47. Gudmundsson LS, Scher AI, Aspelund T, Eliasson JH, Johannsson M, Thorgeirsson G, et al. Migraine with aura and risk of cardiovascular and all cause mortality in men and women: prospective cohort study. BMJ. Aug 24 2010;341:c3966. [Medline]. [Full Text].

  48. Le H, Tfelt-Hansen P, Russell MB, Skytthe A, Kyvik KO, Olesen J. Co-morbidity of migraine with somatic disease in a large population-based study. Cephalalgia. Jan 2011;31(1):43-64. [Medline].

  49. Loder E. Migraine with aura and increased risk of ischaemic stroke. BMJ. Oct 27 2009;339:b4380. [Medline].

  50. Kurth T, Kase CS, Schürks M, Tzourio C, Buring JE. Migraine and risk of haemorrhagic stroke in women: prospective cohort study. BMJ. Aug 24 2010;341:c3659. [Medline]. [Full Text].

  51. Harling DW, Peatfield RC, Van Hille PT, Abbott RJ. Thunderclap headache: is it migraine?. Cephalalgia. Jun 1989;9(2):87-90. [Medline].

  52. Forsyth PA, Posner JB. Headaches in patients with brain tumors: a study of 111 patients. Neurology. Sep 1993;43(9):1678-83. [Medline].

  53. Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging?. JAMA. Sep 13 2006;296(10):1274-83. [Medline].

  54. Sahai-Srivastava S, Desai P, Zheng L. Analysis of headache management in a busy emergency room in the United States. Headache. Jun 2008;48(6):931-8. [Medline].

  55. Friedman BW, Solorzano C, Esses D, Xia S, Hochberg M, Dua N, et al. Treating headache recurrence after emergency department discharge: a randomized controlled trial of naproxen versus sumatriptan. Ann Emerg Med. Jul 2010;56(1):7-17. [Medline]. [Full Text].

  56. Kelman L. Women's issues of migraine in tertiary care. Headache. Jan 2004;44(1):2-7. [Medline].

  57. Derry S, Moore RA, McQuay HJ. Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev. Nov 10 2010;CD008040. [Medline].

  58. Matchar DB. Acute management of migraine: highlights of the US Headache Consortium. Neurology. 60(7):S21-3.

  59. Friedman BW, Mulvey L, Esses D, et al. Metoclopramide for acute migraine: a dose-finding randomized clinical trial. Ann Emerg Med. May 2011;57(5):475-482.e1. [Medline].

  60. Dowson AJ, Mathew NT, Pascual J. Review of clinical trials using early acute intervention with oral triptans for migraine management. Int J Clin Pract. Jun 2006;60(6):698-706. [Medline].

  61. Pierce M, Marbury T, O'Neill C, Siegel S, Du W, Sebree T. Zelrix: a novel transdermal formulation of sumatriptan. Headache. Jun 2009;49(6):817-25. [Medline].

  62. [Best Evidence] Brandes JL, Kudrow D, Stark SR, O'Carroll CP, Adelman JU, O'Donnell FJ, et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA. Apr 4 2007;297(13):1443-54. [Medline].

  63. [Guideline] American Academy of Neurology. Practice parameter: appropriate use of ergotamine tartrate and dihydroergotamine in the treatment of migraine and status migrainosus (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Mar 1995;45(3 Pt 1):585-7. [Medline].

  64. [Best Evidence] Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. Jul 2010;56(1):1-6. [Medline].

  65. Silberstein SD, Freitag FG. Preventative treatment of migraine. Neurology. 2003;60(7):S38-44.

  66. Belotti EA, Taddeo I, Ragazzi M, Pifferini R, Simonetti GD, Bianchetti MG, et al. Chronic impact of topiramate on acid-base balance and potassium in childhood. Eur J Paediatr Neurol. Sep 2010;14(5):445-8. [Medline].

  67. Krymchantowski AV, Jevoux C, Moreira PF. An open pilot study assessing the benefits of quetiapine for the prevention of migraine refractory to the combination of atenolol, nortriptyline, and flunarizine. Pain Med. Jan 2010;11(1):48-52. [Medline].

  68. Brandes JL, Saper JR, Diamond M, Couch JR, Lewis DW, Schmitt J, et al. Topiramate for migraine prevention: a randomized controlled trial. JAMA. Feb 25 2004;291(8):965-73. [Medline].

  69. Mathew NT, Rapoport A, Saper J, Magnus L, Klapper J, Ramadan N, et al. Efficacy of gabapentin in migraine prophylaxis. Headache. Feb 2001;41(2):119-28. [Medline].

  70. Tronvik E, Stovner LJ, Helde G, Sand T, Bovim G. Prophylactic treatment of migraine with an angiotensin II receptor blocker: a randomized controlled trial. JAMA. Jan 1 2003;289(1):65-9. [Medline].

  71. Schrader H, Stovner LJ, Helde G, Sand T, Bovim G. Prophylactic treatment of migraine with angiotensin converting enzyme inhibitor (lisinopril): randomised, placebo controlled, crossover study. BMJ. Jan 6 2001;322(7277):19-22. [Medline]. [Full Text].

  72. Conway S, Delplanche C, Crowder J, Rothrock J. Botox therapy for refractory chronic migraine. Headache. Apr 2005;45(4):355-7. [Medline].

  73. Schulte-Mattler WJ, Martinez-Castrillo JC. Botulinum toxin therapy of migraine and tension-type headache: comparing different botulinum toxin preparations. Eur J Neurol. Feb 2006;13 Suppl 1:51-4. [Medline].

  74. Dodick DW, Turkel CC, DeGryse RE, Aurora SK, Silberstein SD, Lipton RB, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. Jun 2010;50(6):921-36. [Medline].

  75. Edwards KR, Norton J, Behnke M. Comparison of intravenous valproate versus intramuscular dihydroergotamine and metoclopramide for acute treatment of migraine headache. Headache. Nov-Dec 2001;41(10):976-80. [Medline].

  76. von Peter S, Ting W, Scrivani S, Korkin E, Okvat H, Gross M, et al. Survey on the use of complementary and alternative medicine among patients with headache syndromes. Cephalalgia. Jun 2002;22(5):395-400. [Medline].

  77. Lipton RB, Göbel H, Einhäupl KM, Wilks K, Mauskop A. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology. Dec 28 2004;63(12):2240-4. [Medline].

  78. Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology. Feb 1998;50(2):466-70. [Medline].

  79. Ferrari MD, Odink J, Tapparelli C, Van Kempen GM, Pennings EJ, Bruyn GW. Serotonin metabolism in migraine. Neurology. Sep 1989;39(9):1239-42. [Medline].

  80. Linde K, Vickers A, Hondras M, ter Riet G, Thormählen J, Berman B, et al. Systematic reviews of complementary therapies - an annotated bibliography. Part 1: acupuncture. BMC Complement Altern Med. 2001;1:3. [Medline]. [Full Text].

  81. Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. J Psychosom Res. Jan 2010;68(1):29-36. [Medline].

  82. Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical treatment of migraine headaches. Plast Reconstr Surg. Jan 2005;115(1):1-9. [Medline].

  83. Dirnberger F, Becker K. Surgical treatment of migraine headaches by corrugator muscle resection. Plast Reconstr Surg. Sep 1 2004;114(3):652-7; discussion 658-9. [Medline].

  84. Tepper SJ. Complementary and alternative treatments for childhood headaches. Curr Pain Headache Rep. Oct 2008;12(5):379-83. [Medline].

  85. Busch V, Gaul C. Exercise in migraine therapy--is there any evidence for efficacy? A critical review. Headache. Jun 2008;48(6):890-9. [Medline].

  86. Durham PL, Garrett FG. Neurological mechanisms of migraine: potential of the gap-junction modulator tonabersat in prevention of migraine. Cephalalgia. Nov 2009;29 Suppl 2:1-6. [Medline].

  87. Ho TW, Ferrari MD, Dodick DW, Galet V, Kost J, Fan X, et al. Efficacy and tolerability of MK-0974 (telcagepant), a new oral antagonist of calcitonin gene-related peptide receptor, compared with zolmitriptan for acute migraine: a randomised, placebo-controlled, parallel-treatment trial. Lancet. Dec 20 2008;372(9656):2115-23. [Medline].

  88. Farinelli I, De Filippis S, Coloprisco G, Missori S, Martelletti P. Future drugs for migraine. Intern Emerg Med. Oct 2009;4(5):367-73. [Medline].

  89. Imitrex (sumatriptan succinate) injection. Prescribing Information. GlaxoSmithKline. February 2010. [Full Text].

  90. Imitrex (sumatriptan) Nasal Spray. Prescribing Information. GlaxoSmithKline. February 2010. [Full Text].

  91. Imitrex (sumatriptan succinate) tablets. Prescribing Information. GlaxoSmithKline. February 2010. [Full Text].

 
Previous
Next
 
Migraine headache. Example of a visual migraine aura as described by a person who experiences migraines. This patient reported that these visual auras preceded her headache by 20-30 minutes.
Migraine headache. Example of a central scotoma as described by a person who experiences migraines. Note the visual loss in the center of vision.
Migraine headache. Example of a central scotoma as described by a person who experiences migraine headaches. Again note the visual loss in the center of vision.
Migraine headache. Example of visual changes during migraine. Multiple spotty scotomata are described by a person who experiences migraines.
Migraine headache. Frank visual field loss can also occur associated with migraine. This example shows loss of the entire right visual field as described by a person who experiences migraines.
International Headache Society criteria for migraine.
Overview of migraine treatment. Five steps.
International Headache Society (IHS) classification of secondary headaches.
Table 1. Abortive Medication Stratification by Headache Severity
Moderate Severe Extremely Severe
NSAIDsNaratriptanDHE (IV)
IsomethepteneRizatriptanOpioids
ErgotamineSumatriptan (SC,NS)Dopamine antagonists
NaratriptanZolmitriptan
RizatriptanAlmotriptan
SumatriptanFrovatriptan
ZolmitriptanEletriptan
AlmotriptanDHE (NS/IM)
FrovatriptanErgotamine
EletriptanDopamine antagonists
Dopamine antagonists
Table 2. Preventive Drugs
First lineHigh efficacyBeta-blockers



Tricyclic antidepressants



Divalproex



Topiramate



Low efficacyVerapamil



NSAIDs



SSRIs



Second lineHigh efficacyMethysergide



Flunarizine



MAOIs



Unproven efficacyCyproheptadine



Gabapentin



Lamotrigine



Table 3. Preventive Medication for Comorbid Conditions
Comorbid Condition Medication
HypertensionBeta-blockers
AnginaBeta-blockers
StressBeta-blockers
DepressionTricyclic antidepressants, SSRIs
UnderweightTricyclic antidepressants
EpilepsyValproic acid, Topiramate
ManiaValproic acid
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.