Introduction
Background
This complex, recurrent headache disorder is one of the most common complaints in medicine today. The term migraine is derived from the Greek word hemikrania. Later, this term was corrupted into low Latin as hemigranea, which eventually was accepted by the French translation as migraine. A typical episode is characterized by unilateral head pain that may be preceded by various prodromal symptoms. Other focal neurologic symptoms, collectively known as an aura, may also precede or coincide with the onset of a headache.
Although many more headache types are listed in the International Classification of Headache Disorders (ICHD) by the International Headache Society (IHS), the following are the most often encountered in practice, with migraine being the most challenging:
- Migraine without aura
- Probable migraine without aura
- Migraine with aura
- Probable migraine with aura
- Chronic migraine
- Chronic migraine associated with analgesic overuse
- Tension-type headache
- Cluster headache
- Chronic daily headache
Pathophysiology
Historically, migraine has been associated with fluctuations in cerebral perfusion. Investigations show areas of hypoperfusion preceding the onset of a headache, followed by a period of reactive hyperperfusion and eventual normalization of flow.
Current theories advocate a primarily neurogenic phenomenon related to changes in neuropeptide levels of serotonin and dopamine. Certain symptomatic and prophylactic agents are effective in part through binding at specific serotonin (5-hydroxytryptamine [5-HT]) binding sites. Signs and symptoms (eg, anorexia, nausea, vomiting, pallor, yawning) respond to dopaminergic antagonists. The concept of an altered migrainous threshold in individual patients has been advocated. Imbalances in inhibitory and excitatory neuronal pathways may sensitize the trigeminovascular system and provoke a migraine event.
Frequency
United States
Recent epidemiologic studies indicate that 23 million Americans, approximately 18% of females and 6% of males, will have one or more migraine headaches per year. Migraine accounts for 64% of all females and 43% of all males with severe headache.
Mortality/Morbidity
Migraine continues to be a major health problem.
- In the American Migraine Study, more than 85% of women and 82% of men with severe migraine had some headache-related disability.
- Estimated lost productivity is $1-13 billion a year.
- Migraineur males required 3.8 bed rest days per year, whereas women required 5.6 bed rest days per year.
Race
- A recent study showed that among women, 20.4% of Caucasians, 16.2% of African Americans, and only 9.2% of Asian Americans met IHS criteria for migraine.
- Similarly in males, 8.6% of Caucasians, 7.2% of African Americans, and 4.8% of Asian Americans were considered to have migraine.
Sex
Migraine with aura: Incidence or age of onset appears to peak in patients aged 4-5 years (6.6 per 1000 person-years).
- The age-specific incidence of migraine without aura differs; the highest incidence occurs in persons aged 10-11 years (10.1 per 1,000 person-years). In general, the incidence of migraine in males declines to a low rate by 28-29 years (1.0 per 1,000 person-years).
- The incidence rate of migraine with aura peaks in females aged 12-13 years, 3-4 years before that of migraine without aura.
- Among females, migraine prevalence increased sharply up to age 40 years and gradually declined. The male peak prevalence was slightly less and decreased over a broader age range.
- Data further indicate that migraine is a chronic condition, although prolonged remissions are common. One study showed that 62% of young adults were migraine-free for more than 2 years, but only 40% continued to be migraine-free after 30 years. The severity and frequency of attacks tend to diminish with increasing age. After 15 years, approximately 30% of men and 40% of women no longer had migraine attacks.
Age
In patients younger than 10 years, prevalence appears to be higher in males than in females. After the onset of puberty, migraine is considerably more common in females than in males (3:1).
Clinical
History
The migraine headache is typically a unilateral and throbbing pain, but the features often vary. Migraineurs often experience a bilateral event. The pain can be felt anywhere around the head or neck.
- Prodrome (60%)
- Forewarning of a migraine may occur hours to days before a headache event.
- Although the specific features of the prodrome vary, they tend to be consistent for a given individual and include the following:
- Neurologic symptoms (eg, photophobia, phonophobia, osmophobia)
- Lethargy
- Mental and mood changes (eg, depression, anger, euphoria)
- Polyuria
- Meningismus
- Anorexia
- Constipation or diarrhea
- Aura (10-20%)
- In most cases, the headache follows the aura. However, the two events can occur at the same time, or the aura may develop after the headache is in progress.
- Focal neurologic symptoms, listed below, evolve over a period of 5-15 minutes and last approximately 1 hour:
- Visual (most common)
- Negative scotomas or negative visual phenomena - Homonymous hemianopic or quadrantic field defects, central scotomas, tunnel vision, altitudinal visual defects, or even complete blindness
- Positive visual phenomena or scintillating scotomas (most common migraine aura) - This consists of an absent arc or band of vision with a shimmering or glittering zigzag border and often is combined with photopsias or visual hallucinations that may take various shapes. A highly characteristic syndrome always occurs prior to the headache phase of an attack and is pathognomonic of a classic migraine. It is called a fortification spectrum because the serrated edges of the hallucinated "C" resemble a "fortified town with bastions around it."
- Photophobia
- Photopsia (unformed flashes of light) or simple forms of visual hallucinations occur commonly with positive visual phenomena.
- Motor
- Hemiparesis
- Aphasia
- Headache
- Unilateral (60-70%)
- Typically gradual onset, lasting 4-72 hours
- Usually described as a throbbing or pulsatile type of pain but can evolve into a chronic ache or bandlike pattern
- Associated symptoms
- Anorexia
- Nausea
- Vomiting
- Blurred vision
- Skin pallor
- Photophobia
- Phonophobia
- Lightheadedness
Physical
Evidence of autonomic nervous system involvement can be helpful, although most patients with migraine may exhibit little or no findings. Serial neurologic examinations are recommended.
- Possible findings
- Cranial/cervical muscle tenderness
- Horner syndrome (a constricted pupil on the same side of the headache)
- Conjunctival injection
- Tachycardia/bradycardia
- Hypertension/hypotension
- Hemisensory or hemiparetic deficits (complicated migraine)
- Adie-type (dilated) pupil
Causes
No specific etiology is known. Various precipitants of migraine events have been identified, as follows:- Family history
- Stress
- Excessive or insufficient sleep
- Medications (eg, vasodilators, oral contraceptives)
- Smoking
- Foods and food additives, such as alcohol, caffeine, chocolates, artificial sweeteners (eg, aspartame, saccharin), monosodium glutamate (MSG), citrus fruits, and meats with nitrites
- Foods containing tyramines, such as aged cheese, yogurt, sour cream, chicken livers, sausages, bananas, avocados, canned figs, raisins, peanuts, soy sauce, pickled fish, fresh-baked breads, pork, vinegars, and beans
- Exposure to bright or fluorescent lighting
- Strong odors (eg, perfumes, colognes, petroleum distillates)
- Hormonal changes, such as menstruation (common), pregnancy, and ovulation
- Head trauma
- Weather changes
- Metabolic or infectious diseases
- Physical exertion or fatigue
- Motion sickness
- Cold-stimulus (eg, ice cream headaches)
More on Headache, Migraine |
 Overview: Headache, Migraine |
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| Treatment & Medication: Headache, Migraine |
| Follow-up: Headache, Migraine |
| References |
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References
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Jackson CM. Effective headache management. Strategies to help patients gain control over pain. Postgrad Med. Nov 1998;104(5):133-6, 139-40, 143-7. [Medline].
Saper JR. Diagnosis and symptomatic treatment of migraine. Headache. 1997;37 Suppl 1:S1-14. [Medline].
Stewart WF, Linet MS, Celentano DD, et al. Age- and sex-specific incidence rates of migraine with and without visual aura. Am J Epidemiol. Nov 15 1991;134(10):1111-20. [Medline].
Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. Relation to age, income, race, and other sociodemographic factors. JAMA. Jan 1 1992;267(1):64-9. [Medline].
Troost BT. Botulinum toxin type A (Botox) in the treatment of migraine and other headaches. Expert Rev Neurother. Jan 2004;4(1):27-31. [Medline].
Further Reading
Keywords
migraine headache, migraines, aura, ophthalmoplegic migraine, retinal migraine, migrainous disorder, 5-hydroxytryptamine, 5-HT, dihydroergotamine, DHE, selective serotonin reuptake inhibitor, SSRI, monoamine oxidase inhibitor, MAOI, headache disorder
