eMedicine Specialties > Emergency Medicine > Neurology

Headache, Migraine

Author: Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Coauthor(s): Jeff T Wright, MD, Instructor, Department of Emergency Medicine, Summa Health System; Corporation President and Consulting Staff, Summa Emergency Associates, Inc
Contributor Information and Disclosures

Updated: Sep 28, 2009

Introduction

Background

Migraine headaches are recurrent headaches that may be unilateral or bilateral. Migraine headaches may occur with or without a prodrome. The aura of a migraine may consist of neurologic symptoms, such as dizziness, tinnitus, scotomas, photophobia, or visual scintillations (eg, bright zigzag lines). The International Headache Society (IHS) redefined and classified headaches to formulate the current categorization, which has been maintained in the second edition.1 The headache previously described as classic migraine is now known as migraine with aura, and that described as common migraine is now termed migraine without aura. Migraines without aura are the most common, accounting for more than 80% of all migraines.

In April 2000, the US Headache Consortium, a multispecialty group that includes the American College of Emergency Physicians, released evidence-based guidelines for the diagnosis, treatment, and prevention of migraine headaches. Guidelines are also available from the American Academy of Neurology, the National Headache Foundation, and the Canadian Association of Emergency Physicians.2,3,4

Pathophysiology

The pathophysiology of migraine headaches is not clearly understood. Initially migraine headaches were felt to be of vascular origin. Evidence now supports a neurogenic cause, with neurogenic peptides, such as serotonin and dopamine, as a cause.5 These vasoactive neuropeptides stimulate an inflammatory cascade with the release of endothelial cells, mast cells, and platelets. This inflammation causes vasodilation and a perivascular reaction. The serotonin receptor (5-HT) is believed to be the most important receptor in the headache pathway.

Some of the symptoms associated with migraine headaches, such as nausea (80%), vomiting (50%), yawning, irritability, hypotension, and hyperactivity, can be associated with dopamine receptor activation. Dopamine receptor hypersensitivity has been shown experimentally with dopamine agonists such as apomorphine, bromocriptine, and pergolide. Dopamine antagonists, such as metoclopramide (Reglan), haloperidol (Haldol), and prochlorperazine (Compazine), have been shown clinically to treat migraine headaches effectively.

Frequency

United States

An estimated 10-20% of the US population suffers from migraine headaches. Frequency of headaches varies greatly by individual. An estimated 6% of men and 15-17% of women in the United States have migraine. Migraine is the second most common type of headache syndrome in the United States. Tension headaches are the most common.

Sex

Migraines most commonly are found in women, with a 3:1 female-to-male ratio. In childhood, however, migraines are more common in boys than in girls.

Age

The first attack often is in childhood, and incidence increases in adolescence. More than 80% of patients who develop migraines will have a first attack by age 30. Migraines continue through the patient's 30s and 40s. They may begin or occur at any age but are rare after age 50. With increased age, attacks usually decrease in severity and frequency. Age older than 55 years is a strong predictor for intracranial pathology.

Clinical

History

Moderately severe to severe headache with or without a prodrome

  • Aura (20%) - A variety of preceding events that begins and ends days to hours prior to the headache itself. Visual aura symptoms are most common. Nonspecific prodrome may precede migraine without an aura.
    • Scotoma (blind spots)
    • Fortification (zig-zag patterns)
    • Scintilla (flashing lights)
    • Unilateral paresthesia/weakness
    • Hallucinations
    • Hemianopsia
  • Headache
    • Unilateral, also known as hemicrania (30-40% are bilateral)
    • Throbbing or pulsatile (More than 50% of people who suffer from migraines report nonthrobbing pain at some time during the attack.)
    • Lasts 4-72 hours
  • Systemic manifestations
    • Nausea (80-90%)
    • Vomiting (40-60%)
    • Photophobia (80%)
    • Phonophobia (75-80%)
    • Lightheadedness (70%)
  • The patient might prefer to be in a quiet and darkened room.
  • History factors suggesting a more serious underlying cause of headache
    • The first or worst headache of the patient's life, especially if the headache onset was rapid
    • A change in frequency, severity, or clinical features of the attack from what usually is experienced
    • New progressive headache that persists for days
  • Precipitation of headache with Valsalva maneuvers (ie, coughing, sneezing, bearing down)

Physical

  • Usually, patients have no specific physical findings other than the physical manifestations of the associated systemic symptoms listed above (photophobia, phonophobia); abnormality on physical examination may suggest another cause of headache.
  • The physician must perform a thorough screening neurologic examination.
  • Physical examination findings suggesting a more serious cause of headache include the following:
    • Systemic symptoms (eg, myalgia, fever, malaise, weight loss, scalp tenderness, jaw claudication)
    • Focal neurologic abnormalities or confusion, seizures, or any impairment of level of consciousness
    • Focal neurologic findings that occur with the headache and persist temporarily after the pain resolves suggest a migraine variant. In hemiplegic migraine, the patient may have unilateral paralysis or weakness. Aphasia, syncope, and balance problems may be seen in basilar migraines. In ophthalmoplegic migraine, the patient may present with a third nerve palsy, with ocular muscle paralysis, including or sparing the pupillary response, as well as ptosis. 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.

Causes

Exact etiology is unknown.

  • Family history of migraine headaches (70-80%)
  • Medications (ie, birth control pills, vasodilators)
  • Fatigue or emotional stress
  • Specific foods or alcohol
  • Exertion

More on Headache, Migraine

Overview: Headache, Migraine
Differential Diagnoses & Workup: Headache, Migraine
Treatment & Medication: Headache, Migraine
Follow-up: Headache, Migraine
References
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References

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  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. Available at http://www.aan.com. Accessed October 31, 2007.

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

  6. [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].

  7. Bussone G, Grazzi L, D'Amico D, et al. Acute treatment of migraine attacks: efficacy and safety of a nonsteroidal anti-inflammatory drug, diclofenac-potassium, in comparison to oral sumatriptan and placebo. The Diclofenac- K/Sumatriptan Migraine Study Group. Cephalalgia. May 1999;19(4):232-40. [Medline].

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  17. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol. Dec 1997;54(12):1506-9. [Medline].

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  24. Tfelt-Hansen P. Efficacy and adverse events of subcutaneous, oral, and intranasal sumatriptan used for migraine treatment: a systematic review based on number needed to treat. Cephalalgia. Oct 1998;18(8):532-8. [Medline].

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  26. Thomas SH, Stone CK, Ray VG, et al. Intravenous versus rectal prochlorperazine in the treatment of benign vascular or tension headache: a randomized, prospective, double-blind trial. Ann Emerg Med. Nov 1994;24(5):923-7. [Medline].

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Further Reading

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Keywords

migraine, migraine headache, headache, migraine variant, classic migraine, cluster headache, aura, dizziness, tinnitus, scotomas, photophobia, visual scintillations, bright zigzag lines, migraine with aura, migraine without aura, dopamine receptor hypersensitivity, visual aura, fortification spectra, geometric visual patterns, hemianopsia, blind spots, hallucinations, hemicrania,throbbingheadache, pulsatile headache, lightheadedness, phonophobia, Valsalva maneuvers, hemiplegic migraine, aphasia, third nerve palsy, ophthalmoplegic migraine, ocular muscle paralysis, ptosis, alcohol consumption, fatigue, emotional stress, birth control pills, vasodilators

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Contributor Information and Disclosures

Author

Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; 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.

Coauthor(s)

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.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; 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.

 
 
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