migraine%20headache
MIGRAINE HEADACHE
Treatment Guideline Chart
Migraine headache without aura has at least 5 attacks of any 2 symptoms of unilateral headache that is throbbing or pulsating in nature, moderate to severe in pain and activity aggravates pain. It is accompanied with either nausea and vomiting or photophobia and/or phonophobia. The symptoms last for 4-72 hours without signs of secondary headache.
Migraine headache with aura has at least 2 attacks with any of the fully reversible symptoms of flickering lights, spots or lines and/or vision loss, sensory symptoms of pins and needles and/or numbness and dysphasic speech disturbance but without motor weakness. Accompanied by at least 2 of the following symptoms of homonymous visual symptoms and/or unilateral sensory symptoms or at least 1 aura symptom develops gradually over ≥5 minutes and/or different aura symptoms that occur in succession over ≥5 minutes.

Migraine%20headache Diagnosis

Classification

Diagnostic Criteria

Migraine Headache without Aura1

  • At least 5 attacks with any 2 of the following headache characteristics and should last from 4-72 hours without treatment or had unsuccessful treatments:
    • Unilateral
    • Throbbing or pulsating in nature
    • Pain is considered moderate to severe
    • Usual physical activity (eg walking or climbing stairs) aggravates pain
  • Plus any one of the following symptoms:
    • Nausea and/or vomiting
    • Photophobia and phonophobia
  • Headache is not better accounted for by another International Classification of Headache Disorders (ICHD)-3 diagnosis

Migraine Headache with Aura1

  • Headache with accompanying or preceding transient focal neurological symptoms
  • At least 2 attacks with ≥1 of the following fully reversible aura symptoms:
    • Visual symptoms including positive features (flickering lights, spots or lines) and/or negative features (loss of vision)
    • Sensory symptoms including positive features (pins and needles) and/or negative features (numbness)
    • Speech and/or language (eg dysphasic speech disturbance)
    • Motor
    • Brainstem
    • Retinal
  • At least 3 of the following characteristics:
    • At least 1 aura symptom develops gradually over ≥5 minutes
    • ≥2 aura symptoms that occur in succession
    • Every aura symptom lasts 5-60 minutes (if 3 symptoms occur during an aura, 3 x 60 minutes is the acceptable maximum duration; motor symptoms can last up to 72 hours)
    • ≥1 unilateral aura symptom (eg aphasia)
    • ≥1 positive aura symptom (eg scintillations and pins and needles)
    • Headache occurs with the aura or 60 minutes after the aura
  • Headache is not better accounted for by another ICHD-3 diagnosis

 Chronic Migraine1

  • Headache (tension-type-like or migraine-like) occurring for ≥15 days per month for >3 months with the following characteristics:
    • Attacks last for 4-72 hours (without treatment or had unsuccessful treatment)
    • ≥2 of the following features are present: Unilateral location, pulsating quality, pain is moderate or severe in intensity, aggravated by or resulting to avoidance of routine physical activity (eg walking or climbing stairs)
  • ≥5 attacks fulfilling the following criteria:
    • Presence of headache with ≥2 of the 4 characteristics mentioned in the above diagnostic criteria for migraine headache without aura plus during headache there is a presence of 1 of the symptoms mentioned in the above criteria for migraine headache without aura
    • Presence of ≥1 fully reversible aura symptoms enumerated in the above diagnostic criteria for migraine headache with aura plus ≥3 of the characteristics mentioned in the above criteria for migraine headache with aura
  • On ≥8 days/month for >3 months, the patient has any of the following characteristics:
    • Presence of headache with ≥2 of the characteristics mentioned in the above diagnostic criteria for migraine headache without aura plus having 1 of the following during headache: Nausea and/or vomiting or photophobia and phonophobia
    • Presence of ≥1 fully reversible aura symptoms enumerated in the above diagnostic criteria for migraine headache with aura plus ≥3 of the characteristics mentioned in the above criteria for migraine headache with aura
    • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
  • Headache is not better accounted for by another ICHD-3 diagnosis
1Modified from: Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):18-24.

Diagnosis

Status Migrainosus

  • Usually severe and debilitating migraine headache that requires aggressive treatment
  • Often caused by medication (eg analgesic) overuse
  • Treatment may start with intravenous fluids and electrolyte replacement if indicated
  • Some patients may need hospitalization for rehydration, control of vomiting by giving antiemetics and abortive therapy
  • Abortive therapy includes parenteral triptan without ergot and/or Dihydroergotamine 8-12 hours after the last dosage of triptan
  • Ketorolac intramuscular/intravenous or sodium valproate can be given if Dihydroergotamine or triptan is contraindicated or ineffective

Evaluation

  • Therapy decision is made based on severity of headache

Severity Categories

Moderate

  • Patient is not completely incapacitated but daily activities are greatly hindered by headache

Severe

  • Patient’s daily activities are not performed or they are greatly altered because of headache

Status migrainosus

  • Severe headache that lasts >72 hours

Evaluation to determine if patient should receive migraine prophylactic treatment

  • When indicated, prophylactic treatment should be used in addition to acute therapy

Indication for prophylactic therapy may be based on:

  • Frequency of attacks is ≥4 days per month
  • Patients feel that migraines are significantly interfering with their normal daily activities even with acute treatment lasting for ≥4 days per month
  • Failure and contraindication of acute therapies
  • Overuse of acute therapy defined as:
    • ≥10 days per month for combination analgesics, ergot derivatives, opioids, triptans, and a combination of drugs from different classes that are not individually overused
    • ≥15 days per month for Paracetamol, non-opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) including Aspirin
  • Adverse effects from acute therapies
  • Patient preference
  • Menstrual migraine
  • Cost of acute therapy
  • Presence of neurologic damage from uncommon migraine types 
  • Duration of individual attacks >24 hours

Assessment

Initial assessment should include but is not limited to:

  • Detailed history
    • Headache characteristics (nature of pain, severity, location, frequency, duration)
    • Functional impairment
      • Assessment of impact on patient’s life and lifestyle is necessary for planning the best management and may be done using the Migraine Disability Assessment (MIDAS) instrument or Headache-attributed Lost Time (HALT) indices which estimates the total productive time lost due to the disabling effect of headache
    • Accompanying symptoms
    • Past medical history
    • Family history of migraines
    • Social history
    • Medical history
  • Thorough physical and neurological examination

Any of the following signs and symptoms may suggest secondary headache:

  • Symptoms suggesting systemic illness (eg fever)
  • Any other neurological signs or symptoms (focal or non-focal)
  • Most severe headache ever experienced by patient
  • Persistent or progressive worsening of headache
  • Change in usual headache pattern
  • Awakening of patient from sleep
  • New onset in patient >50 years of age
  • Valsalva maneuver (eg sneezing, coughing, bending forward or lying down or exertion) precipitates headache
  • Seizures
  • Maximum severity at onset of headache
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