migraine%20headache
MIGRAINE HEADACHE
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 &/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 &/or vision loss, sensory symptoms of pins & needles &/or numbness and dysphasic speech disturbance but without motor weakness. Accompanied by at least 2 of the following symptoms of homonymous visual symptoms &/or unilateral sensory symptoms or at least 1 aura symptoms develop gradually over ≥5 minutes &/or different aura symptoms that occur in succession over ≥5 minutes.

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 accounted for by another disorder

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:
    • 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 accounted for by another disorder

 Chronic Migraine1

  • Headache (tension-type-like and/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:
    • For migraine without aura having ≥2 of the following characteristics: Unilateral location, pulsating quality, pain is moderate to severe in intensity, aggravated by or resulting to avoidance of routine physical activity plus 1 of the following: Nausea and/or vomiting or photophobia and phonophobia
    • For migraine with aura having ≥1 fully reversible aura symptoms are present:Visual, sensory, speech and/or language, motor, brainstem or retinal plus ≥3 of the following features: At least 1 aura symptom develops gradually over ≥5 minutes, ≥2 aura symptoms that occur in succession, each aura symptom lasts 5-60 minutes, ≥1 unilateral aura symptom, ≥1 positive aura symptom, aura is accompanied or followed within 60 minutes by headache
  • On ≥8 days/month for >3 months, the patient has any of the following characteristics:
    • For migraine without aura having ≥2 of the following characteristics: Unilateral location, pulsating quality, pain is moderate to severe in intensity, aggravated by or resulting to avoidance of routine physical activity plus 1 of the following: Nausea and/or vomiting or photophobia and phonophobia
    • For migraine with aura having ≥1 fully reversible aura symptoms are present: Visual, sensory, speech and/or language, motor, brainstem or retinal plus ≥3 of the following features: At least 1 aura symptom develops gradually over ≥5 minutes, ≥2 aura symptoms that occur in succession, each aura symptom lasts 5-60 minutes, ≥1 unilateral aura symptom, ≥1 positive aura symptom, aura is accompanied or followed within 60 minutes by headache
    • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
  • Headache is not accounted for by another disorder
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
    • 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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