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BASICS

Description

  • Recurrent headaches lasting 4–72 hours.
  • Typical features: unilateral location, pulsating quality, moderate to severe intensity.
  • Associated symptoms: nausea, photophobia, phonophobia.
  • Subtypes:
  • Without aura (>80%)
  • With aura: visual, motor, sensory, or brainstem symptoms, reversible, last <60 minutes.
  • Chronic migraine: >15 days/month for >3 months.
  • Menstrual and menstrually related migraine.
  • Rare types: status migrainosus (>72 hours), prolonged aura (>60 minutes), ocular migraine, vertiginous migraine, acephalgic migraine.

Epidemiology

  • Female predominance 3:1.

  • 28 million affected Americans.

Etiology and Pathophysiology

  • Trigeminovascular system activation → release of substance P, CGRP → vasodilation and neurogenic inflammation.
  • Cortical spreading depression explains aura.

  • 80% have family history.

Risk Factors

  • Female sex (especially menstrual cycle related)
  • Family history
  • Triggers: sleep disruption, skipped meals, alcohol, chocolate, cheese, caffeine overuse, MSG, artificial sweeteners.
  • Medications: estrogens, vasodilators.

General Prevention

  • Lifestyle: sleep hygiene, stress management, healthy diet, hydration, exercise.
  • Prophylactic medications for frequent attacks.

Associated Conditions

  • Depression, anxiety, PTSD
  • Sleep disturbances (including sleep apnea)
  • Cerebrovascular disease
  • Seizure disorders
  • Irritable bowel syndrome
  • Other pain syndromes

DIAGNOSIS

History

  • Use ID Migraine screening tool: nausea, photophobia, disability.
  • Headache usually unilateral (30-40% bilateral), throbbing (40% non-throbbing), 4–72 hours.
  • Aggravated by movement, associated with nausea, vomiting, photophobia, phonophobia, vertigo.
  • Aura symptoms may precede headache.
  • Maintain headache diary for frequency and triggers.

Physical Exam

  • Neurologic exam including funduscopy to rule out other causes.
  • Look for cerebellar signs, motor loss, papilledema.

Differential Diagnosis

  • Other primary headaches (IIH, TAC)
  • Secondary headaches (medication overuse, tumor, infection, vascular disorders)

Diagnostic Tests

  • Neuroimaging (MRI/CT) if atypical or red flags (age >50, changed pattern, progressive symptoms).
  • Evaluate systemic causes as clinically indicated.

TREATMENT

General Measures

  • Consistent sleep and eating patterns.
  • Cold compresses.

Medications

Abortive Therapy

  • Mild-moderate: acetaminophen (± metoclopramide), NSAIDs, aspirin-acetaminophen-caffeine.
  • Moderate-severe: triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan, frovatriptan, eletriptan).
  • Antiemetics as adjuncts.
  • Avoid triptans/ergots in coronary artery disease, uncontrolled hypertension.

Second-line Abortive

  • Ubrogepant, rimegepant (CGRP receptor antagonists)
  • Dihydroergotamine for status migrainosus or triptan failure.
  • Lasmiditan (5-HT1F agonist; caution with driving).

Preventive Therapy

  • Consider if ≥6 headache days/month or severe impairment.
  • Options: divalproex, topiramate, beta-blockers (metoprolol, propranolol), amitriptyline, venlafaxine, lisinopril, candesartan.
  • NSAIDs for predictable triggers.
  • CGRP monoclonal antibodies: erenumab, fremanezumab, galcanezumab, eptinezumab.
  • CGRP small molecules: rimegepant, atogepant.
  • OnobotulinumtoxinA for chronic migraine.

Referral

  • For unclear diagnosis, refractory cases, or comorbidities.

Complementary Medicine

  • Riboflavin 400 mg/day
  • Magnesium 400 mg/day
  • Feverfew (MIG-99)
  • Acupuncture

ONGOING CARE

Follow-Up

  • Frequent visits for uncontrolled headache.
  • Use headache diary.
  • Migraine with aura increases stroke risk; assess and reduce vascular risk factors.

Patient Education

  • Identify and avoid triggers.
  • Set realistic expectations for prophylactic medications.

Prognosis

  • Severity and frequency often reduce with age and menopause.
  • Most attacks resolve within 72 hours.

Complications

  • Status migrainosus (>72 hours)
  • Medication-overuse headache (MOH)
  • Rare cerebral ischemic events

Clinical Pearls

  • Migraine is chronic with unclear etiology.
  • Use migraine-specific abortive meds if OTC analgesics fail.
  • Avoid frequent use of opioids, barbiturates, or triptans to prevent MOH.
  • Prophylactic treatment recommended for frequent, debilitating attacks.

References

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
  2. Sacco S, Merki-Feld GS, Ægidius KL, et al. Hormonal contraceptives and risk of ischemic stroke in women with migraine: consensus statement. J Headache Pain. 2017;18(1):108.
  3. Loder E, Weizenbaum E, Frishberg B, et al. Choosing wisely in headache medicine: American Headache Society list. Headache. 2013;53(10):1651-1659.
  4. Patterson-Gentile C, Szperka CL. Pediatric migraine therapy review. JAMA Neurol. 2018;75(7):881-887.
  5. Becker WJ. Acute migraine treatment in adults. Headache. 2015;55(6):778-793.
  6. Loder E, Burch R, Rizzoli P. 2012 AHS/AAN guidelines for prevention of episodic migraine: summary. Headache. 2012;52(6):930-945.