Chapter 20-14: Migraine Headaches

TEXTBOOK PRESENTATION

Migraines most often first present in women in their teens or 20s. The headaches are unilateral and throbbing and are severe enough to make it impossible to do work during an attack. They are occasionally preceded by about 20 minutes of flickering lights in a visual field (aura). Patients often find it necessary to lie in a dark, quiet room.

DISEASE HIGHLIGHTS

1. The description of migraine headaches adopted by the IHS is, “Recurring headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea, and/or photophobia and phonophobia.”

2. Migraine headaches are a chronic headache syndrome caused by a neurovascular disorder. Neural events lead to intracranial vasodilatation.

3. They may begin at any age but most commonly begin during adolescence.

4. They are more common (2–3 times) and more severe in women than men.

5. Auras can accompany migraines.

   1. About one-third of patients with migraines have auras.

   2. Auras are usually visual, precede the headache, and last for about 20 minutes.

   3. Descriptions of auras

      1. Frequently, patients initially describe a blind spot that is later accompanied by “scintillating scotoma” (flashing lights, spots of light, zigzag lines, or squiggles).

      2. Auras usually involve 1 portion of the visual field.

      3. Common qualities of auras and their frequencies are listed in Table 20-2.

Migraine auras are stereotypical. Listening closely to patients with migraines describe their aura will make it easy to recognize auras in other patients.

EVIDENCE-BASED DIAGNOSIS

1. Migraine headaches are among the most severe of all the recurrent headache syndromes. (Cluster headache is the other primary headache that causes severe pain.)

   1. They should be considered in any patient with headaches severe enough to be the chief concern at a doctor visit.

   2. Of initial visits for headaches in the primary care setting, 90% meet criteria for migraines.

The diagnosis of migraine headache should be seriously considered in any patient who has recurrent headaches that cause disability.

2. As with other primary headaches, diagnosis is guided by the IHS’s diagnostic criteria rather than by diagnostic tests.

3. The criteria for migraines are divided into migraines with and without aura.

   1. Migraine without aura

      1. A patient must have at least 5 attacks that last 4–72 hours.

      2. The headache must have 2 of the following ...