Headache, Migraine

Key Features

Essentials of Diagnosis

• Headache, usually pulsatile, lasting 4 to 72 hours

• Pain typically, but not always, unilateral

• May be accompanied by

  • Nausea

  • Vomiting

  • Photophobia

  • Phonophobia

• Pain is aggravated with routine physical activity

• Classically, an aura of transient neurologic symptoms (typically visual) may precede head pain

• Commonly, head pain occurs with no aura

General Considerations

• Pathophysiology of migraine probably relates to neuronal dysfunction in the trigeminal system resulting in release of vasoactive neuropeptides such as calcitonin gene-related peptide leading to neurogenic inflammation, sensitization, and headache

• Migraine aura is hypothesized to result from cortical spreading depression, a wave of neuronal and glial depolarization that moves slowly across the cerebral cortex corresponding to the clinical symptoms (ie, occipital cortex and visual aura)

Demographics

• Migraine often exhibits a complex, polygenic pattern of inheritance

• Sometimes, an autosomal dominant inheritance pattern is apparent, as in familial hemiplegic migraine (FHM), in which attacks of lateralized weakness represent the aura

Clinical Findings

Symptoms and Signs

Typical migraine

• May be lateralized or generalized

• May be dull or throbbing

• Sometimes associated with

  • Anorexia, nausea, vomiting

  • Photophobia, phonophobia, osmophobia

  • Cognitive impairment

  • Blurring of vision

• Usually builds up gradually and may last for several hours or longer

• Visual disturbances occur quite commonly and may consist of

  • Field defects

  • Luminous visual hallucinations, such as stars, sparks, unformed light flashes (photopsia), geometric patterns, or zigzags of light

  • Some combination of field defects and luminous hallucinations (scintillating scotomas)

• Migraine with aura may be a risk factor for stroke

• Other focal disturbances

  • Aphasia or numbness

  • Paresthesias

  • Clumsiness

  • Dysarthria

  • Dysequilibrium

  • Weakness in a circumscribed distribution

Common migraine

• Commonly bilateral and periorbital

• Visual disturbances and other focal neurologic deficits do not occur

Basilar artery migraine

• Blindness or disturbances throughout both visual fields are accompanied or followed by

  • Dysarthria

  • Dysequilibrium

  • Tinnitus

  • Perioral and distal paresthesias

• Blindness or visual disturbances sometimes followed by

  • Transient loss or impairment of consciousness or a confusional state

  • This, in turn, is followed by a throbbing (usually occipital) headache, often with nausea and vomiting

Ophthalmoplegic migraine

• Lateralized pain, often about the eye, is accompanied by

  • Nausea

  • Vomiting

  • Diplopia due to transient external ophthalmoplegia

• Due to third nerve palsy, sometimes with accompanying sixth nerve involvement, and may outlast the orbital pain by several days or even weeks

• Ophthalmic division of the fifth nerve has also been affected in some patients

Migraine equivalent

• In rare instances, the neurologic or somatic disturbance accompanying typical migrainous headaches becomes the sole manifestation of an attack without headaches occurring ("migraine equivalent")

Familial hemiplegic migraine (FHM)