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For further information, see CMDT Part 24-01: Headache

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)


  • 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

Migraine with brainstem aura

  • 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

Recurrent painful ophthalmoplegic neuropathy (formerly 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 aura without headache

  • In rare instances, the neurologic or somatic disturbance accompanying typical migrainous headaches becomes the ...

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