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Migraine

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Overview

A migraine is a common primary headache disorder characterised by disabling attacks lasting from 4-72 hours. It can have a severe effect on one’s quality of life and is often underdiagnosed and undertreated. This section will cover two main types of migraine:

  • Migraine with aura – seen in 1/3 of patients
  • Migraine without aura

Episodic migraines occur <15 days per month, chronic migraines occur >15 days per month for >3 months with at least 8 days having features of migraines.

Epidemiology

  • Globally affects 1/7 people
  • Migraine is one of the most common causes of headache in children
  • 2-3 times more common in women
  • Most common between 25-55 years of age
  • Often underdiagnosed

Classification

International Classification of Headache Disorders (ICHD)

  • Migraine with aura
  • Migraine without aura
  • Migraine without headache
  • Hemiplegic migraines – can mimic strokes
  • Complications of migraines e.g. persistent aura without infarction/migraine aura-triggered seizure
  • Probable migraine
  • Episodic syndromes that may be associated with migraine

Risk Factors

  • Family history
  • Female sex
  • Obesity
  • Stress
  • Medication overuse
  • Sleep problems
  • Alcohol consumption
  • Dehydration or missing meals
  • Combined oral contraceptive pill
  • Menstruation
  • Tyramine-rich foods e.g. cheese, chocolate, red wines

Presentation

In migraines, patients usually have a severe and unilateral pulsatile (or throbbing) headache:

  • Attacks usually last from 4-72 hours
  • There may be associated nausea, photophobia, or phonophobia
  • The headaches are usually worse with activity
  • Patients often go to dark and quiet rooms during attacks – reduced ability to function
  • There may be a preceding aura – seen in migraines with aura:
    • Patients may see visual sparkles, flashing lights, or may even lose vision
    • In some cases, patients may even experience numbness/tingling

POUNDing can be useful in remembering the key features of migraines:

  • Pulsatile quality
  • Duration of 4-72 hOurs
  • Unilateral location
  • Nausea/vomiting
  • Disabling intensity

Differential Diagnoses

Ischaemic stroke

  • Can mimic migraine with aura/hemiplegic migraine
  • Migraine with aura usually develops gradually and is fully reversible and usually has no focal neurological deficit

Medicine overuse headache

  • Patient usually taking excess analgesia with headaches becoming worse when stopping them – usually opiates/barbiturates
  • They can co-exist

Tension-type headache (TTH)

  • They can often co-exist and may be hard to differentiate based on clinical features
  • The pain in TTH is usually more diffuse and non-pulsatile

Diagnostic Criteria

Migraine with aura

At least 2 attacks with:

  • One or more fully reversible aura symptom including:
    • Visual symptoms – lines/lights/scotoma
    • Sensory symptoms – pins and needles/numbness
    • Speech and/or language problems – dysphasia
  • At least 3 of the following:
    • At least one aura symptom spreads gradually over at least 5 minutes
    • 2 or more aura symptoms occur in succession
    • Each aura lasts 5-60 minutes
    • At least one aura symptom is unilateral
    • At least one aura symptom is positive
    • The aura is accompanied with/followed within 60 minutes by headache

Migraine without aura

At least 5 attacks with:

  • Headaches lasting 4-72 hours in adults or 2-72 hours in adults
  • At least 2 of the following characteristics:
    • Unilateral nature – more commonly bilateral in children
    • Pulsating/throbbing nature
    • Moderate-sever pain intensity
    • Worsening or causing avoidance of routine activities of daily living
  • At least 1 of:
    • Nausea and/or vomiting
    • Photophobia and/or phonophobia

NICE add that migraines may have auras that are fully reversible, develop over at least 5 minutes and last from 5 minutes to 1 hour.

Management

Acute migraine

  • 1st-line: oral triptan (e.g. sumatriptan) + NSAID/paracetamol
    • Consider intranasal/subcutaneous triptans if oral not tolerated
  • Consider adding metoclopramide even if the absence of nausea/vomiting
  • Urgent referral/admission if patient is in status migrainosus (migraine >72 hours)

Prophylaxis

Consider prophylaxis if 2 or more attacks/month or significant risk of medication overuse headache:

  • 1st-line: propranolol or topiramate
    • Topiramate is teratogenic and can reduce the effectiveness of hormonal contraceptives and should be avoided/used with caution in women of childbearing age

Menstrual-related migraine

  • 1st-line: standard acute treatment (as mentioned above)
  • 2nd-line: if standard acute treatment and lifestyle changes fail consider frovatriptan/zolmitriptan 2 days before or 3 days after bleeding starts

Pregnant patients

  • 1st-line: paracetamol
  • 2nd-line: ibuprofen only in 1st and 2nd trimesters
    • Avoid in 3rd trimester due to the risk of premature closure of ductus arteriosus
  • Consider triptan – sumatriptan is preferred
  • Do not prescribe aspirin or opiates to pregnant/breastfeeding people
  • Review contraception:
    • Migraine with aura is an absolute contraindication to the combined oral contraceptive pill (COCP) due to the increased risk of stroke
    • Hormonal replacement therapy is safe but may make migraines worse

Monitoring and Patient Advice

Monitoring

  • Following treatment for acute migraine, patients should be followed up within 2-8 weeks
  • For prophylaxis, patients are usually followed up every 2-3 weeks
  • After 6-12 months of successful treatment, consider gradual drug withdrawal

Patient Advice

  • Patients should be advised to only use triptans at the start of the headache and not at the start of the aura unless they both arise simultaneously
  • Patients should keep a headache diary and seek help if new signs or symptoms arise
  • Patients should be made aware that improvements may take 4-8 weeks from starting treatment

Complications

  • Reduced functional ability and quality of life
  • Medication overused headache
  • Status migrainosus – migraine lasting >72 hours
  • Progression to chronic migraine
  • Migrainous infarction – aura >60 minutes + evidence of brain infarction
  • Increased risk of ischaemic stroke and possibly haemorrhagic stroke
    • Ischaemic stroke risk is higher in people using the COCP, therefore it is contraindicated in people with migraine with aura

Prognosis

  • Migraine generally improves with increasing age
  • In pregnancy, migraine usually improves in the 2nd and 3rd trimester
  • Migraine often improves after the menopause

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