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
- Use with caution due to extrapyramidal side effects
- 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
