International Headache Society 2004 Migraine without aura def:
- A – at least 5 attacks fulfilling B-D
- B – lasting 1-72hr
- C – at least 2 of:
- unilateral, may be bilateral frontotemporal but not occipital;
- pulsing;
- moderate or worse pain;
- aggravation by routine physical activity eg walking, stairs
- D – during headache at least 1 of: nausea +/or vomiting, photophobia and phonophobia (which may be inferred from behaviour)
- E – not attributed to other disorder
Aura – Hemianopia or spreading scintillating scotoma. Note that migraine with aura is a contraindication to treatment with combined oral contraceptives.
Some specific types:
- Hemiplegic – can be familial or sporadic. Can be confusion. Rare to not have headache with it (but then diagnosis perhaps not recognised!?). Triptans were initially thought to be risky, but more recently good evidence of usefulness and no longer contraindicated in BNFc.
- Ocular/retinal – blindness or flashing lights, may not be headache. NOT aura, which is prodromal. Horner’s syndrome seen.
- Basilar (also called Bickerstaff’s – but better termed migraine with brainstem aura) – transient dysarthria, vertigo, tinnitus, hearing impairment, diplopia, ataxia, confusion, bilateral paresthesia,
- Confusional
Pathology
Neuronovascular condition – baseline hyperexcitability in cortex.
Double the risk if you had infant colic, which is not true for tension headache! Sleep disruption as common factor? [JAMA 2013;309:1607-12]
Several genetic links found eg C677T mutation of the methylenetetrahydrofolate reductase gene (MTHFR), EAAT2. [J Headache Pain. Jan 2012; 13(1): 1–9. doi: 10.1007/s10194-011-0399-0]
Investigations
Beware Occipital epilepsy!
American Academy of Neurology recommendations are that neuroimaging should be considered in:
- recent onset of severe headache;
- change in type of headache;
- or neurological dysfunction;
- seizures
Factors
- Biofeedback and relaxation/stress management are as effective as beta blockers. Indian trial of yoga for migraine showed substantial improvement at 3 months [neurology 2020]
- Sleep disturbance is associated but not necessarily causal – so recommend good sleep hygiene.
- Exercise is beneficial.
- Obesity – clusters with diet, exercise, sleep issues of course.
- Missing breakfast is a common precipitant.
- Episodic migraine (without aura) can become chronic (ie 15 days per month or more), but in this case you would always want to exclude medication overuse.
- Caffeine is linked to headache and also sleep/mood disorder which exacerbates. Withdrawal headache can last as long as a week.
- Wine is well recognised trigger in adults!
- Often linked to menstrual cycle.
- Screen time (>2hrs per day) linked to migraine but not non-migraine headache in French and Sri Lankan students. Doesn’t necessarily mean reducing screen time helps, of course. But note eye strain, posture relevant too. And possibly differences between TV/PC use and mobile devices.
- Some evidence for magnesium and zinc supplementation
[CurrOpPeds Dec 2004]
Diet
Although popular perception is that migraine is caused or at least triggered by dietary factors, there is a wide variation in reporting of dietary triggers. Certainly migraine is associated with obesity, and dietary habits seem to be as important as specific foods, and there is probably a cycle of inconsistent nutrition and poor control of migraine.
My colleagues talk about 4Cs (chocolate, cheese, coffee, citrus) but I have found no evidence for this. Awareness of possibility of dietary triggers actually has greater influence on perception of personal triggers than personal experience! See below.
Some evidence for lipid intake esp PUFA (decreased ingestion of lipids was associated with a decrease in the frequency, intensity, and duration of migraines and a decrease in the use of medication) but confounded by obesity, weight reduction, and changes in nutrient intake. Another study found reduced migraine spells among children subjected to a diet rich in fibre. Not much evidence for cheese at all! [Nutrition Reviews. 70(6):337-56, 2012 Jun. UI: 22646127]
Trial of cyanocobalamin, folate, and pyridoxine (2 mg of folic acid, 25 mg vitamin B6, and 400 microg of vitamin B12) in patients with MTHFR gene defects found a reduction of homocysteine levels and improvement of migraines. [Pharmacogenetics and Genomics. 22(10):741-749, October 2012]
Medication
Paracetamol, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic treatments for episodes of migraine (peds sys rv 2005). Migraleve is paracetamol, codeine (8mg), buclizine – for 10yr plus. Paramax, with metoclopramide, for 12 yr plus. Anti-emetic improves pain killer absorption so potential benefit even if no nausea!
Sumatriptan was previously contraindicated for hemiplegic migraine, but this was probably a theoretical concern, and there is evidence that it works. No caution or contraindication mentioned in BNF now.
Mefenamic acid for menstrual, esp with dysmenorrhea.
CGRP receptor antagonists – olcegepant, telcagepant [not in BNF]. Now erenumab [monthly subcut injections, BNF says specialist use only, minimum 4 migraines per month – SMC approved with restrictions], eptinezumab etc vs same calcitonin gene-related peptide receptor. Significant improvement in headaches in 40%, about 3 less headache days per month.
For prophylaxis, Pizotifen does not work (grade I evidence, plus makes you fat), flunarizine (CCB) is the most effective (not in BNF), also amitriptyline (dangerous in overdose), propanolol (dizziness, sleep disturbance, depression etc, also dangerous in overdose). Encouraging data (grade IV) for anti-epileptic mediations topiramate, valproate, levetiracetam, zonisamide. Cyproheptadine? Candesartan (anti-hypertensive, in BNF for migraine prevention)?
Always increase preventer dose to maximum before giving up, note that often symptoms worsen after initial benefit.
Current evidence on the efficacy of percutaneous closure of patent foramen ovale (PFO) for recurrent migraine is inadequate in quality and quantity. The evidence on safety shows a small incidence of well-recognised but sometimes serious adverse events, including device embolisation and device prolapse (each reported in less than 1% of patients). Therefore this procedure should only be used with special arrangements for clinical governance, consent and audit or research. [NICE]
Contraception
Combined oral contraceptives are contraindicated in migraine with aura. But may be useful if menstrual pattern to headaches if no aura.
Prognosis
50% migraine in childhood remits at puberty. Onset in adolescence associated with persistence.
Support
Patient support at Migraine Trust.