Migraine Treatment From A to Z: 2014
Migraine headaches are a common cause of disability in the United States, affecting approximately 60 million American adults, or 17.1% of women and 5.6% of men.1 To help define migraines better, the term classical migraine has been replaced with migraine with aura, and nonclassical migraine now is referred to as migraine without aura. Chronic migraine, which affects 3.2 million Americans (2%), is defined as having migraine symptoms for at least 15 days per month, lasting at least 4 hours, and for longer than 3 months in duration. This is in contrast to episodic migraine, which causes symptoms on fewer than 15 days per month.2 Current treatment for chronic migraine is divided into acute abortive agents (analgesics, triptans, ergots, etc) and medications to prevent migraine onset.
This review will highlight the current definitions of migraines as well as treatment options.
A recurring headache that is of moderate or severe intensity and is triggered by migraine-precipitating factors usually is considered to be migraine. Precipitating factors can include stress, certain foods, weather changes, smoke, hunger, fatigue, hormones, and so on. Migraine without aura is a chronic idiopathic headache disorder with attacks lasting 4 to 72 hours. Status migrainosis applies to migraine headaches that exceed 72 hours. Migraine features often include a unilateral location and a throbbing or pulsating nature to the pain. There may be associated nausea, photophobia, phonophobia, or dizziness (Table 1). Further characteristics include a positive relationship with menses, decreased frequency during pregnancy, increased pain with physical activity, and history of migraine in first-degree relatives. Between 70% and 75% of migraine patients report that they have a first-degree relative with a history of migraines.3
Patients who suffer from migraines often have colder hands and feet compared with controls, and the prevalence of motion sickness is much higher in migraine patients. Although most patients will not have all of these characteristics, there are certain diagnostic criteria that have been established by the International Headache Society for the definitive diagnosis of migraine.2 Distinguishing a milder migraine without aura from a moderate or severe tension headache may be difficult, and it is not surprising when “pure” migraine medications are effective for severe tension-type headaches.
Taking a History
The patient’s history is used to make the diagnosis of migraine. Physical examination and magnetic resonance imaging (MRI) or computed tomography (CT) scans are helpful only in ruling out organic pathology. Recent-onset headaches need to be investigated with an MRI scan to rule out other organic disorders, particularly brain tumors. In addition to physical exam and imaging, a check of intraocular pressure (IOP) may be warranted. With new-onset headaches, an eye exam is always warranted.
Although the pain is unilateral in 50% of migraine patients, the entire head often becomes involved. The pain may be in the facial or the cervical areas, and often will shift sides from one occurrence to another. Most patients, however, suffer the severe pain on one favored side from attack to attack.
The typical migraine patient suffers 1 to 5 attacks in a month, but many patients average less than 1 (episodic) or more than 10 per month (chronic). The attack frequency varies with the seasons, and many patients can identify a time of year when their headaches increase significantly. Patients with chronic migraine may have 15 days a month of headache, and many even have 30 days per month, with pain described as 24/7.
The pain of the migraine often follows a bell-shaped curve, with a gradual ascent, a peak for a number of hours, and then a slow decline (Table 2). Occasionally, the pain may be at its peak within minutes of onset. Many patients with migraine suffer some degree of nausea during the attack, and many patients experience vomiting as well. The nausea is often mild, and some patients are not bothered by it. Many patients state that the headache is lessened after they vomit. Diarrhea may occur and usually is mild to moderate. The presence of diarrhea renders the use of rectal suppositories impossible.
Lightheadedness often accompanies the migraine, and syncope may occur. Most patients become very sensitive to bright lights (photophobia), sounds (phonophobia), and/or odors. Between migraine attacks, many patients retain the photophobia, and it is common for migraine patients to wear sunglasses most of the time. Sensitivity to bright lights is a distinctive migraine characteristic.
Pallor of the face is common during a migraine; flushing may occur as well but is seen less often. Patients complain of feeling excessively hot or cold during an attack, and the skin temperature may increase or decrease on the side with pain. Patients with migraines often experience tenderness of the scalp that may linger for hours or days after the migraine pain has ceased. This tenderness actually may occur during the prodrome of the migraine. Both vascular and muscular factors contribute to the scalp tenderness. Autonomic disturbances, such as pupillary miosis or dilation, runny nose, eye tearing, and nasal stuffiness, are relatively common. These also are symptoms of cluster headache, including the sharp pain about one eye or temple.
Alterations of mood are seen in many patients before, during, and after migraine attacks. Patients are usually anxious, tired, or depressed. They often feel “washed out” after an attack, but a calm or an euphoric state occasionally is seen as a postdrome to the migraine. Rarely, euphoria or exhilaration may precede a migraine.
Weight gain due to fluid retention may occur prior to the onset of the migraine. The weight gain is usually less than 6 pounds, and is transient. At some point during the migraine, patients often experience polyuria.
Approximately 20% of patients experience visual neurologic disturbances preceding or during the migraine; these auras may be as disturbing to the patient as the migraine pain itself. The visual symptoms usually last 15 to 20 minutes, and most often will be followed by the migraine headache. Most migraine sufferers experience the same aura with each migraine, but, occasionally, one person may have several types of auras. “The light of a flashbulb going off” is the description many patients give to describe their aura. The visual hallucinations seen most often consist of spots, stars, lines (often wavy), color splashes, and waves resembling heat waves. The images may seem to shimmer, sparkle, or flicker. These visual occurrences are referred to as photopsia.
Fortification spectra are seen much less often than photopsia. They usually begin with a decrease in vision and visual hallucinations that are unformed. Within minutes, a paracentral scotoma becomes evident and assumes a crescent shape, usually with zigzags. There often is associated shimmering, sparkling, or flickering at the edges of the scotoma.