Headache, Migraine

Description

• Chronic episodic headache disorder
• Neurovascular pathophysiology:
  • Aberrant trigeminal nerve activation
  • Activation of nociceptive pathways within brainstem
  • Vascular dilation is reactive rather than causative
  • No longer considered primarily a vascular headache
  • Disordered sensory processing and autonomic dysfunction
  • Cortical spreading depression underlies aura
• 1.2 million ED visits per year
• Causes majority of ED headache visits
• 3× as common in women
• Prevalence peaks in fourth decade of life
• Established criteria for migraine without aura:
  • A. 5 attacks fulfilling criteria B, C, D, E
  • B. Attack lasts 4–72 hr
  • C. Headache has 2 of the following:
    • 1. Unilateral location
    • 2. Pulsating
    • 3. Moderate to severe pain (impairs activities)
    • 4. Aggravation by or avoidance of physical activity
  • D. During headache, nausea, or vomiting and/or photophobia + phonophobia
  • E. Not attributable to other cause
• Migraine with aura:
  • Less common
  • Classically, reversible neurologic symptoms that precede headache
  • Some patients report aura at the same time or after the headache
  • Rarer subtypes of migraine include:
    • Basilar type migraine:
      • Dysarthria, vertigo, ataxia, diplopia, or decreased level of consciousness
    • Hemiplegic migraine:
      • Full reversible motor weakness
    • Retinal migraine:
      • Repeated attacks of monocular visual disturbance

• More commonly bilateral pain and shorter duration of headache
• Associated symptoms may be difficult to elicit and can be inferred from behavior
• Cyclical vomiting syndrome associated with migraine
• High placebo response

Etiology

Genetic disorder with variable penetrance, influenced by the environmental factors