Headache, Migraine



  • 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

Pediatric Considerations
  • 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


Genetic disorder with variable penetrance, influenced by the environmental factors

There's more to see -- the rest of this topic is available only to subscribers.