Diagnosis of Migraine

Headache

• A general term referring to a persistent or lasting pain in the head region
• Can be caused by many disorders, such as inflammation of pain-sensitive structures within the head or disorders of extra-cranial structures like the eyes, ears, or sinuses

Types of Headaches

• Primary headache: characterized by the lack of an identifiable and treatable underlying cause
• Secondary headache: associated with a variety of organic disorders, such as trauma, cerebrovascular malformations, and brain tumors

Migraine

• Characterized by recurring episodes of throbbing head pain, frequently unilateral
• Can be severe and associated with nausea, vomiting, and sensitivity to light, sound, and/or movement
• Typically occurs in the early morning hours on awakening
• Pain is usually gradual in onset, peaking in intensity over minutes to hours, and lasting between 4 and 72 hours untreated

Migraine Characteristics

• Pain is typically reported as moderate to severe
• Most often involves the frontotemporal region
• Headache is typically unilateral and throbbing or pulsating in nature
• About 77% of migraineurs have premonitory symptoms (not to be confused with aura) in the hours or days before the onset of headache

Premonitory Symptoms

• Neurological symptoms: phonophobia, photophobia, hyperosmia, difficulty concentrating
• Psychological symptoms: anxiety, depression, euphoria, irritability, drowsiness, hyperactivity, and restlessness
• Autonomic symptoms: polyuria, diarrhea, constipation
• Constitutional symptoms: stiff neck, thirst, food cravings, anorexia

Migraine Aura

• Experienced by approximately 31% of migraineurs
• Typically evolves over 5 to 20 minutes and lasts less than 60 minutes
• Headache usually occurs within 60 minutes of the end of the aura
• Visual auras can include both positive features (e.g., scintillations, photopsia, teichopsia, fortification spectrum) and negative features (e.g., scotoma, hemianopsia)

Diagnosis of Migraine

• Check for abnormalities: vital signs (fever, hypertension), fundoscopy (papilledema and hemorrhage), neurologic examination (abnormalities or deficits in mental status), neuroimaging (computed tomography or magnetic resonance imaging), and laboratory tests
• In secondary headache presentation, serum chemistries, and other blood tests, such as a complete blood count, antinuclear antibody titer, ESR, and thyroid function tests may be considered

Non-Pharmacological Management of Migraine

• Keep a headache diary to identify patterns/triggers
• Increasing hydration
• Regular sleep
• Regular exercise
• Cognitive behavioral therapy
• Biofeedback
• Wearable devices

Pharmacological Management of Migraine

• Beta-blockers
• NSAIDS
• Anticonvulsants
• Triptans
• Dihydroergotamine
• Calcium channel blockers
• tricyclic antidepressants
• Antiemetics (e.g., metoclopramide, chlorpromazine, or prochlorperazine)
• Non-oral treatments (e.g., rectal suppositories, nasal spray, injections) may be advisable when nausea and vomiting are severe