THE CLINICAL SYNDROME

• Migraine headache is a type of periodic unilateral headache that can start in childhood, but almost always develops before the age of 30 years old.

• Migraine headaches are usually severe enough to require hospitalization. The frequency of attacks varies widely, occurring anywhere from once every several months to once every few days on average.

  • There is a phenomenon known as analgesic rebound that is commonly associated with increased frequency of migraine headaches.

• Patients who suffer from migraines tend to be female (between 60 and 70 percent), and many of them report a history of migraine headaches in their families.

  • It has been hypothesized that people who suffer from migraines have a personality type that is meticulous, neat, compulsive, and frequently rigid. They have a propensity to become compulsive in their daily routines and frequently struggle to deal with the pressures that come with living a normal life.

  • Changes in sleep patterns or diet, as well as the consumption of foods containing tyramine, monosodium glutamate, nitrates, chocolate, wine, or citrus fruits can all bring on a migraine headache.

• Migraine headaches can also be brought on by an allergic reaction to certain foods. Both changes in endogenous and exogenous hormones, such as those brought on by the use of birth control pills, as well as the consumption of nitroglycerine for the treatment of angina, have been linked to the onset of migraine headaches.

SIGNS AND SYMPTOMS

• A migraine headache is, by definition, only experienced on one side of the head. Even though the side of the head that hurts may switch with each episode, a headache is never on both sides when it first starts.

• Migraine headaches typically cause pain around or behind the eye, known as periorbital or retroorbital pain.

  • It is relentless in its pounding, and the intensity is high.

  • Patients who suffer from migraines occasionally experience neurologic dysfunction that is associated with the headache pain for a longer period of time.

• A migraine with prolonged aura is characterized by neurologic dysfunction that lasts for more than 24 hours and carries the same name.

  • These patients are at an increased risk for the development of a neurologic deficit that is permanent; therefore, the risk factors, which include hypertension, smoking, and the use of oral contraceptives, need to be addressed.

• Migraines with complex auras are even less common than migraines with prolonged auras. Significant neurologic dysfunction, which may include phasia or hemiplegia, is experienced by patients who have migraines with complex auras.

• Patients who suffer from migraines with complex auras have an increased risk of developing long-term neurologic deficits, similar to patients who have migraines with prolonged auras.

TESTING

• There is currently no reliable diagnostic test for migraine headaches.

• The primary goal of the testing is to identify other diseases or hidden pathologic processes that may cause symptoms that are similar to migraine headaches.

• It is recommended that magnetic resonance imaging (MRI) be performed on the brains of all patients who have recently started complaining of headaches that may be migraines.

• If the patient also exhibits symptoms of neurologic dysfunction, an MRI with and without gadolinium contrast medium should be performed on the patient, and magnetic resonance angiography should also be considered.

• Patients who have been diagnosed with migraine headaches in the past and whose symptoms have changed in a manner that cannot be explained should also undergo MRI testing.

  • If the diagnosis of migraine is in question, screening laboratory tests, such as an erythrocyte sedimentation rate, a complete blood count, and automated blood chemistry, should be performed.

• Patients who are experiencing significant ocular symptoms should have an evaluation by an ophthalmologist.

DIFFERENTIAL DIAGNOSIS

• Migraine headache is typically diagnosed on clinical grounds through the process of obtaining a headache history that is specific to the condition.

  • This misdiagnosis can lead to treatment plans that are illogical because tension headaches and migraines are managed quite differently.

  • The two types of headache syndromes are often confused with one another because of their similar symptoms.

• Migraine headache symptoms can also be caused by conditions affecting the eyes, ears, nose, and sinuses.

  • The specific history and physical examination, when combined with the appropriate testing, should make it possible for the clinician to identify and treat appropriately any diseases that are lurking in the background of these organ systems.

    • When diagnosing and treating patients with headaches, it is important to keep in mind that patients may have one or more of the following conditions in addition to migraine: glaucoma, temporal arteritis; sinusitis; intracranial disease, such as chronic subdural hematoma, tumor, brain abscess, hydrocephalus, and pseudotumor cerebri; and inflammatory conditions, such as sarcoidosis.

TREATMENT

Abortive Therapy

• In order for abortive therapy to be effective, it must be started as soon as the patient experiences even the slightest hint of a headache.

  • This is frequently challenging for a number of reasons, including the fact that there is a brief period of time between the beginning of a migraine and its most severe phase, as well as the fact that people who suffer from migraines frequently experience nausea and vomiting, which can make it difficult for them to take oral medications.

  • This problem can be solved by switching the method of administration to either parenteral or transmucosal administration instead.

• Compounds that contain isometheptene mucate (such as Midrin), the nonsteroidal anti-inflammatory drug (NSAID) naproxen, ergot alkaloids, the triptans including sumatriptan, rizatriptan, almotriptan, naratriptan, zolmitriptan, frovatriptan, and eletriptan, and intravenous lidocaine combined with antiemetic compounds are all examples of medications Both the inhalation of 100 percent oxygen and a sphenopalatine ganglion block performed with a local anesthetic have shown promise in the treatment of migraine headaches.

• Preparations that contain caffeine, barbiturates, ergotamines, triptans, and opioids have a propensity to cause a phenomenon known as analgesic rebound headache, which may ultimately be more difficult to treat than the migraine that was initially being treated.

  • Patients who also have coronary artery disease, peripheral vascular disease, or hypertension are not candidates for treatment with ergotamines or triptans and should not take them.

Prophylactic Therapy

• Prophylactic treatment is recommended over abortive treatment for the vast majority of patients who suffer from migraine headaches.

• The use of beta-blocking agents constitutes the bulk of prophylactic treatment. The majority of the other medications in this class, as well as propranolol, metoprolol, and timolol, have the ability to prevent auras, as well as control or lessen the frequency and intensity of migraine headaches.

• A starting point that is appropriate for the majority of patients who suffer from migraines is a daily dose of 80 milligrams of the long-acting formulation. Patients who suffer from asthma or any other condition that affects their reactive airways should not take propranolol.

COMPLICATIONS AND PITFALLS

• The majority of people who suffer from migraine headaches do not put their lives in danger from the disease.

  • Nevertheless, patients who suffer from migraines with auras that last for a prolonged period of time or migraines with complex auras are at risk for the development of neurologic deficits that are permanent.

• Patients with headaches like these should seek treatment from headache specialists, who are more knowledgeable about these particular dangers and are better able to manage them.

  • Sometimes, the prolonged nausea and vomiting that accompany a severe migraine headache can lead to dehydration, which then requires hospitalization and treatment with intravenous fluids. This can only be prevented by receiving treatment in a medical setting.

• the short amount of time that passes between the beginning of a migraine and its worst symptoms, combined with the fact that people who get migraines frequently experience nausea and vomiting, can make it difficult to treat.