PRIMARY HEADACHES

MIGRAINE HEADACHE

History of migraine:

An early description consistent with migraines is contained in the Ebers papyrus,

written around 1500 BCE in ancient Egypt In 200 BC, writings from the
Hippocratic school of medicine described the visual aura that can precede the
headache and a partial relief occurring through vomiting.

A second-century description by Aretaeus of Cappadocia divided headaches into

three types: cephalalgia, cephalea, and heterocrania. Galen of Pergamon used the
term hemicrania (half-head), from which the word migraine was eventually
derived. He also proposed that the pain arose from the meninges and blood vessels
of the head. Migraines were first divided into the two now used types - migraine
with aura (migraine ophthalmique) and migraine without aura (migraine vulgaire)
in 1887 by Louis Hyacinthe Thomas a French Librarian.

Trepanation, the deliberate drilling of holes into a skull, was practiced as early as
7,000 BCE while sometimes people survived, many would have died from the
procedure due to infection.It was believed to work via "letting evil spirits escape".
William Harvey recommended trepanation as a treatment for migraines in the 17th
century.While many treatments for migraines have been attempted, it was not until
1868 that use of a substance which eventually turned out to be effective began. This
substance was the fungus ergot from which ergotamine was isolated in 1918.
Methysergide was developed in 1959 and the first triptan, sumatriptan, was
developed in 1988.[107] During the 20th century with better study design effective
preventative measures were found and confirmed

Epidemiology

Worldwide, migraines affect more than 10% of people. In the United States, about
6% of men and 18% of women get a migraine in a given year, with a lifetime risk of
about 18% and 43% respectively. In Europe, migraines affect 12–28% of people at
some point in their lives with about 6–15% of adult men and 14–35% of adult
women getting at least one yearly. Rates of migraines are slightly lower in Asia and
Africa than in Western countries. Chronic migraines occur in approximately 1.4 to
2.2% of the population.

Incidence of migraine by age and sex

These figures vary substantially with age: migraines most commonly start between
15 and 24 years of age and occur most frequently in those 35 to 45 years of age. In
children, about 1.7% of 7 year olds and 3.9% of those between 7 and 15 years have
migraines, with the condition being slightly more common in boys before puberty.
During adolescence migraines becomes more common among women. and this
persists for the rest of the lifespan, being two times more common among elderly
females than males. In women migraines without aura is more common than
migraines with aura, however in men the two types occur with similar frequency.
During perimenopause symptoms often get worse before decreasing in severity.
While symptoms resolve in about two thirds of the elderly, in between 3 and 10%
they persist.

Pathophysiology
The brain itself is not sensitive to pain, because it lacks pain receptors.
However, several areas of the head and neck do have NOCICEPTORS, and can
thus sense pain. These include the extracranial arteries, large veins, cranial and
spinal nerves, head and neck muscles and the meninges.
Headache often results from traction to or irritation of the meninges and blood
vessels. The nociceptors may also be stimulated by other factors than head trauma
or tumors and cause headaches. Some of these include stress, dilated blood vessels
and muscular tension. Once stimulated, a nociceptor sends a message up the length
of the nerve fiber to the nerve cells in the brain, signaling that a part of the body
hurts.
It has been suggested that the level of ENDORPHINS in one's body may have a g
reat impact on how people feel headaches[citation needed]. Thus, it is believed that
people who suffer from chronic headaches or severe headaches have LOW
LEVEL OF ENDORPHINS lower levels of endorphins compared to people who
do not complain of headaches.
Primary headaches are even more difficult to understand than secondary
headaches. Although the pathophysiology of migraines, cluster headaches and
tension headaches is still not well understood, there have been different theories
over time which attempt to provide an explanation of what exactly happens within
the brain when individuals suffer from headaches. One of the oldest such theories
is referred to as the vascular theory which was developed in the middle of the 20th
century. The vascular theory was proposed by Wolff and it described the
intracranial vasoconstriction as being responsible for the aura of the migraine.
The headache was believed to result from the subsequent rebound of the dilatation
of the blood vessels which led to the activation of the perivascular nociceptive
nerves. The developers of this theory took into consideration the changes that occur
within the blood vessels outside the cranium when a migraine attack occurs and
other data that was available at that time including the effect of vasodilators and
vasoconstrictors on headaches.
The neurovascular approach towards primary headaches is currently accepted by
most specialists. According to this newer theory, migraines are triggered by a
complex series of neural and vascular events. Different studies concluded that
individuals who suffer from migraines but not from headache have a state of
neuronal hyperexcitability in the cerebral cortex, especially in the occipital
cortex.People who are more susceptible to experience migraines without headache
are those who have a family history of migraines genetic predisposition,, women,
and women who are experiencing hormonal changes or are taking birth control
pills or are prescribed hormone replacement therapy.
Examination:
The time spent will likely be saved several times over, if it avoids unnecessary
future consultations by a still-worried patient.

 EYE : The optic fundi should always be examined during the diagnostic
consultation.
 Blood pressure measurement is recommended:
o Raised blood pressure is very rarely a cause of headache, but
patients often think it may be.
o Raised blood pressure may make headache of other causes,
including migraine, more difficult to treat unless itself treated.
o Drugs used for headache treatment can affect blood pressure.
 Palpate the temporal arteries if the patient is over 50 years of age.
 Examine the head and neck for muscle tenderness and stiffness. Limitation
in range of movement and crepitation are often revealed, especially in TTH.
 Routine examinations of the jaw and bite rarely contribute to diagnosis.
 Some paediatricians recommend that head circumference be measured at
the diagnostic visit, and plotted on a centile chart.
 The physical examination adds to the reassurance of the patient. The more
thorough the examination, the better - within reason

MIGRAINE TYPES
CLASSIFICATION OF MIGRAINE:
ICHD classification and diagnosis of migraine
According to ICHD classification Primary Headaches classified into:
Migraine, tension-type headaches and cluster headaches, others primary
Migraines are divided into subclasses:
-Migraine without aura, or "common migraine", involves migraine headaches that are not
accompanied by an aura
-Migraine with aura, or "classic migraine", usually involves migraine headaches
accompanied by an aura.
Less commonly, an aura can occur without a headache, or with a non migraine headache.
Migraine without aura subclassified into: two other varieties are
-familial hemiplegic migraine and
-sporadic hemiplegic migraine, in which a person has migraines with aura and with
accompanying motor weakness. If a close relative has had the same condition, it is called
"familial", otherwise it is called "sporadic".
- Migraine without Headache (Silent Migraines)
When is a migraine not a headache? While this might sound like a riddle, it
actually has a serious answer. Surprisingly, migraines can occur without the
classic pulsing head pain. In fact, about 3 to 5% of people with chronic migraines
experience such headache-free migraines, known as "silent migraines."
-Migraine Aura Without Headache:
In this type of migraine, the typical visual and neurological symptoms of aura
occur, but there is no headache that follows
-Basilar-type migraine:
where a headache and aura are accompanied by difficulty speaking, world spinning,
ringing in ears, or a number of other brainstem-related symptoms, but not motor weakness.
This type was initially believed to be due to spasms of the basilar artery, the artery that
supplies the brainstem
- Childhood onset migraine :
Childhood periodic syndromes that are commonly precursors of migraine include:
-cyclical vomiting (occasional intense periods of vomiting),
-abdominal migraine (abdominal pain, usually accompanied by nausea),and
-benign paroxysmal vertigo of childhood (occasional attacks of vertigo).
The diagnosis of abdominal migraines is controversial. Some evidence indicates that
recurrent episodes of abdominal pain in the absence of a headache may be a type of
migraine Or are at least a precursor to migraines. These episodes of pain may or may not
follow a migraine like prodrome and typically last minutes to hours. They often occur in
those with either a personal or family history of typical migraines. Other syndromes that
are believed to be precursors include: cyclical vomiting syndrome and benign paroxysmal
vertigo of childhood.
-Retinal migraine involves migraine headaches accompanied by visual disturbances or
even temporary blindness in one eye.
-Secondry migraine:
describe migraine headaches and/or auras that are unusually long or unusually frequent,
or associated with a seizure or brain lesion.
Probable migraine describes conditions that have some characteristics of migraines, but
where there is not enough evidence to diagnose it as a migraine with certainty (in the
presence of concurrent medication overuse).
-Chronic migraine is a complication of migraines, and is a headache that fulfills diagnostic
criteria for migraine headache and occurs for a greater time interval. Specifically, greater
or equal to 15 days/month for longer than 3 months
-Status Migrainous - an attack that lasts 72 hours or longer.
This is the condition most likely to do grievous harm and people suffering from these
MUST seek immediate medical treatment to reduce to chances of stroke, coma or death.
-Transformed Migraine - attacks that become increasing frequent.change of pattern,
frequency ,intensity, locality,duration ............ secondary headache, CT investigation
recommended, They are daily attacks that vary in intensity from mild to severe debilitating
migraine attacks
- Menstrual Migraines:
In addition to typical premenstrual syndrome (PMS), many women also endure
migraine headaches during the same few days. Menstrual migraines are often
more severe, last longer, involve vomiting and are more resistant to treatment
than the usual migraines. But research is growing on how to treat and even
prevent these crippling episodes.

- Crash migraine :
Severe headache of sudden onset is a concern despite its occurrence in primary
headache disorders. Migraine headaches may have an abrupt onset; these are
termed "crash" migraine and are similar to a "thunderclap" headache. Cluster
headache also may be sudden and excruciating, but it lasts only 15-180 minutes
and is recognized easily if the patient has had previous attacks.

Anatomy of a Migraine
Typical migraine attack:
1-The prodrome, which occurs hours or days before the headache
2-The aura, which immediately precedes the headache
3-The pain phase, also known as headache phase
4- Associated symptoms
5-The postdrome, the effects experienced following the end of a migraine attack
1- Prodrome phase
Prodromal or premonitory symptoms
Symptoms that anticipate the start of a migraine attack are known as the
prodrome phase of the migraine. Not everyone experiences a prodrome —
it's estimated that between 25 and 60 percent of migraineurs experience
prodromal symptoms anywhere from one to twenty-four hours prior to a
migraine attack. Prodrome can occur in both migraine with aura and migraine
without aura.
Prodromal symptoms can be physical and mental in nature. The most common
reported symptoms are fatigue and mood changes such as irritability,
depression, and euphoria. Gastrointestinal symptoms such as diarrhea,
constipation, and stomach pain are also reported. Other prodromal symptoms
include neck pain, sensitivity to smell and light, hearing loss, dizziness, yawning,
weakness, food cravings, tingling of the head and/or extremities, and nose and
sinus problems. Migraineurs may experience some, all, or none of these
symptoms
2-Aura phase :
An aura is a transient focal neurological phenomenon that occurs before or during the
headache. They appear gradually over a number of minutes and generally last fewer than
60 minutes. Symptoms can be visual, sensory or motor in nature and many people
experience more than one.
Visual aura : are the most common, occurring in up to 99% of cases and exclusively in
more than half. Vision disturbances often consist of a scintillating scotoma (an area of
partial alteration in the field of vision which flickers.) These typically start near the center
of vision and then spread out to the sides with zigzagging lines which have been described
to look like fortifications or walls of a castle. Usually the lines are in black and white but
some people also see colored lines Some people lose part of their field of vision known as
hemianopsia while others experience blurring.
Sensory aura: are the second most common occurring in 30-40% of people with auras
Often a feeling of pins-and-needles begins on one side in the hand and arm and spreads
to the nose-mouth area on the same side. Numbness usually occurs after the tingling has
passed with a loss of position sense
Other symptoms of the aura phase can include: speech or language disturbances, world
spinning, and less commonly motor problems.
Motor aura: motor symptoms indicate that this is a hemiplegic migraine, and weakness
often lasts longer than one hour unlike other auras.
An aura rarely occurs without a subsequent headache, known as a silent migraine.,
and so must differentiated from epileptic psychomotor attack

3- Pain phase
Classically the headache is unilateral( classic migraine) , throbbing, and moderate to
severe in intensity. It usually comes on gradually- chronic- and is aggravated by physical
activity. In more than 40% of cases however the pain may be bilateral ( common
migraine), and neck pain is commonly associated. Bilateral pain is particularly common in
those who have migraines without an aura. Less commonly pain may occur primarily in
the back or top of the head. The pain usually lasts 4 to 72 hours in adults however in young
children frequently lasts less than 1 hour.The frequency of attacks is variable, from a few
in a lifetime to several a week, with the average being about one a month.
4-Associated symptoms :
The pain is frequently accompanied by nausea, vomiting, sensitivity to light, sensitivity to
sound, sensitivity to smells, fatigue and irritability. In a basilar migraine, a migraine with
neurological symptoms related to the brain stem or with neurological symptoms on both
sides of the body, common effects include: a sense of the world spinning, light-headedness,
and confusion. Nausea occurs in almost 90% of people, and vomiting occurs in about one-
third. Many thus seek a dark and quiet room. Other symptoms may include: blurred vision,
nasal stuffiness, diarrhea, frequent urination, pallor, or sweating. Swelling or tenderness
of the scalp may occur as can neck stiffness. Associated symptoms are less common in the
elderly

5-Postdrome
The effects of migraine may persist for some days after the main headache has ended; this
is called the migraine postdrome. Many report a sore feeling in the area where the
migraine was, and some report impaired thinking for a few days after the headache has
passed. The patient may feel tired or "hung over" and have head pain, cognitive
difficulties, gastrointestinal symptoms, mood changes, and weakness. [29] According to one
summary, "Some people feel unusually refreshed or euphoric after an attack, whereas
others note depression and malaise.

Differential diagnosis
DIAGNOSTIC TOOL -MARKER- FOR MIGRAINE ATTACKS:
increase of level of 5 hydroxyindoleacetic acid in urine after migrainous attack
Differential Diagnosis OF MIGRAINE:

=MIGRAINE WITHOUT AURA:

--TENSION HEADACHE: BILATERAL-PRESSING PAIN
--CLUSTER HEADACHE: EYE LACRIMATION, CONJUNCTIVAL INJECTION, EYE LID
OEDEMA,MIOSIS, PTOSIS
--SECONDARY MIGRAINE WITHOUT AURA----- ASSOCIATED WITH ANOTHER DISORDER
-SECONDARY MIGRAINE WITHOUT AURA CAUSES:
HEAD TRAUMA- AV MALFORMATION- ENCEPHALOMYLOPATHY- LACTIC ACIDOSIS-STROKE-
ANTIPHOSPHOLIPID ANTIBODY DISEASE-
-SUSPICIOUS SECONDARY CAUSE FOR MIGRAINE IN THE FOLLOWING :
INCREASE DURATION, SEVERITY,FREQUENCY, ONSET AFTER 40 YEARS--------- MRI BRAIN

= Differential Diagnosis OF THE AURA:

AURA MEANS REVERSIBLE CORTICAL DYSFUNCTION OF VISION, SPEECH, MOTOR, SENSORY
FUNCTION ------ CORTICAL SPREADING DEPRESSION, IN WHICH BRIEF EXCITATION OF THE
OCCIPITAL CORTICAL NEURONS INITIATES A DEPOLIRIZATION WAVE THAT MOVES ACROSS
THE CORTEX AT A RATE OF 3-5 MM\MINUTE , AND FOLLOWED BY PROLONGED
DEPRESSION OF THE NEURONS----- REDUCTION IN REGIONAL CEREBRAL BLOOD FLOW IN
MIGRAINE WITH AURA, NOT OCCUR IN MIGRAINE WITHOUT AURA -
TYPICAL MIGRAINE: VISUAL AURA 1\4 cases , DYSPHASIA 1\3 cases,then SENSORY AURA,
SEQUENCE OF AURA: VISUAL-- DYSPHASIA---SENSORY
- MOTOR AURA: HEMIPLEGIC MIGRAINE
IN HEMIPLEGIC MIGRAINE: VISUAL, DYSPHASIC, SENSORY, MOTOR, BASILAR- LIKE AURA
ARE PRESENT
AURA DURATION = 20 MINUTES
THE AURA differentiated from :
EPILEPTIC = FEW SECONDS
TIAS =LOSS OF FUNCTION LESS THAN 24 HOURS,
SUDDEN ONSET STROKE = PERMANENT DAMAGE, NEUROLOGICAL DEFICIT,

=Differential diagnosis OF MIGRAINE WITH AURA:

MIGRAINE WITH AURA WITHOUT HEADACHE HAVE ONSET LATER IN LIFE ,
MIGRAINE WITH AURA IS SERIOUS IN THE FOLLOWING :
DRAMATIC CHANGE IN FREQUENCY, PATIENT WITH CEREBRAL AUTOSOMAL DOMINANAT
ARTERIOPATHY WITH SUBCORTICAL INFARCTS, PATIENT WITH MIGRAINE WITH AURA
OTHER THAN VISUAL AURA, NON VISUAL AURA IS SUSPECIOUS------ SECONDARY
MIGRAINE

Differential Diagnosis OF HEMIPLEGIC MIGRAINE:

STOKE- RISK FOR STOKE IN HEMIPLEGIC MIGRAINE IS HIGH
ALTERNATING CHILDHOOD HEMIPLEGIA---- MENTAL RETARDATION
-COMA IN HEMIPLEGIC MIGRAINE ---- HYPOGLYCEMIA -CEREBRAL HGE- MASS LESION-
MENINGITIS- MENINGISMUS - PERMANENT CEREBELLAR SIGNS-
- SECONDARY CAUSES OF HEMIPLEGIC MIGRAINE :MENINGEOMA- STURGE WEBERS
SYNDROME-EPSTEIN BARR VIRAL INFECTION- LUPUS ER- ANTI CARDIOLIPIN ANTIBODIES
AVASCULAR NECROSIS-PROGRESSIVE FACIAL HEMIATROPHY-
-SUSPECT SECONDARY CAUSES FOR HEMIPLEGIC MIGRAINE IN :
PERMANENT AURA ON ONE SIDE, NOT CHANGING SIDE IN HEMIPLEGIC MIGRAINE ,
ATYPICAL AURA, INCREASE IN THE FREQUENCY,CHANGE CHARACTER OF PAIN, PERSISTENT
NEUROLOGICAL DEFICIT, NOT RESPOND TO MEDICATIONS

Migraine and Epilepsy, differential diagnosis:

migraine with aura and seizures with visual manifestations : both are chronic disturbance
in the brain function,episodic,
COMPLEX PARTIAL SEIZURES AND MIGRAINE---- altered consciousness , EEG, CLINICAL
BACK GROUND
similarities in classification, ictal progression, symptomatology,
migraine and epilepsy may be primary or secondary
migraine with aura and epilepsy --- loss of consciousness, confusion
clinical manifestations: both have positive neurological signs and symptoms- similar ictal
progression- ictal progression in the form of prodroma-- aura- ictus- postdrome-
prodroma in both : prodroma is common in migraine , not in epilepsy-
in migraine behavioural irritability, sleep disturbance,
in epilepsy .... vague symptoms, depression, irritability
ictus: in migraine unilateral - duration in migraine 4-72 hours, in epilepsy 1- 5 minutes,
automatism in epilepsy,
postdrome: in migraine malaise, decrease in concentration, euphoria,
postictus in epilepsy: in form of confusion , todd's paralysis, unresponsiveness
Aura in epilepsy amnesia for event
aura in migraine 15- 30 minutes , in epilepsy 1 minute
aura in migraine visual , motor , sensory aura, in epileptic de je va,
migrainous aura without headache
visual aura: achromatic linear, zigzag shapes,flashes begin at the center of visual field,
expand to the hemianoptic field, scotomas are common white or black in colour ,
in epilepsy: colored, circular, spherical shapes in a hemifield,
fortification spectra are common in migraine, visual hallucinations in migraine,
visual changes in occipital epilepsy
benign childhood epilepsy ( late type) .......visual symptoms and postictal headache

Differential diagnosis of migraine with aura & other primary,

secondary headaches:
1- other types of primary headache
Tension headaches typically occur on both sides, are not pounding, and are less
disabling.
 Differentiating migraine from other primary headaches (eg, muscle contraction
tension headache, cluster headache) is important, as optimal treatment may differ.
2- other causes of secondary headache
3-Other conditions that can cause similar symptoms to a migraine headache
include: temporal arteritis, cluster headaches, acute glaucoma, meningitis and
subarachnoid hemorrhage.
Temporal arteritis typically occurs in people over 50 years old and presents with
tenderness over the temple,
cluster headaches presents with one-sided nose stuffiness, tears and severe pain
around the orbits,
acute glaucoma is associated with vision problems,
meningitis with fevers,
and subaracchnoid hemorrhage with a very fast onset.
Intracranial aneurysm
Despite these possibilities, a ruptured intracranial aneurysm is the primary
consideration if the headache is severe with sudden onset and reaches maximum
intensity in minutes. The classical presentation of an aneurysmal subarachnoid
hemorrhage (SAH) is a severe headache with sudden, explosive onset, stiff neck,
photophobia, nausea and vomiting, and possibly alteration of consciousness.

An extensive evaluation is indicated in such cases, including initial CT scan of the

head without contrast. Lumbar puncture (LP) should be considered if CT scan is
negative, as 25% of cases are missed by CT. Questions remain over whether an
angiogram should be performed if the patient has normal findings on neurologic
examination, cerebrospinal fluid (CSF) examination, and CT or MRI.

In one study, acute severe thunderclap headache comparable to that of SAH

without the nuchal rigidity occurred in 6.3% of patients with unruptured aneurysm.
Other studies have revealed that in patients with severe thunderclap headache with
normal CT and CSF findings, none developed SAH.[56]

If the CT scan and LP are performed late after symptom onset, so that negative
results are unreliable, and if clinical features such as family history or past medical
history, classic SAH-like symptoms, or the presence of neurological signs (in
particular a third cranial nerve palsy affecting the pupil) suggest that the patient is
at risk, angiography should probably be performed if an experienced angiographer
is available.

In patients with unrevealing studies in whom the diagnosis of aneurysmal SAH is

possible but very unlikely, MRI and magnetic resonance angiography (MRA) are
screening tests, and close follow-up is appropriate if the findings of these tests are
negative.

Space-occupying lesion

Another concern is the possibility of a space-occupying lesion mimicking migraine.

In a series of 111 patients with primary (34%) or metastatic (66%) brain tumor,
headache was reported in 48%; the headache had characteristics similar to
migraine in 9% and to tension-type headache in 77%, while the so-called classic
brain tumor headache occurred in only 17%. Headache was intermittent in 62%,
usually lasting a few hours.

All patients with headaches similar to migraine had other neurological symptoms
or abnormal signs. Of note is that 32% had history of headache; in 36% of those,
the headache was of identical character to prior headaches but was more severe or
frequent and was associated with other symptoms such as seizures, confusion,
prolonged nausea, and hemiparesis.

These data indicate that patients with a history of headache should have further
diagnostic workup if the headache is accompanied by new symptoms or abnormal
signs or differs in any way from their usual headache. With new-onset headache,
imaging should be obtained if headache is severe or occurs with nausea, vomiting,
or abnormal signs.

Other space-occupying lesions must be considered in the appropriate clinical

setting. Large intraparenchymal hemorrhage presents dramatically with headache
and neurological symptoms or signs shortly after onset. Of patients with chronic,
subacute, or acute subdural hematoma, 81%, 53%, and 11%, respectively, have
headaches. In brain abscesses, a progressive, severe, intractable headache is
common, and headache is reported in 70-90% of patients.

Cerebral venous thrombosis

Cerebral venous thrombosis involves the sagittal sinus in about 70% of cases; these
patients present with signs and symptoms of increased intracranial pressure (ICP),
such as headache and papilledema. Should the thrombus extend to the superficial
cortical veins, then focal findings may be noted. In the appropriate setting with
known risk factors, cerebral venous thrombosis must be considered and evaluated
with MRI, MRA, or magnetic resonance venography (MRV).

Spontaneous internal carotid artery dissection

Spontaneous internal carotid artery dissection is an uncommon cause of headache

and acute neurological deficit, but it must be considered in the younger individuals
who have unilateral, severe, persistent head pain of sudden onset preceding
neurological signs, most commonly Horner syndrome, differentiating it from
traumatic causes, in which cerebral ischemic symptoms are more common.

Other secondary causes

Other secondary causes of alarming headaches should be sought in the presence of

the "red flags" mentioned above and must be sought in the appropriate clinical
setting. Other features needing further diagnostic workup include positional
headaches, which may occur in colloid cysts or other ventricular tumors such as
ependymomas, Chiari malformations, and low CSF pressure headache.

Headaches after age 50 years must be investigated to consider temporal or giant

cell arteritis. Headaches associated with systemic disease require consideration of
infectious and non-infectious inflammatory processes.
Bear in mind that sumatriptan and related compounds, by virtue of being able to
block expression of c-fos by their action on 5-HT1 receptors, decrease headaches
with diverse pathogenesis. These agents may be effective in decreasing headache
pain associated with meningovascular irritation, such as viral and bacterial
infections and subarachnoid hemorrhage. Hence, response to 5-HT1 agonists is not
diagnostic of a migraine headache.

Migraine also simulate or be simulated by secondary headache disorders or

coexist with a secondary headache disorder. Any of the f Any of the following
features suggest a secondary headache disorder and warrant further investigation:

 The first or worst headache of the patient's life, especially if rapid in onset
 A change in frequency, severity, or clinical features of the attack from what the
patient usually experiences
 New progressive headache that persists for days
 Precipitation of headache with Valsalva maneuvers (ie, coughing, sneezing,
bearing down)
 The presence of associated neurological signs or symptoms (eg, diplopia, loss of
sensation, weakness, ataxia)
 Onset of headaches after the age of 55 years
 Headache developing after head injury or major trauma
 Persistent one-sided throbbing headaches
 Headaches that are associated with stiff neck or fever
 Atypical history or unusual character that does not fulfill the criteria for migraine
 Inadequate response to optimal therapy

Management
There are three main aspects of treatment:
trigger avoidance, acute symptomatic control, and pharmacological prevention.

Prevention of migraines
Preventive treatments of migraines include:
medications, nutritional supplements, lifestyle alterations, and surgery.
Prevention is recommended in those who have headaches more than two days a
week, cannot tolerate the medications used to treat acute attacks, or those with
severe attacks that are not easily controlled

The goal is to reduce the frequency, painfulness, and/or duration of migraines, and
to increase the effectiveness of abortive therapy Another reason prevention is to
avoid medication overuse headache. This is a common problem and can result in
chronic daily headache

Medication

Preventive migraine medications are considered effective if they reduce the

frequency or severity of the migraine attacks by at least 50%.
Medications are more effective if used earlier in an attack ,the frequent use of
medications may result in medication overuse headache, in which the headaches
become more severe and more frequent. This may occur with triptans, ergotamines,
and analgesics, especially narcotic analgesics.
Guidelines are fairly consistent in rating topiramate, divalproex/sodium valproate,
propranolol, and metoprolol as having the highest level of evidence for first-line
use. Recommendations regarding effectiveness varied however for gabapentin.
Timolol is also effective for migraine prevention and in reducing migraine attack
frequency and severity, while frovatriptan is effective for prevention of menstrual
migraine. Amitriptyline and venlafaxine are probably also effective Botox has been
found to be useful in those with chronic migraines but not those with episodic ones

Analgesics

Recommended initial treatment for those with mild to moderate symptoms are
simple analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or the
combination of acetaminophen, acetylsalicylic acid, and caffeine .A number of
NSAIDs have evidence to support their use. Ibuprofen has been found to provide
effective pain relief in about half of people. and diclofenac has been found
effective.Aspirin can relieve moderate to severe migraine pain, with an effectiveness
similar to sumatriptan. Ketorolac is available in an intravenous formulation.
Paracetamol (also known as acetaminophen), either alone or in combination with
metoclopramide, is another effective treatment with a low risk of adverse effects. In
pregnancy acetaminophen and metoclopramide are deemed safe as are NSAIDs
until the third trimester

Triptans
such as sumatriptan are effective for both pain and nausea in up to 75% of
people.They are the initially recommended treatments for those with moderate to
severe pain or those with milder symptoms who do not respond to simple analgesics.
The different forms available include oral, injectable, nasal spray, and oral
dissolving tablets. In general, all the triptans appear equally effective, with similar
side effects. However, individuals may respond better to specific ones. Most side
effects are mild, such as flushing; however, rare cases of myocardial ischemia have
occurred. They are thus not recommended for people with cardiovascular disease.
While historically not recommended in those with basilar migraines there is no
specific evidence of harm from their use in this population to support this caution.
They are not addictive, but may cause medication overuse headaches if used more
than 10 days per month.

Ergotamines

Ergotamine and dihydroergotamine are older medications still prescribed for

migraines, the latter in nasal spray and injectable forms. They appear equally
effective to the triptans,[ are less expensive, and experience adverse effects that
typically are benign. In the most debilitating cases, such as those with status
migrainosus, they appear to be the most effective treatment option.
 Other
Intravenous metoclopramide or intranasal lidocaine are other potential options
Metoclopramide is the recommended treatment for those who present to the
emergency department. A single dose of intravenous dexamethasone, when
added to standard treatment of a migraine attack, is associated with a 26%
decrease in headache recurrence in the following 72 hours.Spinal
manipulation for treating an ongoing migraine headache is not supported by
evidence. It is recommended that opioids and barbiturates not be used.

Prescription Nausea Medications for Migraines

Nausea is a common symptom that can accompany migraine headaches. For
many people this can be one of the most debilitating parts of the episode.
Besides treating the headache pain, it is sometimes necessary to treat the
nausea at the same time. Below is a list of some common prescription
medications that can be used for treating nausea. As with all medical treatments,
consult your health care

Alternative therapies
Petasites hybridus (butterbur) root extract has proven effective for migraine prevention.

Acupuncture is effective in the treatment of migraines.The use of "true"

acupuncture is not more efficient than sham acupuncture, however, both "true"
and sham acupuncture appear more effective than routine care, with fewer adverse
effects than prophylactic drug treatment.
Chiropractic manipulation, physiotherapy, massage and relaxation might be as
effective as propranolol or topiramate in the prevention of migraine headaches;
however, the research had some problems with methodology.
There is some tentative evidence of benefit for: magnesium, coenzyme Q(10),
riboflavin, vitamin B(12), and feverfew, although better quality trials must be done
to confirm these preliminary results. Of the alternative medicines butterbur has the
best evidence for its use.

Devices and surgery

Medical devices, such as biofeedback and neurostimulators, have some advantages

in migraine prevention, mainly when common anti-migraine medications are
contraindicated or in case of medication overuse. Biofeedback helps people be
conscious of some physiological parameters so as to control them and try to relax
and may be efficient for migraine treatment.Neurostimulation uses implantable
neurostimulators similar to pacemakers for the treatment of intractable chronic
migraines with encouraging results for severe cases. Migraine surgery, which
involves decompression of certain nerves around the head and neck, may be an
option in certain people who do not improve with medications

Prognosis
Long term prognosis in people with migraines is variable. Most
people with migraines have periods of lost productivity due to their
disease. however typically the condition is fairly benig .and is not
associated with an increased risk of death. There are four main
patterns to the disease: symptoms can resolve completely,
symptoms can continue but become gradually less with time,
symptoms may continue at the same frequency and severity, or
attacks may become worse and more frequent.

Migraines with aura appear to be a risk factor for ischemic stroke. doubling the
risk.Being a young adult, being female, using hormonal contraception, and
smoking further increases this risk. There also appears to be an association with
cervical artery dissection. Migraines without aura do not appear to be a factor. The
relationship with heart problems is inconclusive with a single study supporting an
association. Overall however migraines do not appear to increase the risk of death
from stroke or heart disease. Preventative therapy of migraines in those with
migraines with auras may prevent associated strokes.

Women With Migraines

Considerations for the Fairer Sex
given that some estimates say up to 75% of migraine sufferers are women, it is
worthwhile to explore important distinctions of women and migraines. Before
puberty, boys are more commonly affected by migraines than girls, but after
about age 11 girls begin to have migraines more frequently. Women can benefit
by understanding special circumstances and health risks unique to them.

Estrogen and Migraines

While the causes of migraines are not understood completely, we do think that
the female hormone estrogen may affect the way our bodies perceive pain.
Estrogen levels can affect levels of chemicals such as serotonin that help
regulate the dilation of blood vessels around the brain. These same chemicals
also make the nerves surrounding the brain more sensitive to pain. The central
nervous system is affected by these normal fluctuations in hormones. Other
sources of estrogen may include oral contraceptives and hormone replacement
therapy (HRT) used during menopause.

Menstrually Related Migraine (MRM)

Estrogen-withdrawal migraine or Menstrually Related Migraine (MRM) is now

being recognized as a separate subcategory of migraines. As estrogen levels fall
right before menstruation, some women experience an increase in migraines,
especially those who have migraines without aura. Migraine headaches seem to
change in character at different stages in a woman’s life as well, varying during
puberty, pregnancy, lactation, and menopause. Research is being done to
determine whether estrogen supplementation is a valuable tool in treating MRM.

Migraines and Vascular Disease

A 2008 study published in Neurology discusses a gene that may, in some women,
relate migraine headaches with heart attack and stroke. Roughly 11% of people
carry to copies of the gene alteration, or are "recessive" carriers of the gene
alteration (alson known as "polymorphism). Women that have this gene
alteration and also have migraines with aura are up to 3 times more likely to
have a cardiovascular incident. It is too early to recommend genetic testing for
all migraine sufferers, but some researchers are recommending that women with
migraines (especially those with aura) should consider discontinuing estrogen-
containing medications. Of course, anyone considering a medication switch
should discuss this with her doctor

Pregnancy and Migraines

A Few Basics You Should Know

Avoiding Pregnancy
Symptoms to Pregnancy
Avoid Foods Pregnancy
Health Pregnancy
How to Prevent Migraines

Pregnancy and migraines have an interesting relationship. Many women report

that their migraine headaches improve during pregnancy, but for others they may
get much worse. And for other women, they may experience their first migraines
during pregnancy. Whatever your situation may be, keep a few things in mind as
your pregnancy progresses.

Warning Signs During Pregnancy

You should always discuss any headache symptoms you are having with your
prenatal healthcare provider. Immediately notify him if you develop one of the
following: Fever with your headache
A headache that lasts more than a few hours, or that returns frequently
Blurry vision along with your headache

Treating Migraines During Pregnancy

Treating any medical condition during pregnancy can be tricky since you not only
have to consider the mother’s health, but also the health of the growing baby.
Many pregnant mothers like to try “natural” headache remedies first. Avoiding
obvious headache triggers would be the first step. Many migraines can be caused
by diet, especially foods containing caffeine like coffee or chocolate, or foods rich
in tyramine, like some cheeses and processed meats. Stress can also cause a
migraine to appear. Keeping a headache diary so you can start to notice personal
headache triggers is a good first step.

If natural treatments don’t help you, your healthcare provider may decide to use
medications. When using prescription medications paying attention to pregnancy
categories is important. Acetaminophen (Tylenol) is the main pain reliever used
during pregnancy, but your healthcare provider may consider other prescription
medications should this fail to work. Avoid using over-the-counter anti-
inflammatory medications (such as naproxen or ibuprofen) or aspirin without
first speaking to your prenatal care provider. In rare instances, a pregnant
woman may need to take prophylactic medications to prevent migraines from
occurring.

Menopause and Migraines

 Headaches are a common perimenopausal symptom. Some women will
experience migraine headaches for the first time during this period, or a
worsening of a long-standing migraine condition. Others will notice an increase
in tension headaches. Whether it is migraine or tension, a headache can seriously
limit your productivity and well-being.

Migraine Headaches

Migraine headaches are vascular, and are caused by blood vessels in the head
enlarging, and then nerves around the blood vessels releasing chemicals that
cause inflammation and pain. This migraine event usually triggers the
“sympathetic” nervous system, the so-called “fight or flight” response, and
thereby may cause nausea, vomiting, and diarrhea.

Since migraine headaches are sensitive to hormone shifts, women tend to have
more of them during times when hormones fluctuate, such as the premenstruum,
pregnancy, and menopause. They can be little more than a nuisance, or they can
be debilitating events that put you out of commission for days at a time.

Fact
As many as 20 percent of migraine headaches are immediately preceded by an
“aura” or sensory change. The aura may be a visual change such as flashing
lights or a blind spot in the visual field, a “pins and needles” sensation on one
side, or even a strange taste or sound. This aura is sometimes enough of a heads-
up that medication can be started in time to diminish the headache.

Some women experience an advanced warning other than an aura that comes
days or hours before the headache. It may take any of a number of forms,
including:

 Irritability

 Sadness

 Euphoria

 Sleepiness

 Yawning

 Food cravings

People with this sort of migraine learn to heed the warning and seek treatment
before the headache hits. Often there are triggers for migraine headaches,
including foods (aged cheese, coffee, chocolate, pickled items, and others),
changes in sleep patterns (too much or too little), stress, artificial sweeteners
such as aspartame, fasting, odors, alcohol, food additives such as monosodium
glutamate (MSG), bright and flashing lights, and others. Sometimes avoiding
triggers is effective in reducing the headaches significantly.

There are many ways to treat migraine headaches, some of them requiring
prescription and some available over the counter. Combining caffeine with
common pain medications is effective for some. Others find that they need to try
prescription medications such as triptans or ergot formulas. Talking to your
health care provider is important to determine which medications are best for
you, and which will not interact badly with other medications you may be taking.
 Non-medication approaches for migraine headaches include relaxation
techniques and biofeedback. Ice can be effective in aborting headaches, and
getting sufficient sleep is also important in preventing migraine attacks.

Essential
If you notice an increase in migraine headaches with menopause, see your health
care provider. He or she can help you choose prevention and treatment options,
and can sort out whether this change is related to a more serious medical
condition, such as stroke or neurological disease.

Non-Migraine Headaches

A non-migraine headache is usually called a “tension headache.” As with

migraines, these are more common in women than men, and often begin in
middle adulthood. Tension headaches, as the name implies, seem to result in the
muscular tension in the neck and shoulders. As life, work and family become
increasingly stressful, women notice more severe and more frequent tension
headaches. Tension headaches may be associated with anxiety or depression,
and are often treated successfully.

Treatment of tension headaches may be with common pain medications such as

ibuprofen or acetaminophen, or with relaxation techniques and biofeedback, or
some combination of the two. The most effective approach also is one that
reduces the stress that causes the headache to begin with. Some women find
that chiropractic care, acupuncture, and/or massage can significantly reduce the
number or severity of their tension headaches.

Alert
A headache that comes on suddenly after the age of fifty can be a sign of serious
illness. If you are a regular headache sufferer who notices a change in your
headache pattern; if you have never had headaches and suddenly begin to have
them; if your headache lasts for more than a day; or if your headache is not
relieved with simple pain relievers, see your medical provider right away.

Vision and Migraine

How A migraine Can Affect Your Eyes and Vision
Have you ever had a headache that affected your vision? Sometimes a headache
can cause pain around your eyes, even though the headache is not associated
with a vision problem. A headache can sometimes be a sign that your eyes are
changing and that it may be time to schedule an eye exam. Although headaches
can often be attributed to the ways in which we use our eyes, a severe headache
should always be taken seriously. The following conditions that often trigger a
headache can be associated with your eyes and vision.

 Migraine Headache A migraine headache can cause intense pain in and

around your eyes. A migraine aura resembling flashing lights, a prismatic
rainbow of lights or a zig-zag pattern of shimmering lights often precedes the
actual headache. The aura typically last around 20 minutes. Some patients
who experience the aura never develop the headache afterward.

Migraines can also cause tingling or numbness of the skin. People with severe
migraines also have nausea, vomiting and light sensitivity. Medications,
 certain foods, smells, loud noises and bright lights can all trigger a migraine
headache.

 Eye Strain Simply overusing the focusing muscles of your eyes can cause eye
strain, which often results in a headache. Our high tech world has improved
our lives considerably, but small-screen texting and web browsing often
causes strain on our eyes. Words and images on a computer screen do not
have well-defined edges, as they are made up of several small dots, or pixels.
The eyes cannot easily focus on pixels, so they must work harder to see the
computer screen clearly. When the eye muscles become fatigued, a headache
often develops around or behind the eyes.

 Farsightedness Adults and children with uncorrected farsightedness often

complain of a frontal headaches or a brow ache. If you are farsighted, you may
find it difficult to focus on nearby objects and may feel eye strain, pain around
the eyes, or a headache around the forehead. Headaches often occur because
you are able to compensate for your farsightedness by subconsciously
focusing harder.

 Presbyopia Around the age of 40, people begin to find it difficult to focus on
nearby objects. Near point activities, such as reading, are often blurry. This is
an unavoidable condition known as presbyopia and affects everyone at some
point. Headaches often result due to trying to compensate for the lack of
focusing power.

Dealing With Migraine Related Depression

When the people we care about are depressed - we'll try everything in our power
to support them. And when they're also dealing with the debilitating symptoms
of migraine, they may need more than just a shoulder to cry on. For years we
believed that the only reason migraine sufferers were depressed was because
they had bad headaches. Today we know much more about the brain chemistry
and genetic differences that make migraine sufferers more susceptible to
depression. And though the biological relationship between migraines and
depression is a complicated one, dealing with the symptoms doesn't have to be.
The good news is that if you or someone you know has migraine related
depression, there are several things you can do to fight this disease and help
maintain some control over your life.

Understanding the link between migraine and depression.

Several decades of research have shown a link between migraines and

depression.

Findings from recent studies of twins (who share identical genes)suggest that
the relationship between migraines and depression could be genetic in nature.
Scientists found that twins, as well people who share a similar genetic
background tended to have similar health outcomes. They showed that the
presence of certain genes in an individual, could often predict whether they
would experience migraine with depression. In addition, subjects with similar
genes had similar migraine and depressive symptoms.

These studies support the idea that the relationship between migraines and
depression is a two-way street. The same genes that can cause some migraines
sufferers to be at greater risk for developing clinical depression may also put
depressed patients at greater risk for developing migraines.

The research also suggests that migraines and depression don't always have to
occur as a consequence of the other. The genetic pathways associated with
either condition can allow a person to develop both migraine headaches and
depression independently.

serotonin and noreprenephrine form complex circuits in the brain that underlie
depression. Many antidepressants act by modifying the levels of one or more of
these chemicals in the brain. Interestingly, several groups have shown that
during migraines one or more of these chemicals also show alterations in a
pattern similar t depression. For example, one theory behind depression is that a
lack of serotonin in the brain causes depression. Similar studies have shown that
migraine attacks can also coincide with a drop in serotonin levels in some
patients.

Identify your depressive symptoms.Though doctors frequently see migraine

sufferers who are depressed, addressing the combination of depressive
symptoms and pain management issues can be challenging. In any case,
depression is a serious condition that requires medical attention. Migraine
sufferers with the following symptoms may be clinically depressed and should
seek help immediately:
• Feelings of sadness, worthlessness or pessimism
• Heightened agitation and restlessness
• Constant movement, pacing or hand-wringing
• Loss of interest in activities that were once enjoyed
• Reduced sex drive
• Extreme fatigue and loss of energy
• Poorer concentration and decision making ability
• Memory loss
• Changes in sleep pattern - either too much or too little sleep
• Unexplained crying
• Physical aches and pains throughout the body for no apparent reason

Recognize the presence of other mental health conditions.

To further complicate matters, several studies have shown that migraines can
induce more than just depression. Because a variety of mental conditions are
controlled by the same brain mechanisms, the same systems that might put a
person with migraines at risk for depression can also put them at greater risk for
anxiety, phobias and substance abuse. And, because your depression treatment
can affect any other mental health conditions that you are suffering from, it's
important to try to identify any mental health issues with your physician early
on.

Establish a health care team.

Because the mechanisms of migraine and depression go hand in hand, it's very
important that you choose both a neurologist and psychiatrist that will work
together to fully evaluate your symptoms and treatment options.
It is also important that your health care practicioners recognize that migraines
should not be treated as just a symptom of depression, but they should be
treated as an important condition that occurs with depression. For example,
several patients have been known to report that their headache worsens after a
depressive episode.

Your physician will want to do a thorough physical exam on you to evaluate

whether you're experiencing true migraines (as opposed to another form of
headache). She may also order some lab work and tests to rule out the possibility
of some other physiological explanation for your headache and depression, such
as musculoskeletal abnormalities or brain lesions.

Evaluate your treatment options.

When it was discovered that the biological factors that make some of us more
vulnerable to depression can also make us more vulnerable to migraines, it was
also uncovered that antidepressants can reduce the severity and frequency of
migraines. However finding the right treatment regimen can prove challenging,
and studies have shown mixed results regarding the ability of any one drug to
eliminate all symptoms in patients.

While it's possible to treat some patients' depression and migraine with a single
pill, some clinicians will choose to focus more on the physical pain associated
with the migraine symptoms. Because being in pain can have such a negative
impact on a person's overall quality of life, it can also exacerbate your already
depressed mood and make it hard to isolate your depressive symptoms.

To treat migraine and depression, many physicians choose to prescribe tricyclic

antidepressants like Elavil (amitriptyline), which modify the levels of serotonin
and other chemicals in your brain, or Effexor (venlafaine), a drug that modifies
the levels of noreprenephine in your brain. However because higher doses of
antidepressants are often required for treating depression than would be safe for
treating migraines, this treatment is not always effective at treating depression.

To get around this, some clinicians may prescribe selective serotonin re-uptake
inhibitors (SSRIs)or monamine oxidase inhibitors, which are drugs that can be
used in combination with certain migraine pain medicines. In some cases they
can be combined with tricyclic antidepressants. However, your clinician may be
hesitant to prescribe this combination regimen because of the potential risk for
potentially lethal serotonin toxicty; the combined effects of these drugs may be
dangerous if too much serotonin is allowed to circulate in your system.

In addition to working with your physicians, you might also enlist the services of
a psychotherapist and social worker to help manage your health and lifestyle.
Cognitive-behavioral therapy combined with meditation and breathing
techniques have shown to be beneficial for reducing migraine and depressive
symptoms in some patients. These providers may be able to facilitate group or
individual counseling sessions, provide you with other useful resources, or refer
you to a support group where you might benefit