Migraine headache

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What this article covers

• Overview

  Primary episodic headache disorder: migraine is a recurrent, disabling headache syndrome diagnosed entirely by clinical criteria, with no confirmatory blood test or imaging finding; it is…

• Epidemiology

  Common: annual prevalence approximates 13% of adults, and migraine accounts for more than 90% of headache visits to primary care and headache specialty clinics, making it the most common cause of severe recurrent headache.

• Risk factors

  Female sex and reproductive hormones: hormonal fluctuation around menses is a recognized trigger, and estrogen-containing oral contraceptives raise stroke risk specifically in women with migraine with aura.

• Pathophysiology

  Trigeminovascular activation: nociceptive input from meningeal and vascular afferents converges on the trigeminal nucleus caudalis, generating the referred, often unilateral, throbbing pain of an attack.

• Clinical features

  International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria for migraine without aura (the most prevalent subtype): at least 5 attacks lasting 4 to 72 hours untreated, with at…

• Differential diagnosis

  Tension-type headache: bilateral, pressing/tightening, mild-moderate intensity, not worsened by routine activity, and lacking the nausea or dual photophobia-phonophobia required for migraine.

• Diagnosis

  Migraine is a clinical diagnosis established by meeting ICHD-3 criteria for migraine without or with aura on history alone; no laboratory test or imaging finding confirms it.

• Management

  First, treat early in the attack: give acute therapy at the onset of mild pain rather than waiting for it to become moderate-severe, since early dosing improves response.

• Complications

  Chronic migraine: untreated or undertreated episodic migraine transforms to chronic migraine (=15 days/month) at roughly 3% per year, with greater disability and comorbidity burden.

• Prognosis

  Generally favorable with treatment: most patients with episodic migraine maintain good function with appropriate acute and, when indicated, preventive therapy.

• Prevention

  Start preventive medication at a headache frequency of =4 days/month, and essentially always by 10 days/month, rather than waiting for further escalation.