Migraine headache

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Migraine headaches are "a class of disabling primary headache disorders, characterized by recurrent unilateral pulsatile headaches. The two major subtypes are common migraine (without aura) and classic migraine (with aura or neurological symptoms)."[1] Laymen often use the term for any severe headache, especially with nausea and sensitivity to light and sound, but there are specific criteria. Just as the term is overused in some contexts, however, true migraine has different manifestations, is underdiagnosed, and is sometimes preventable as well as treatable.

Classification

  • Common migraine (without aura)
  • Classic migraine (with aura or neurological symptoms)

Diagnosis

Migraines are underdiagnosed[2] and misdiagnosed.[3] About a third of headaches that patients report as being migraines are truly migraines[4]; while about 90% of headaches that are self-reported not to be migraines are truly not migraines.[4] The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":

  • 5 or more attacks
  • 4 hours to 3 days in duration
  • 2 or more of - unilateral location, pulsating quality, moderate to severe pain, aggravation by or avoidance of routine physical activity
  • 1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia

For migraine with aura, only two attacks are required to justify the diagnosis.

The mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.[5]

The presence of either disability, nausea, or sensitivity to light can diagnose migraine with[6]:

Treatment

Abortive treatment

General-purpose analgesics, from acetylsalicylic acid and acetaminophen, to NSAIDs to opioids, may be useful in attacks, but there are some potential problems with overuse. Caffeine may improve their effectiveness. When the diagnosis is confirmed, much more specific drugs may be useful.

Since the pain comes significantly from dilated blood vessels, drugs that contract the painful vessels, with due care for vascular disease that may increase risk, are disease-modifying. In the past, ergotamine was the standard, but it has significant risks although it is still used. The triptan class of specific vasoconstrictors is now the standard. There are some agents that desensitize the receptor involved the vasodilation.

A randomized controlled trial found that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and low dose ibuprofen 400 mg are equally effective at reducing pain to mild or none at two hours; however, sumatriptan was led to more patients being pain free at two hours (37% versus less than 33% for other groups).[7]

Another randomized controlled trial, funded by the manufacturer of the study drug, found that a combination of sumatriptan 85 mg and naproxen sodium 200 mg was better than either drug alone.[8]

Some patients report that inhaling pure oxygen can abort an attack, although this is more associated with cluster headache, another severe headache type that differs from migraine.

Nonpharmacological treatments

Investigational treatments

Corticosteroids may help prevent recurrence after abortive treatment according to a meta-analyses of randomized controlled trials with number needed to treat of nine[9] or 10[10].

Telcagepant (MK-0974), an oral antagonist of calcitonin gene-related peptide receptor, may be as effective as zolmitriptan but with less drug toxicity according to a randomized controlled trial.[11]

Preventive treatment

Perhaps a third of patients meet consensus criteria for preventive treatment.[12]

The antiepileptic drug topiramate can increase response among patients with migraine according to a randomized controlled trial.[13]> The relative benefit increase was 113.0%. For patients at similar risk to those in this study (23.0% had response), this leads to an absolute benefit increase of 26%. 3.8 patients must be treated for one to benefit (number needed to treat = 3.8). Click here to adjust these results for patients at higher or lower risk of response.

Prognosis

Migraines with auras in mid-life may be associated with stroke[14] brain infarcts on magnetic resonance imaging[15].

References

  1. ↑ National Library of Medicine. Migraine Disorders. Retrieved on 2007-11-02.
  2. ↑ Lipton RB, Stewart WF, Celentano DD, Reed ML (1992). "Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis". Arch. Intern. Med. 152 (6): 1273–8. PMID 1599358. [e]
  3. ↑ Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C (2004). "Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache". Arch. Intern. Med. 164 (16): 1769–72. DOI:10.1001/archinte.164.16.1769. PMID 15364670. Research Blogging.
  4. ↑ 4.0 4.1 Lipton RB, Stewart WF, Liberman JN (2002). "Self-awareness of migraine: interpreting the labels that headache sufferers apply to their headaches". Neurology 58 (9 Suppl 6): S21–6. PMID 12011270. [e]
  5. ↑ Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM (2006). "Does this patient with headache have a migraine or need neuroimaging?". JAMA 296 (10): 1274–83. DOI:10.1001/jama.296.10.1274. PMID 16968852. Research Blogging.
  6. ↑ Lipton RB, Dodick D, Sadovsky R, et al (2003). "A self-administered screener for migraine in primary care: The ID Migraine validation study". Neurology 61 (3): 375-82. PMID 12913201. [e]
  7. ↑ Diener HC, Bussone G, de Liano H, et al (2004). "Placebo-controlled comparison of effervescent acetylsalicylic acid, sumatriptan and ibuprofen in the treatment of migraine attacks". Cephalalgia : an international journal of headache 24 (11): 947–54. DOI:10.1111/j.1468-2982.2004.00783.x. PMID 15482357. Research Blogging.
  8. ↑ Brandes JL, Kudrow D, Stark SR, et al (2007). "Sumatriptan-naproxen for acute treatment of migraine: a randomized trial". JAMA 297 (13): 1443-54. DOI:10.1001/jama.297.13.1443. PMID 17405970. Research Blogging.
  9. ↑ Colman I, Friedman BW, Brown MD, et al (June 2008). "Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence". BMJ 336 (7657): 1359–61. DOI:10.1136/bmj.39566.806725.BE. PMID 18541610. PMC 2427093. Research Blogging.
  10. ↑ Singh A, Alter HJ, Zaia B (October 2008). "Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta-analysis and Systematic Review of the Literature". Acad Emerg Med. DOI:10.1111/j.1553-2712.2008.00283.x. PMID 18976336. Research Blogging.
  11. ↑ Ho TW, Ferrari MD, Dodick DW, et al (December 2008). "Efficacy and tolerability of MK-0974 (telcagepant), a new oral antagonist of calcitonin gene-related peptide receptor, compared with zolmitriptan for acute migraine: a randomised, placebo-controlled, parallel-treatment trial". Lancet 372 (9656): 2115–23. DOI:10.1016/S0140-6736(08)61626-8. PMID 19036425. Research Blogging.
  12. ↑ Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF (2007). "Migraine prevalence, disease burden, and the need for preventive therapy". Neurology 68 (5): 343–9. DOI:10.1212/01.wnl.0000252808.97649.21. PMID 17261680. Research Blogging.
  13. ↑ Brandes JL, Saper JR, Diamond M, et al (2004). "Topiramate for migraine prevention: a randomized controlled trial". JAMA 291 (8): 965–73. DOI:10.1001/jama.291.8.965. PMID 14982912. Research Blogging.
  14. ↑ Schürks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T (2009). "Migraine and cardiovascular disease: systematic review and meta-analysis.". BMJ 339: b3914. DOI:10.1136/bmj.b3914. PMID 19861375. Research Blogging.
  15. ↑ Scher, Ann I.; Larus S. Gudmundsson, Sigurdur Sigurdsson, Anna Ghambaryan, Thor Aspelund, Guthny Eiriksdottir, Mark A. van Buchem, Vilmundur Gudnason, Lenore J. Launer (2009-06-24). "Migraine Headache in Middle Age and Late-Life Brain Infarcts". JAMA 301 (24): 2563-2570. DOI:10.1001/jama.2009.932. Retrieved on 2009-06-24. Research Blogging.
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