Migraine headache is a chronic, genetic, neurologic disorder involving abnormal sensory processing. Migraines are often disabling, leading to dramatic lifestyle changes and limitations for the migraineur. Clinicians must be confident in their diagnosis and treatment of migraine headaches if patient outcomes are to improve.
The pathophysiology of migraine headache has not been clearly elucidated. Early theories positing that migraine and migraine aura were solely due to vasodilation and vasoconstriction of cranial vasculature have been largely disproven. Recent theories emphasize the importance of close interactions between meningeal/cranial vessels and nerves; neuropeptides; and CNS structures, especially the trigeminal neurovascular unit and the brainstem.1,2 The migraineur's brain most likely has dysfunctional descending pain inhibition, is hyperexcitable, and has a decreased pain threshold. Several authors have discussed the pathophysiology of migraine.1,2
The diagnosis of migraine headache is straightforward and follows the guidelines established by the International Headache Society (IHS) in its second edition of the International Headache Classification (IHCD-2)3 (Table 1). Migraine headache is often characterized by moderate to severe unilateral throbbing pain and accompanied by nausea or vomiting, with sensitivities to lights and sounds. Note, however, that not all these elements need be present for a diagnosis of migraine.
Migraine aura can occur in up to 30% of persons with migraine headache.4 An aura is a stereotypical, reversible neurologic event that may occur either prior to or during a migraine headache. The aura can be visual, auditory, sensory, motor, or a combination of these. The most common aura is visual; the second most common is sensory. Visual auras include seeing light or dark spots, unformed flashes of light, or expanding zigzag lines, or they can manifest as tunnel vision. First-time visual loss or monocular visual loss warrants further investigation to rule out other neurologic problems, such as amaurosis fugax in the setting of a transient ischemic attack (TIA). Sensory auras are typically experienced either as tingling or numbness in the face or extremities or as a “sensory march,” which begins with sensory symptoms in the hand that may then progress upward along the arm or shoulder. A motor aura causes weakness, usually in an extremity, and may need further evaluation during a first-time event.
In addition to migraine with and without aura, there are four other subclassifications of migraine: childhood periodic syndromes that are commonly precursors of migraine, retinal migraine, complications of migraine, and probable migraine. Migraine with aura includes the following subtypes: typical aura with migraine headache, typical aura with nonmigraine headache, typical aura without headache, basilartype migraine, familial hemiplegic migraine, and sporadic hemiplegic migraine.3 The complications of migraine subclassification include chronic migraine and status migrainosus. Chronic migraine headache is a migraine headache that occurs on 15 or more days per month for at least 3 months.
Migraine headaches are often misdiagnosed. Migraineurs are frequently told they have sinus headache, toothache, “allergy headache,” or tension headache. By applying IHS-ICHD-2 migraine criteria, performing a thorough examination, and bearing in mind the cranial and cervical anatomy (particularly the three divisions of the trigeminal nerve), the clinician can correctly diagnose migraine.
In most patients, the diagnosis of migraine is straightforward and additional testing or imaging is not needed. However, certain headache patterns or features are more ominous and may reflect serious underlying abnormalities requiring immediate attention. Some of these red-flag patterns include headache with rapid onset and peak (seconds to minutes); a first or worst headache; headache with abnormal neurologic symptoms or signs; headache accompanied by a change in level of consciousness; headache associated with fever/chills or a stiff neck; headache following trauma (particularly head trauma); new-onset headache in a patient older than 50 years; headaches in patients who are immunosuppressed, have a malignancy, or are HIVpositive; headache during pregnancy or postpartum; and headache caused by exertion, sexual intercourse, or Valsalva maneuver.5,6
Various medical conditions are frequently accompanied by headaches, and it is important to remember that patients may have more than one headache disorder. Taking into consideration systemic symptoms, neurologic symptoms, onset timing, onset after age 50 years, and pattern change in the patient with a history of headaches will help identify the cause of secondary headaches (Table 2). The mnemonic SNOOP4 is a helpful tool for this purpose.
The evaluation of a secondary headache disorder depends on the clinical presentation. The diagnostic evaluation may include brain imaging (CT, MRI, magnetic resonance angiography [MRA], magnetic resonance venography [MRV]) with or without IV contrast enhancement; lumbar puncture; serum testing, including ESR; and assessment for malignancies or an immunosuppressed state. Not all testing is needed for all patients.
Migraine treatment is divided into preventive and acute therapies. The treatment plan will depend on headache frequency, severity, and associated disability for the patient. The plan should involve both nonpharmacologic and pharmacologic management.
Begin by addressing lifestyle issues and headache triggers with all patients. The three most common triggers for migraine headaches are poorly managed stress, hormonal changes, and poor sleep patterns, so educating the patient in these areas is essential. Proper diet and exercise are also important. Many patients with frequent migraines are overusing caffeine products and OTC analgesics. Narcotic use is also common in these patients. All these products have been implicated in migraine progression and can contribute to medication overuse headaches (MOHs), which make chronic migraines more resistant to treatment. (See “Medication overuse headaches.”) A key approach to therapy is to have patients taper off and/or discontinue use of caffeine, OTC analgesics, and narcotics. Inform them that they may feel worse before they begin to improve while they are discontinuing these products.
“A stepped-care approach has been shown to be time-consuming and ineffectual overall, and it often worsens the migraine condition.”
Preventive therapy Patients with three or more disabling headaches per month may benefit by using a preventive medication.7 When choosing an agent, consider a medication's efficacy and side-effect profile as well as the patient's comorbid conditions. Table: Medications for prevention of migraine headache (available online) lists the most commonly used preventives. Other agents include onabotulinum toxin type A injections (Botox), magnesium, riboflavin, and butterbur (an herb of the genus Petasites). While numerous preventative treatments are available, the treating clinician should become comfortable with using two to three medications and be aware of other options that are available if needed.
- Migraine headache is often characterized by moderate to severe unilateral, throbbing pain and accompanied by nausea or vomiting, with sensitivities to lights and sounds.
- The three most common triggers for migraine headaches are poorly managed stress, hormonal changes, and poor sleep patterns.
- While numerous preventive treatments are available, the treating clinician should become comfortable with using two to three medications and be aware of other options that are available if needed.
- The triptans treat associated migraine symptoms as well as the migraine pain.
Medication overuse headaches8
Medication overuse headaches (MOHs) are considered secondary headaches and are caused by the chronic overuse of symptomatic headache medications, such as analgesics, triptans, ergots, and opioids. The complex biochemical nature of MOH is not known at this time; however, these headaches impose a hurdle that must be overcome before successful treatment of chronic migraine headaches can be achieved. abrupt cessation of the offending medication is usually recommended. However, withdrawal of the overused medications can also lead to headaches and other symptoms that include worsening migraine headaches, anxiety, nausea and vomiting, sleep disturbances, and hypotension. Treatment of MOH ranges from preventive medication and nerve blocks to admission to an outpatient unit where the patient receives IV corticosteroids along with IV hydration.
Patients often do not notice benefit with a particular preventive medication for at least 6 weeks, and the medication frequently needs to be titrated to higher doses before it is effective. Educating the patient about this fact and providing the proper support is crucial to successful therapy. Other, nonmedicinal treatment options include biofeedback, meditation, physical and massage therapy, acupuncture, exercise, and counseling.
Acute treatment There are both pharmacologic and nonpharmacologic treatments for an acute migraine headache. In the past, patients were often treated acutely using a stepped-care approach, starting with the least effective, “weakest,” or least intrusive treatment and then adding or changing treatments when the current treatment proved suboptimal. This has been shown to be a time-consuming and, overall, ineffectual approach, and it often worsens the migraine headache condition. A stratifiedcare approach has proven to be much more successful in a shorter amount of time. In this situation, the patient with a known diagnosis of migraine headache is started on disease-specific treatments for his or her individual acute headache. Here again, treating headaches acutely without working on headache prevention often leads to MOH that can evolve and become chronic migraine.
Individual acute treatments include limiting the use of oral OTC medications while judiciously prescribing analgesics, prescription muscle relaxers, prescription triptans, prescription antiemetics, and prescription “rescue” medications, along with performing trigger point injections (TPIs) and nerve blocks. Probably the most important recent addition to acute migraine therapy has been the introduction of the triptan medications. The triptans are migrainespecific, treat associated migraine symptoms as well as the migraine pain, and are available in multiple brands and routes of administration (Table 3).
Most triptans have the same instructions for use, but clinicians should become familiar with the several triptans they usually prescribe. All are contraindicated in patients with cardiovascular disease, peripheral vascular disease, uncontrolled hypertension, basilar-type migraine, migraine with prolonged aura, and hemiplegic migraine. Patients with cardiovascular risk factors, such as obesity, hypertension, hypercholesterolemia, diabetes mellitus, sleep apnea, and estrogen use, and those who smoke may not be good candidates for treatment with a triptan, especially if they have multiple risk factors. Additionally, all triptans are dosed so that the patient takes one tablet as early as possible during the onset of headache. For most medications, another dose can be taken after 2 hours if the headache persists. Exceptions to that schedule include having to wait 4 hours to take a second dose of Amerge; Sumavel DosePro can be repeated in 1 hour. The patient should try a specific triptan with at least two to three headaches before deciding if it works or not. Two different triptans should not be used within 24 hours of one another. Additionally, triptan use should be limited to 1 to 2 days a week, as more frequent use can lead to MOH.
Neuroleptic drugs, such as metoclopramide (Reglan, generics), chlorpromazine, and olanzapine (Zyprexa generics), are also effective for migraine headaches. Some practices avoid using chlorpromazine because of an increased risk of cardiac arrhythmias. Neuroleptic drugs can be used when NSAIDs or triptans are contraindicated or as rescue medications.
treatment summary At the patient's initial visit to our practice, we often administer a series of nerve blocks and TPIs to help break the current headache cycle. (See “Nerve blocks and trigger point injections.”) In addition, the patient is usually started on a preventive medication and given a muscle relaxer or rescue medication to treat acute headaches. At a follow-up appointment 2 weeks later, we perform the second of a series of three nerve blocks/TPIs. We further reinforce positive lifestyle choices, adjust medications when needed, and answer any questions the patient may have. This process is repeated in 2 more weeks. The next appointment is scheduled 6 to 8 weeks later. Patients do better if they are seen more frequently at first, after which they can spread out their appointments as their condition improves.
Nerve blocks and trigger point injections
for nerve blocks and trigger point injections (TPIs), we use a mixture of lidocaine, marcaine, and dexamethasone in a 2:2:1 ratio. Injections are typically given in the areas of the greater and lesser occipital nerves, bilateral supraorbital nerves, bilateral suprascapular nerves, bilateral paraspinal muscles at the level of C7-T1, paracervical muscles, and bilateral posterior superior trapezius muscles. Other nerve blocks can be administered on an as-indicated basis. a number of articles on nerve blocks and TPIs have been published in the medical literature.1–3
1. ashkenazi a, blumenfeld a, Napchan u, et al. Peripheral nerve blocks and trigger point injections in headache management-a systematic review and suggestions for future research. Headache. 2010;50(6):943-952.
2. blumenfeld a, ashkenazi a. Nerve blocks trigger point injections and headache. Headache. 2010;50(6):953-954.
3. Tobin J, flitman S. Occipital nerve blocks: when and what to inject? Headache. 2009;49(10):1521-1533.
Patients who suffer from migraine headaches often have comorbid conditions, including obesity, fibromyalgia, insomnia, sleep apnea, depression, and anxiety. Recognizing these comorbid conditions is important, as treating them often results in improvement of the migraine headaches. Patients benefit from a coordinated effort from their various health care providers.
Once patients have been given a diagnosis of migraine headache, proactive treatment should be started immediately. Discussing and reviewing lifestyle changes is an important key to treatment. Regular followup is also important, and patients are usually willing to come in more frequently if they see that the provider cares and that they are making progress. A patient who notes a change in headache pattern, worsening headaches, or new neurologic symptoms may require further evaluation.
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8th ed. New York, NY: Oxford University Press; 2008:105-112.
2. Levy D. Migraine pain and nociceptor activation—where do we stand? Headache.
3. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Part I. The primary headaches. Cephalalgia.
4. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia.
5. Saper J, Silberstein S, Gordon CD, et al. Handbook of Headache Management: A Practical Guide to Diagnosis and Treatment of Head, Neck, and Facial Pain.
2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999:57.
6. Dodick DW. Pearls: headache. Semin Neurol.
7. Loder E, Biondi D. General principles of migraine management: the changing role of prevention. Headache.
8. Trucco M, Meineri P, Ruiz, L, et al. Medication overuse headache: withdrawal and prophylactic therapeutic regimen. Headache.
9. Migraine and headache. In: Ernst D, Lee A, eds. Physician Assistants' Prescribing Reference.
New York, NY: Haymarket Media; Winter 2010-2011;17(4):270-275.
EARN CATEGORY I CME CREDIT by reading this article and the article beginning on page 30 and successfully completing the posttest on page 53. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CMe credit by the aaPa. The term of approval is for 1 year from the publication date of february 2012.