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Introduction to Migraine
Posted February 2000

Definition and Characteristics of Migraine
Migraine with aura and migraine without aura have replaced the older terms "classical migraine" and "nonclassical migraine." In my treatment of migraine, I usually do not differentiate between migraine with or without aura, as the therapy generally remains the same. Migraine without aura is a chronic idiopathic headache disorder with attacks lasting 4 to 72 hours. Status migrainosis applies to migraine headaches that exceed 72 hours in length. Migraine features often include unilateral location; moderate, moderate-to-severe, or severe intensity of the pain; and a throbbing or pulsating nature to the pain. There may be associated nausea, photophobia, or phonophobia. Migraine in first-degree relatives (70% to 75% of migraine patients report a first-degree relative having had migraine), positive relationship with menses, decreased frequency during pregnancy, and increase of the pain with physical activity are further characteristics (See Table 1.1).

A recurring headache that is moderate or severe and is triggered by migraine precipitating factors is usually considered to be migraine. These factors include stress, certain foods, weather changes, smoke, hunger, fatigue, etc. Migraineurs often have colder hands and feet than controls, and the prevalence of motion sickness is much higher in migraine patients. Patients usually do not have all of the above characteristics, and there are certain diagnositc criteria that have been established by the International Headache Society for the definite diagnosis of migraine. Many patients do not have nausea, photophobia, or phonophobia. Distinguishing a milder migraine without aura from a moderate or severe tension headache may be very difficult, and I am not surprised when "pure" migraine medications are effective for severe tension headaches.

Table 1.1. Characteristics of Migraine:

Attacks are 4 to 72 hours
Moderate or moderate-to-severe pain
History by the patient gives the diagnosis, not lab tests
Often early morning, but may be anytime
Unilateral in one half of patients
One to five migraines per month is typical
Gradual onset of pain, a peak for hours, slow decline
Pain is throbbing, pounding, pulsatile, or deep aching
Sharp "ice-pick" jabs are common
Peak ages are between 20 and 35 years
20% of women, 7% of men experience migraine in their lifetime; female/male ratio is 3:1
Family history is often positive for migraine
Associated nausea, photophobia, blurred vision, phonophobia, dizzinessis common; however, these may be absent
In women, there is often a positive relationship with menses: period
Cold hands and feet, or motion sickness is common in migraine patients

I generally regard recurrent, repeated attacks of throbbing or severe aching headache as migraine, whether or not the patient has nausea, photophobia, or phonophobia. We are assuming that organic disorders, particularly brain tumors, have been ruled out or excluded. Eighteen percent of women and 7% of men experience recurring migraine headaches at some point during their lifetime. The peak ages are between 20 and 35 years old.

The patient's history gives us the diagnosis of migraine. Physical exam and MRI or CAT scans are helpful only in ruling out organic pathology. Although migraine headadches may begin at any time during the day, they often begin early in the morning, upon awakening. Headaches that are of recent onset need to be investigated with an MRI scan. A check of intraocular pressure may be warranted. Although the pain is unilateral in 50% of migraineurs, the entire head often becomes involved. The pain may be in the facial or cervical areas, and often will shift sides from one occurrence to another. Most patients, however, suffer the severe pain on one favored side from attack to attack.

The typical migraine patient suffers one to five attacks per month, but many patients average less than one or more than 10 per month. The attack frequency varies with the seasons, and many patients can identify the time of year when their headaches increase significantly.

The pain of the migraine often follows a bell shaped curve, with a gradual ascent, a peak for a number of hours (or longer), and then a slow decline. Occasionally the pain may be at its peak within minutes of the onset.

Migraine pain is often throbbing, pounding, or pulsatile, particularly when the patient's head is bent. The pain may simply be a steady, severe ache. Jabs of sharp pain, lasting seconds, are frequently experienced by migraineurs.

Most patients with migraine suffer some degree of nausea during the attack, and many patients have vomiting as well. T he nausea is often mild, and some migraineurs are not bothered by it. Many patients state that the headache is lessened after they vomit. Diarrhea occurs in some patients, and is usually mild to moderate. The presence of diarrhea renders the use of rectal suppositories very difficult (See Table 1.2).

Lightheadedness often accompanies the migraine, and syncope may occur; some patients pass out regularly with their attacks. Most patients become very sensitive to bright lights, sounds, and to odors. In between migraine attacks, many patients retain the photophobia and it is common for migraine patients to wear sunglasses most of the time. Sensitivity to bright lights is a distinictive migraine characteristic.

Table 1.2. Somatic Symptoms Accompanying Migraine:
Listed in order of frequency:

  1. Sensitivity to light
  2. Blurred vision
  3. Nausea
  4. Tenderness about the scalp
  5. Dizziness or lighheadedness
  6. Lethargy
  7. Vomiting
  8. Retention of fluid, with with gain
  9. Photopsia
  10. Vertigo
  11. Anxiety
  12. Paresthesias
  13. Diarrhea
  14. Fortification spectra
  15. Nasal stuffiness
  16. Mild aphasia
  17. Syncope or near syncope
  18. Severe confusion
  19. Seizures
  20. Fever
  21. Hemiparesis or hemiplegia
  22. Ataxia and/or dysarthria (brain stem dysfunction)

Pallor of the face is common during a migraine; flushing may occur as well, but is seen less often. Patients often complain of feeling excessively hot or cold during an attack, and the skin temperature may increase or decrease on the side of the pain. Migraineurs often have cold hands and/or feet at all times.

Migraineurs often experience tenderness of the scalp that may linger on for hours or days after the migraine pain has ceased. This tenderness may actually occur during the prodrome of the migraine. Both vascular and muscular factors contribute to the scalp tenderness.

Mild elevations in temperature are more commonly seen with migraines than is generally appreciated. Autonomic disturbances are relatively common, such as pupillary miosis or dilatation, rhinorrhea, eye tearing and nasal stuffiness. These are also symptoms of cluster headache, and migraineurs often experience aspects of cluster headache, including the sharp pain about one eye or temple.

Alterations in mood are seen with many patients prior to, during, and after migraine attacks. Patients are usually anxious, tired, or depressed. They often feel "washed out" after an attack, but a calm or euphoric state occasionally is seen as a postdrome to the migraine. Rarely, euphoria or exhilaration may precede a migraine.

Weight gain due to fluid retention is common, and begins prior to the migraine. At some point during the migraine, patients often experience polyuria. The weight gain is usually less than 6 pounds, and is transient.

Visual Disturbances:
Blurred vision is very common during migraine attacks, and is usually only mild or moderate. Approximately 40% of patients experience visual neurologic distrurbances preceding or during the migraine; these auras may be as disturbing to the patient as the migraine pain itself. Most migraineurs experience the same aura with each migraine, but occasionally one person may have several types of auras. "The light of a flashbulb going off" is the description that many migraineurs give to their aura. The visual hallucinations seen most often consist of spots, stars, lines (often wavy), color splashes, and waves resembling heat waves. The images may seem to shimmer, sparkle or flicker. The above visual occurences are referred to as photopsia.

Fortification spectra are seen much less often than photopsia. They usually begin with a decrease in vision and visual hallucinations that are unformed. Within minutes, a paracentral scotoma becomes evident, and this assumes a crescent shape, usually with "zig-zags". There is often associated shimmering, sparkling, or flickering at the edges of the scotoma.

Patients may experience a "graying out" of their vision, or a "whiteout" may occur. Some patients suffer complete visual loss, usually for some minutes. Photopsia may be experienced at the same time as the grayout, whiteout, or visual loss.

The visual symptoms usually last 15 to 20 minutes, and most often will be followed by the migraine headache. Visual symptoms without the headache are common, and are often very distressing to the patient; the aura may last as little as 1 to 2 minutes.

Miscellaneous Neurologic Symptoms Associated with Migraine:
Numbness or tingling (paresthesias) are commonly experienced as part of the migraine. These are most often experienced in one hand and forearm, but may be felt in the face, periorally, or in both arms and legs. Like the visual disturbances, they often last only minutes preceeding the pain, but the numbness may go on for hours, and at times the paresthesias are severe. The sensory disturbances usually increase slowly over 15 to 25 minutes, differentiating them from the more rapid pace seen with epilepsy.

Paralysis of the limbs may occur, but this is rare. This is occasionally seen as a familial autosomal dominant trait, and the term familial hemiplegic migraine is applied to this form. With the weakness, aphasia or slurred speech may also occur, and sensory disturbances are seen ipsilateral to the weakness.

Vertigo is occasionally experienced during the attack of migraine, and may be disabling. Ataxia may occur, but is not common. Rarely, multiple symptoms of brain stem dysfunction may occur, with the term basilar migraine being applied to this type of syndrome. The attack usually begins with visual disturbances (most often photopsia), followed by ataxia, vertigo, paresthesias, and other brain stem symptoms. After 15 to 30 minutes, these severe neurologic symptoms usually abate, and are followed by a headache. This type of migraine often stops over months or years, and the patient is simply left with migraine headaches without neurologic dysfunction.