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SOURCE

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Source: Minor DS, Harrell TK. Headache disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L, eds. Pharmacotherapy: A Pathophysiologic Approach, 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146063736. Accessed January 19, 2017.

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DEFINITION

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  • Common, recurrent, primary headache of moderate to severe intensity interfering with normal functioning and associated with gastrointestinal (GI), neurologic, and autonomic symptoms.

  • In migraine with aura, focal neurologic symptoms precede or accompany attack.

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ETIOLOGY

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  • Believed to result from activity within trigeminovascular system, network of nerve fibers that innervate the pain-sensitive intracranial extracerebral blood vessels, dura mater, and large venous sinuses.

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PATHOPHYSIOLOGY

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  • Trigeminovascular system may be regulated by serotonergic neurons within brainstem.

  • Possible defect in activity of neuronal calcium channels mediating neurotransmitter release in brainstem areas that modulate cerebrovascular tone and nociception.

  • Vasodilation of intracranial extracerebral blood vessels with activation of trigeminovascular system.

  • Specific populations of vascular and neuronal serotonin (5-hydroxytryptamine [5-HT]) receptor subtypes may be involved.

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EPIDEMIOLOGY

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  • In United States, 17.1% of women and 5.6% of men experience one or more episodes per year.

  • Prevalence highest in both men and women between ages of 18 and 44 years.

  • Gender differences in migraine prevalence linked to menstruation but differences persist beyond menopause.

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RISK FACTORS

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  • Family history.

  • Age (adolescent onset)

  • Female sex (after puberty)

  • Hormonal changes associated with menstruation or pregnancy.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Recurring episodes of throbbing head pain, frequently unilateral; can be severe and associated with nausea, vomiting, and sensitivity to light, sound, and/or movement.

  • Premonitory symptoms may occur hours or days before headache onset.

    • Neurologic:

      • Allodynia.

      • Phonophobia.

      • Photophobia.

      • Hyperosmia.

      • Difficulty concentrating.

    • Psychological:

      • Anxiety.

      • Depression.

      • Euphoria.

      • Irritability.

      • Drowsiness.

      • Fatigue.

      • Hyperactivity.

      • Restlessness.

    • Autonomic:

      • Polyuria.

      • Diarrhea.

      • Constipation.

    • Constitutional:

      • Stiff neck.

      • Yawning.

      • Thirst.

      • Food cravings.

      • Anorexia.

  • Aura may evolve over 5 min or longer and last <60 min; headache begins within 60 min of end of aura.

    • Visual auras:

      • Scintillations.

      • Photopsia.

      • Teichopsia.

      • Fortification spectrum.

      • Scotoma.

      • Hemianopsia.

    • Sensory and motor:

      • Paresthesias or numbness of arms and face.

      • Dysphasia or aphasia.

      • Weakness.

      • Hemiparesis.

  • Pain gradual in onset, peaks in intensity over minutes to hours, and lasts 4–72 hours if untreated.

  • Pain can occur anywhere in the face or head but most often involves the frontotemporal region.

  • Headache is typically unilateral and throbbing or pulsating in nature.

  • Other symptoms include.

    • Anorexia.

    • Food cravings.

    • Constipation.

    • Diarrhea.

    • Abdominal cramps.

    • Nasal stuffiness.

    • Blurred vision.

    • Sensory hyperacuity (photophobia, phonophobia, or osmophobia)

  • Physical signs may include.

    • Diaphoresis.

    • Facial pallor.

    • Localized facial, scalp, or periorbital edema.

  • A resolution phase characterized by exhaustion, malaise, and irritability often ensues as pain recedes.

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DIAGNOSIS

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  • Obtain comprehensive headache history.

  • Features suggesting migraine headache.

    • Stable pattern of headaches.

    • Absence of daily headache.

    • Positive family history for migraine.

    • Normal neurologic examination.

    • Presence of food triggers.

    • Menstrual ...

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