Chapter 55: Headache: Migraine and Tension-Type

MIGRAINE HEADACHE

• Migraine, a common, recurrent, primary headache of moderate-to-severe intensity, interferes with normal functioning and is associated with gastrointestinal (GI), neurologic, and autonomic symptoms. In migraine with aura, focal neurologic symptoms precede or accompany the attack.

Pathophysiology

• Activation of trigeminal sensory nerves triggers the release of vasoactive neuropeptides, including calcitonin gene-related peptide (CGRP), neurokinin A, and substance P from perivascular axons. Vasodilation of dural blood vessels may occur with extravasation of dural plasma resulting in inflammation.

• Twin studies suggest 50% heritability of migraine, with a multifactorial polygenic basis. Migraine triggers may be modulators of the genetic set point that predisposes to migraine headache.

• Specific populations of serotonin (5-HT) receptors appear to be involved in the pathophysiology and treatment of migraine headache.

Clinical Presentation

• Migraine headache is characterized by recurring episodes of throbbing head pain, frequently unilateral.

• Up to 79% of patients with migraines have premonitory symptoms (not to be confused with aura) in the hours or days before headache onset. Neurologic symptoms (phonophobia, photophobia, hyperosmia, and difficulty concentrating) are most common, but psychological (anxiety, depression, euphoria, irritability, drowsiness, hyperactivity, and restlessness), autonomic (eg, polyuria, diarrhea, and constipation), and constitutional (eg, stiff neck, yawning, thirst, food cravings, and anorexia) symptoms may also occur.

• A migraine aura is experienced by approximately 25% of patients with migraines. Aura evolves over 5–20 minutes and lasts less than 60 minutes. Headache usually occurs within 60 minutes of the end of the aura. Visual auras can include both positive features (eg, scintillations, photopsia, teichopsia, and fortification spectrum) and negative features (eg, scotoma and hemianopsia). Sensory symptoms such as paresthesias or numbness of the arms and face, dysphasia or aphasia, weakness, and hemiparesis may also occur.

• Migraine headache may occur at any time but usually occurs in the early morning. Pain is usually gradual in onset, peaking in intensity over minutes to hours and lasting 4–72 hours. Pain is typically in the frontotemporal region and is moderate to severe. Headache is usually unilateral and throbbing with GI symptoms (eg, nausea and vomiting) almost invariably accompanying the headache. Other systemic symptoms include anorexia, constipation, diarrhea, abdominal cramps, nasal stuffiness, blurred vision, diaphoresis, facial pallor, and localized facial, scalp, or periorbital edema. Sensory hyperacuity (photophobia, phonophobia, or osmophobia) is frequent. Many patients seek a dark, quiet place.

• Once the headache pain wanes, a resolution phase characterized by exhaustion, malaise, and irritability ensues.

Diagnosis

• The International Headache Society (IHS) has published diagnostic criteria for classic migraine variants and other migraine subtypes

• A comprehensive headache history is essential and includes age at onset; frequency, timing, and duration of attacks; possible triggers; ameliorating factors; description and characteristics of symptoms; associated signs and symptoms; treatment history; and family and social history.

• Neuroimaging should be considered in patients with unexplained abnormal neurologic examination or atypical headache history.

• Onset of migraine ...