Source: Minor DS. Headache Disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7986542. Accessed June 9, 2012.
- 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
- 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
- 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.
- In United States, 17.1% of women and 5.6% of
men experience one or more episodes per year.
- More common in boys than girls before age of 12 years; prevalence
increases more rapidly in girls after puberty.
- After age 12 years, females 2–3 times more likely
than males to suffer from migraine.
- Prevalence highest in both men and women between ages of 30–49
- Usual age of onset 12–17 years for females and 5–11
years for males.
- Family history
- Age (adolescent onset)
- Female sex (after puberty)
- Hormonal changes associated with menstruation or pregnancy
- 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
- Difficulty concentrating
- Stiff neck
- Food cravings
- Aura may evolve over 5–20 minutes and last <60
minutes; headache begins within 60 minutes of end of aura.
- Visual auras:
- Fortification spectrum
- Sensory and motor:
- Paresthesias or numbness
of arms and face
- Dysphasia or aphasia
- Pain gradual in onset, peaks in intensity over minutes to
hours, and lasts 4–72 hours if untreated.
- Other symptoms include:
- Abdominal cramps
- Nasal stuffiness
- Blurred vision
- Sensory hyperacuity (photophobia, phonophobia, or osmophobia)
- Physical signs may include:
- Facial pallor
- Localized facial, scalp, or periorbital edema
- A resolution phase characterized by exhaustion, malaise, and
irritability often ensues as pain recedes.
- Obtain comprehensive headache history.
- Features suggesting migraine headache:
pattern of headaches
- Absence of daily headache
- Positive family history for migraine
- Normal neurologic examination
- Presence of food triggers
- Menstrual association
- Longstanding history
- Improvement with sleep
- Subacute evolution
- Aura may signal migraine headache but not required for diagnosis.
- Perform full physical examination to exclude other causes
- When appropriate, consider:
- Serum chemistries
- Urine toxicology profiles
- Thyroid function tests
- Lyme disease studies
- Complete blood count (CBC)
- Antinuclear antibody titer
- Erythrocyte sedimentation rate (ESR)
- Antiphospholipid antibody titer