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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 accompany attack.

  • 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.

  • 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 years.
  • 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

Signs and Symptoms

  • 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:
      • Phonophobia
      • Photophobia
      • Hyperosmia
      • Difficulty concentrating
    • Psychological:
      • Anxiety
      • Depression
      • Euphoria
      • Irritability
      • Drowsiness
      • Hyperactivity
      • Restlessness
    • Autonomic:
    • Constitutional:
      • Stiff neck
      • Yawning
      • Thirst
      • Food cravings
      • Anorexia
  • Aura may evolve over 5–20 minutes and last <60 minutes; headache begins within 60 minutes 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.
  • Other symptoms include:
    • Anorexia
    • 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.

  • 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 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 for headache.

Laboratory Tests

  • 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

Imaging

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