Migraine Headache

By admin On Oct 15, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Migraine Headache

Jennifer J. Mitchell

Tim Sprockel

Basics

Description

Common cause of benign episodic headache:
- Sensory sensitivity
- Frequently altering activities of daily living
Characterized by at least 2 of the following (1):
- Chronic
- Unilateral
- Throbbing or pulsating
- Worsened by movement or activity
- Moderate-to-severe pain intensity
Including at least 1 of the following:
- Nausea
- Vomiting
- Photophobia
- Phonophobia
Subtypes:
- Migraine without aura:
  - Common migraine
  - Most frequent variant
  - No sensory, motor, or visual disturbances
- Migraine with aura:
  - Classic migraine
  - Characteristically with sensory, motor, and/or visual disturbances at onset
- Acephalgic migraine (less common subtype):
  - Typical aura occurs, but no headache
- Basilar migraine (less common subtype):
  - Headache with aura
  - Disturbances in brainstem function; diplopia, dysarthria, paresthesias, tinnitus, vertigo
  - No motor weakness
- Familial hemiplegic migraine (less common subtype):
  - Headache with aura
  - Hemiparesis or hemiplegia
  - Patient with a 1st- or 2nd-degree relative with similar symptoms
- Medication overuse migraine (less common subtype):
  - Excessive use or consumption of analgesic medications
- Menstrual migraine (less common subtype):
  - Headaches present 2 days before through 1st 3 days of menses
- Retinal migraine (less common subtype):
  - Headache with recurrent monocular visual disturbances
  - Normal ophthalmologic exam in between migraine attacks
- Sporadic hemiplegic migraine (less common subtype):
  - Headache with aura
  - Hemiparesis or hemiplegia

Epidemiology

Females > Males (2)
Before puberty, Males > Females
Throughout puberty and adolescence, prevalence and incidence increase rapidly in females.

Risk Factors

Family history of migraine headaches
Female gender, in particular after onset of menses
Certain foods (red wine, cheese, deli meats, MSG)
Sleep cycle disturbances (lack of sleep)
Emotional or psychological disturbances
Oral contraceptive pills; estrogen therapy
Missing or skipping meals

Genetics

Migraine with aura has a hereditary component,
Chromosome 19 associated with familial hemiplegic migraine
MELAS syndrome (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes):
- Extremely rare progressive neurological disorder leading to dementia:
  - May present with migraine-like headaches
  - Linked to a mutation in a mitochondrial gene

General Prevention

Identify and avoid triggers:
- Foods—cheeses, meats, MSG
- Red wine:
  - Postulated causative agents tyramines and tannins (plant polyphenols)
- Inadequate sleep patterns
- Irregular eating times/skipping meals
- Consider discontinuation of:
  - Oral contraceptive pills
  - Hormone replacement therapy
Establish and implement ways to manage emotional and/or psychological stressors.
Evaluate association with menstrual cycle.
Use medications for prophylactic treatment.

Etiology

2 potential causes:
- Vascular theory:
  - Vasodilation and vasoconstriction of cerebral blood vessels
- Neurovascular theory:
  - Neuronal excitation in the gray matter with simultaneous vasodilation and vasoconstriction
  - Excitation of sensory neurons in the occipital region, brainstem, hypothalamus, and thalamus
Ongoing research examining the role of serotonin and calcitonin gene-related peptide as possible etiologies

Commonly Associated Conditions

Anxiety (2)
Asthma/allergy
Atrial septal aneurysm
Bipolar disorder
Cerebrovascular accident: Ischemic, subclinical, or white matter abnormality
Depression
Epilepsy
Fluctuations in BP
Irritable bowel syndrome
Mitral valve prolapse
Panic disorder
Patent foramen ovale
Reynaud's phenomenon
Sleep apnea/snoring
Systemic lupus erythematosus
Tourette's syndrome

Diagnosis

History

Migraine without aura:
- Episodic headaches lasting 4–72 hr
- Includes at least 2 of the following:
  - Unilateral
  - Throbbing
  - Worsened by movement
  - Moderate or severe
- And includes at least 1 of the following:
  - Nausea
  - Vomiting
  - Photophobia
  - Phonophobia

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Migraine with aura:
- Headache consistent with migraine without aura AND
- Includes at least 1 temporary disturbance: Visual, sensory, speech
- Includes at least 2 of the following:
  - Each disturbance lasts at least 5 min, not >60 min, and is fully reversible.
  - 1 disturbance develops slowly over time, and other disturbances appear in succession over time.
  - Homonymous visual symptoms and/or unilateral sensory symptoms
- Aura is characterized, in order of incidence, by visual, sensory, language, motor disturbances
- Other associated symptoms include:
  - Diarrhea
  - Lightheadedness
  - Muscular tenderness
  - Vertigo
  - Syncope
  - Paresthesias

Physical Exam

General physical examination
Detailed neurological examination

Diagnostic Tests & Interpretation

Lab

Typically not needed, especially in those with established migraines with typical symptoms
Labs to consider if concern for other diagnoses:
- Pseudotumor cerebri:
  - Lumbar puncture (LP) with opening pressure
  - No LP until after cerebral imaging to rule out intracranial mass, which could cause cerebral herniation
- Meningitis:
  - CT or MRI 1st as above, then LP
- Temporal arteritis:
  - Erythrocyte sedimentation rate
  - C-reactive protein
- Hypoxia from carbon monoxide poisoning:
  - Carbon monoxide level

Imaging

CT scan or MRI to rule out intracranial hemorrhage or tumor
MRI is preferred over CT (3)[B].
Red flags to prompt imaging:
- 1st or worst headache
- Subacute headaches with increased frequency and/or severity
- Progressively worsening headache
- Headache always on the same side
- Not responding to treatment
- New-onset headache in immunocompromised individuals or with history of malignancy
- New-onset headache after age 50
- Seizures with headaches
- Headache with:
  - Signs of meningitis:
    - Fever
    - Stiff neck
    - Altered mental status
    - Sick contacts
  - Focal neurological deficits
  - Papilledema
  - Cognitive impairment
  - Personality changes

Differential Diagnosis

Acid/base disturbance
Acute ischemic cerebrovascular accident (CVA)
Cerebral aneurysm/vascular malformation
Cluster headache
Dental abscess
Exertional headache
Head trauma
Hemorrhagic CVA
Hypoglycemia
Hypoxia
Intracranial infection
Intracranial malignancy
Medication side effects (eg, nitroglycerin, sildenafil)
Nonintracranial infections
Poor visual acuity
Pseudotumor cerebri
Psychiatric disorder
Secondary gain
Sinus infection or congestion
Substance withdrawal or exposure
Temporal arteritis
Temporomandibular joint disorders
Transient ischemic attack
Tension headache
Uncontrolled HTN

Treatment

Preventive treatment (4)[A]:

Determining initiation:
- Significantly impacting patient's daily life
- Failure or contraindication to abortive medications
- Overuse of abortive medications
- Patient preference
Start at low dose and increase slowly until desired effect
Allow adequate time for medication to work:
- 6–8 wks for some
Examples of preventive medications with recommended doses:
- Anticonvulsants:
  - Topiramate 15–25 mg PO at bedtime
- Antidepressants:
  - Amitriptyline 10 mg PO at bedtime
  - Venalfaxine 37.5 mg PO in morning
- Beta-blockers:
  - Atenolol 50 mg PO daily
  - Propranolol 40 mg PO b.i.d.
- Calcium channel blockers:
  - Verapamil 80 mg PO b.i.d. or t.i.d.
  - Flunarizine 5 mg PO at bedtime
Selective serotonin reuptake inhibitors not effective (5)

Medication

Medication contraindications/cautions:

Serotonin agonists contraindicated in patients with:
- Coronary artery disease
- Peripheral vascular disease
- Uncontrolled HTN
- Patients with a complicated migraine course
Do not use serotonin agonists in patients who:
- Have taken ergotamine derivatives within 24 hr
- Have taken other serotonin agonists within 24 hr
- Utilize monamine oxidase inhibitors.
Do not use NSAIDs or ASA in patients with known gastric ulcers.
Do not use NSAIDs in patients with liver or renal compromise.
Do not use narcotics if suspected secondary gain.
Avoid medications in patients with suspected or documented allergy to that substance.
Consider that frequent use of a medication may lead to overuse headache or rebound headache.
Pregnancy:
- Serotonin agonists are not FDA-approved for use during pregnancy, Category C
- Ergot derivatives are contraindicated, Category X
- Narcotic medications are Category B and C
- Serotonin agonists pass through breast milk.
Pediatrics:
- Serotonin agonists are not recommended for use in patients under 18 yrs of age.

First Line

OTC medications:
- NSAIDs
- Aspirin (ASA)
- Acetaminophen (APAP)
- Combination medications that include caffeine, ASA, and APAP

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Prescription medications:
- Ketorolac 30–60 mg IM/IV
- Midrin 2 caps PO at onset of headache
Serotonin agonists (triptans) chosen based on:
- Onset of action
- Mode of delivery
- Cost to patient
- Examples:
  - Sumatriptan 25 mg PO or 5 mg nasal spray or 4 mg SC
  - Zolmitriptan 2.5 mg PO or 5 mg nasal spray
Ergotamine use has declined since the introduction of serotonin agonists
Potential problems with medication use:
- Medication overuse
- Withdrawal/rebound headaches (6)[A]

Second Line

Use of narcotic in refractory migraine headaches:
- Morphine 2–4 mg IV
- Meperidine 50–100 mg IM/IV
- Caution advised with use of narcotics (6)[A]
Adjunct therapy (antiemetics) (6)[A]:
- Promethazine 25–50 mg PR/IM/IV
- Metoclopramide 10 mg IV/IM
- Prochlorperazine 5–10 mg PO
- Ondansetron 4 mg IV/IM
- Some antiemetics themselves treat migraine pain.
- Otherwise, used as adjunctive treatment to allow patient to tolerate oral abortive medications

Additional Treatment

Remove from known environmental stimuli or stressors.
Encourage sleep.
Avoid known triggers.

Complementary and Alternative Medicine

Preventive therapies (4)[A]:

Evidence of efficacy in reducing frequency:
- Riboflavin 400 mg (vitamin B₂) daily
- Butterbur extract 75 mg b.i.d.
- Acupuncture effective as prophylaxis alone or in conjunction with analgesics, antidepressants, beta-blockers or anticonvulsants (7)
No evidence of efficacy:
- Botulinum toxin type A (Botox)
- Herbal supplements such as feverfew

In-Patient Considerations

Initial Stabilization

ABCs
IV fluids
Medications:
- Analgesics
- Antiemetics
Removal from environmental stimuli

Admission Criteria

Unstable vital signs
Neurologic exam with focal deficits that do not resolve
Unclear diagnosis or to exclude life-threatening illness
Intractable migraine despite appropriate therapy
Intractable nausea and vomiting
Electrolyte imbalance
Potential self-harm or harm to others due to symptoms or medications

Discharge Criteria

Resolution or improvement of symptoms
Certain of diagnosis
Life-threatening pathology ruled out
Able to tolerate oral liquids/food and medications

Ongoing Care

Return to play criteria:

No neurological or cognitive deficits
Resolution of symptoms:
- Movement or activity can worsen migraine symptoms
- Play with ongoing symptoms could create difficulty in evaluation if the athlete sustains a concussion.
Migraine headache after concussion:
- May not return to play until all symptoms resolved (increased risk for 2nd impact syndrome if still symptomatic)
- High school and college athletes with migraine after concussion may have increased neurocognitive impairment.
Consider potential medication side effects and how these may affect performance.

Follow-Up Recommendations

Patient education on:
- Etiology
- Natural course of illness
- Cautions concerning progression of illness
- Use of medications/avoiding overuse
Headache journal to identify potential triggers
Discuss lifestyle modifications:
- Avoidance of triggers
- Abortive treatment
Follow-up visits based on patient's:
- Understanding of condition
- Ability to self-assess and self-treat
- Frequency of headaches

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Prognosis

Most migraines last from 4–72 hr:
- If persisting, must consider other pathology
Most patients dramatically reduce the number of migraine episodes by avoiding triggers.
Remission increases with age.

Complications

Status migrainous:
- Migraine lasting >72 hr
- Severely alters patient's activities
Migrainous stroke:
- Presence of 1 or more aura symptoms
- Associated lesion demonstrated on brain imaging
Chronic migraine:
- Headache without aura
- Present for at least 15 days per month
- Over a time span >3 mos (8)
Medication overuse migraines
Medication side effects

References

1. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalgia. 2004;24(Suppl 1):1–160.

2. Bigal ME, Lipton RB. The epidemiology, burden, and comorbidities of migraine. Neurol Clin. 2009;27:321–334.

3. Evans RW. Diagnostic testing for migraine and other primary headaches. Neurol Clin. 2009;27:393–415.

4. Silberstein SD. Preventive migraine treatment. Neurol Clin. 2009;27:429–443.

5. Moja L, Cusi C, Sterzi R, et al. Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. Cochrane Database of Systematic Reviews 2005;3:CD002919. DOI: 10.1002/14651858.CD002919.pub2.

6. Tepper SJ, Spears RC. Acute treatment of migraine. Neurol Clin. 2009;27:417–427.

7. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews. 2008;2:CD001218. DOI: 10.1002/14651858.CD001218.pub2.

8. Vargas BB, Dodick DW. The face of chronic migraine: epidemiology, demographics, and treatment strategies. Neurol Clin. 2009;27:467–479.

Additional Reading

Goadsby PJ. Pathophysiology of migraine. Neurol Clin. 2009;27:335–360.

Lay CL, Broner SW. Migraine in women. Neurol Clin. 2009;27:503–511.

Codes

ICD9

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus
346.10 Migraine without aura, without mention of intractable migraine without mention of status migrainosus
346.20 Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus