Migraine Headache

Ovid: 5-Minute Sports Medicine Consult, The

Migraine Headache
Jennifer J. Mitchell
Tim Sprockel
  • 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
  • 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
  • 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.
  • 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
  • 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
  • P.389

  • 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
  • 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
  • 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
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


  • 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.
  • 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

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