Diagnosis

Migraine

Etiology

Cause [fbw]

• Not exactly known, many unconfirmed theories

• Vascular theory: Intracranial vasoconstriction followed by rebound vasodilation

  • Vessels dilate during a migraine attack

  • Stimulation of intracranial vessels induces headache

  • Vasoconstrictors (ergots) improve the headache

  • Vasodilators (nitroglycerin) provoke an attack

  • Do not explain the efficacy of some drugs that have no effect on blood vessels

• Neurovascular theory:

  • Primarily a neurogenic process with secondary changes in cerebral perfusion

• Biochemical theory: Vasoactive substances and neurotransmitters

• Anatomical: A potential "migraine center" in the brainstem

• Genetic factor: 70% of patients have a first-degree relative with a history of migraine

• Environmental/behavioral factors: persons with a predisposition

• Magnesium deficiency

• Endothelial dysfunction

• Serotonin: An important receptor in the headache pathway

Pathophysiology [9vo]

1. A premonitory phase:

   • Yawning, mood changes, lethargy, neck stiffness, sensitivity to light and sound, restlessness, difficulty focusing vision, feeling cold, cravings, sweating, increased energy, thirst, and edema

2. Transient neurological symptoms (migraine aura)

   • Positive symptoms (scintillating scotoma, bright lines or shapes, tinnitus, noises, paresthesias, allodynia, or rhythmic movements)

   • Negative symptoms (visual field defects, hearing, sensation, or movement)

3. Headache lasting from hours to days:

   • Unilateral, pulsating pain with nausea, vomiting, photophobia, phonophobia, rhinorrhea, lachrymation, allodynia, and osmophobia

4. Postdrome phase: movement-vulnerable headache, exhaustion, dizziness, difficulty concentrating, and euphoria

Risk factor [bfk][fbw]

• Advanced age

• Head trauma

• Lower socioeconomic status

• Stress

• Sleep problems

• Obesity

• Pain syndrome

• Pro-inflammatory states (increased CRP, TNF-alpha )

• Pro-thrombotic states

• Hormonal imbalances: pregnancy, ovulation, estrogen, cortisol, thyroid

• Psychological factors

• High blood pressure

• Hypercholesterolemia

• Impaired insulin sensitivity

• High homocysteine levels

• Stroke

• Coronary heart disease

• Medications (vasodilators, oral contraceptives)

• Smoking

• Caffeine

• Citrus fruits

• Aged cheese

• Alcohol (red wine)

• Fasting or skipping meals

• Strong odors (perfumes, colognes, petroleum distillates)

Epidemiology

Incidence per 100.000 [bfk][s9o][9os][cgo][gai][2vq][vt9]

Approach

• Migraine is a clinical diagnosis [fbw]

  • Exclude structural and metabolic causes of headache

  • Rule out comorbid diseases that could complicate headache

• Screening tool: ID-CM (sensitivity of 82% and a specificity of 87%)

• Blood test: CRP/ESR to rule out temporal arteritis

• Lumbar Puncture and CT/MRI caput if: [fbw]

  • First or worst severe headache

  • Abnormal neurologic examination

  • Change in the pattern of previous migraine

  • Headache with fever

  • Migraine and epilepsy

  • New daily, persistent headache

  • Escalation of headache frequency/intensity

  • Posteriorly located headaches

Treatment

1. Non-pharmacological: [fbw]

   • Reduction of triggers: lack of sleep, fatigue, stress, certain foods (alcohol, caffein, chocolate, aspartame, citrus fruits, bananas, avocados, dried fruit, nuts and soy

   • Cognitive-behavioral therapy

2. Acute phase: [fbw]

   • Selective serotonin receptor agonists (triptans)

   • Serotonin agonists (ditans, lasmiditan)

   • Calcitonin gene-related peptide receptor antagonists (rimegepant, ubrogepant)

   • Ergot alkaloids (ergotamine, dihydroergotamine)

   • Analgesics

   • NSAIDs

   • Antiemetics

3. Prophylactic treatment if >2 attacks per month or duration of attacks >24 hours or symptomatic medications are ineffective: [fbw]

   • Antiepileptic drugs

   • Beta blockers

   • Tricyclic antidepressants

   • Calcium channel blockers

   • SSRIs

   • NSAIDs

   • Serotonin antagonists

   • Botulinum toxin

   • CGRP inhibitors

Differential diagnoses

Benign paroxysmal positional vertigo, Brain abscess, Brain tumor, Carotid artery dissection, Cerebral aneurysm, Cerebral venous sinus thrombosis, Cluster headache, Encephalitis, Intracerebral hemorrhage, Labyrinthitis, Medication-overuse headache, Meniere disease, Meningitis, Subarachnoid hemorrhage, Temporal arteritis, Tension headache