Migraine - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Headache Moderate to severe, unilateral headache is the characterized symptom which is usually throbbing in nature and worsening with routine activity. Usually the duration of headache is 4-72 hours. Headache
Moderate to severe, unilateral headache is the characterized symptom which is usually throbbing in nature and worsening with routine activity. Usually the duration of headache is 4-72 hours.
Aura It is important to know whether there is a history of characteristic aura before the onset of pain or not. Usually the aura consists of visual distortions, including scotomas, loss of vision, speech disturbances, pins and needles. Aura
It is important to know whether there is a history of characteristic aura before the onset of pain or not. Usually the aura consists of visual distortions, including scotomas, loss of vision, speech disturbances, pins and needles.
Nausea and vomiting Usually associated with acute migraine events. Nausea and vomiting
Usually associated with acute migraine events.
Photophobia and phonophobia Commonly found symptom in majority of patients. Photophobia and phonophobia
Commonly found symptom in majority of patients.
Vertigo Also known to associated with migraine. Vertigo
Also known to associated with migraine.
Mood or behavior changes Commonly found as a prodromal symptom which signals the commencement of an acute migraine episode. Mood or behavior changes
Commonly found as a prodromal symptom which signals the commencement of an acute migraine episode.
Food cravings, heightened sensory perceptions These symptoms also found as prodromal symptoms. Food cravings, heightened sensory perceptions
These symptoms also found as prodromal symptoms.
Past personal history or family history of migraine Presence of personal or family history of migraine will help diagnosing migraine attack. Past personal history or family history of migraine
Presence of personal or family history of migraine will help diagnosing migraine attack.
History of triggering event Hormonal changes (menstrual cycle), some foods, light, smell sensory stimuli, missing meals, relief of tension after stressful events, exercise can trigger development of acute attack of migraine. History of triggering event
Hormonal changes (menstrual cycle), some foods, light, smell sensory stimuli, missing meals, relief of tension after stressful events, exercise can trigger development of acute attack of migraine.

Clinicals - Examination

Fact Explanation
Completely normal findings in neurological examination Complete neurological examination including the level of consciousness should be done to exclude secondary life threatening causes of headache. Should look for focal neurological signs, cranial nerve palsies, deep tendon reflexes, power of muscle groups, coordination and gait. Absence of findings in clinical neurological examination favors the diagnosis of migraine. Completely normal findings in neurological examination
Complete neurological examination including the level of consciousness should be done to exclude secondary life threatening causes of headache. Should look for focal neurological signs, cranial nerve palsies, deep tendon reflexes, power of muscle groups, coordination and gait. Absence of findings in clinical neurological examination favors the diagnosis of migraine.
Blood pressure Should be measured to rule out severe hypertension as a cause for headache. Blood pressure
Should be measured to rule out severe hypertension as a cause for headache.
Ophthalmological examination To exclude acute glaucoma, eye pressure should be measured. Should look for papilledema using a ophthalmoscope, which is a sign of increased intracranial pressure. Ophthalmological examination
To exclude acute glaucoma, eye pressure should be measured. Should look for papilledema using a ophthalmoscope, which is a sign of increased intracranial pressure.
Kernig's sign and Brudzinski's sign These signs may be positive in meningitis. This is an important negative finding in excluding differentials. Kernig's sign and Brudzinski's sign
These signs may be positive in meningitis. This is an important negative finding in excluding differentials.

Investigations - Diagnosis

Fact Explanation
Neuro imaging - Computer tomography or magnetic resonence imaging of brain Should not be done routinely. Recommended for patients with migraine who have atypical headache patterns such as rapidly increasing frequency of headache, a headache that awakens the patient from sleep, persistent headache following head trauma, a history of poor coordination or focal neurological signs or symptoms. Neuro imaging - Computer tomography or magnetic resonence imaging of brain
Should not be done routinely. Recommended for patients with migraine who have atypical headache patterns such as rapidly increasing frequency of headache, a headache that awakens the patient from sleep, persistent headache following head trauma, a history of poor coordination or focal neurological signs or symptoms.
Electroencephalograpy Not done routinely, but useful in assessing patients who have associated symptoms suggestive of a seizure disorder, atypical migrainous aura, or episodic loss of consciousness. Electroencephalograpy
Not done routinely, but useful in assessing patients who have associated symptoms suggestive of a seizure disorder, atypical migrainous aura, or episodic loss of consciousness.
Lumbar puncture Should be done only suspecting meningitis or subarachnoid hemorrhage. Lumbar puncture
Should be done only suspecting meningitis or subarachnoid hemorrhage.

Management - Supportive

Fact Explanation
Patient and family education It is important to educate patients and their families when they are out of danger from the acute event and also to highlight the value of self-participation in the management of migraines. Patient and family education
It is important to educate patients and their families when they are out of danger from the acute event and also to highlight the value of self-participation in the management of migraines.
Adjunctive therapy - Metoclopramide, Prochlorperazine Adjunctive therapy is used to treat the associated symptoms of migraine and provide synergistic analgesia. While metoclopramide (Reglan) is sometimes recommended as a single agent in the treatment of migraine pain, its main use is for treating accompanying nausea and improving gastric motility, which may be impaired during migraine attacks. Prochlorperazine (Compazine) can effectively relieve headache pain. Caffeine and sleep are also recommend as an adjunctive therapy. Adjunctive therapy - Metoclopramide, Prochlorperazine
Adjunctive therapy is used to treat the associated symptoms of migraine and provide synergistic analgesia. While metoclopramide (Reglan) is sometimes recommended as a single agent in the treatment of migraine pain, its main use is for treating accompanying nausea and improving gastric motility, which may be impaired during migraine attacks. Prochlorperazine (Compazine) can effectively relieve headache pain. Caffeine and sleep are also recommend as an adjunctive therapy.
Sedatives Sedatives such as the barbiturates have been used to induce sleep in patients with migraine. However, with the advent of effective nonsedating agents and migraine-specific therapy, sedatives are no longer widely used in migraine therapy. Sedatives
Sedatives such as the barbiturates have been used to induce sleep in patients with migraine. However, with the advent of effective nonsedating agents and migraine-specific therapy, sedatives are no longer widely used in migraine therapy.
Steroids and intra-nasal lidocaine Steroid therapy, intravenous dexamethasone may be the treatment of choice for patients with status migrainosus, known to reduce recurrences but there are no good evidence to prove its efficacy in the treatment of the acute migraine attack. Intranasal lidocaine (Xylocaine) has a rapid onset of action and may be useful as a measure to control symptoms rapidly until the action of other drugs take place. Steroids and intra-nasal lidocaine
Steroid therapy, intravenous dexamethasone may be the treatment of choice for patients with status migrainosus, known to reduce recurrences but there are no good evidence to prove its efficacy in the treatment of the acute migraine attack. Intranasal lidocaine (Xylocaine) has a rapid onset of action and may be useful as a measure to control symptoms rapidly until the action of other drugs take place.

Management - Specific

Fact Explanation
Out patient management or hospitalization Generally acute migraine event can be treated as an out patient basis, but a migraine attack that lasts for more than 72 hours which is called status migrainosus, requires hospital inward treatment to relieve the pain and treat dehydration from vomiting. Out patient management or hospitalization
Generally acute migraine event can be treated as an out patient basis, but a migraine attack that lasts for more than 72 hours which is called status migrainosus, requires hospital inward treatment to relieve the pain and treat dehydration from vomiting.
Acute pain management Available migraine-specific drugs are triptans such as sumatriptan, naratriptan, ergotamine and its derivatives or combined drug therapy (eg: aspirin plus acetaminophen plus caffeine). Non steroidal anti inflmmatory drugs such as ibuprofen, naprexon can be given for mild to moderate pain as a non specific therapy. If patient is having nausea or vomiting, rectal, nasal, subcutaneous or intravenous routes can be used to administer drugs. A self-administered rescue medication can be used in selected patients. Note: Opiates and butalbital-containing analgesics should be avoided. Acute pain management
Available migraine-specific drugs are triptans such as sumatriptan, naratriptan, ergotamine and its derivatives or combined drug therapy (eg: aspirin plus acetaminophen plus caffeine). Non steroidal anti inflmmatory drugs such as ibuprofen, naprexon can be given for mild to moderate pain as a non specific therapy. If patient is having nausea or vomiting, rectal, nasal, subcutaneous or intravenous routes can be used to administer drugs. A self-administered rescue medication can be used in selected patients. Note: Opiates and butalbital-containing analgesics should be avoided.
Ergotamine (5-hydroxytryptamine (5-HT1) nonselective agonist) and its derivatives Ergotamine is the standard therapy to halt acute migraine headache and its effectiveness depends on its administration at the onset of migraine pain. Can be given as a nasal spray or through an injection. Note: Unwanted effects include, its ability to cause medication-overuse headaches and increase the frequency of headaches, ergot poisoning and negative effects on migraine prophylactic medications. Ergotamine (5-hydroxytryptamine (5-HT1) nonselective agonist) and its derivatives
Ergotamine is the standard therapy to halt acute migraine headache and its effectiveness depends on its administration at the onset of migraine pain. Can be given as a nasal spray or through an injection. Note: Unwanted effects include, its ability to cause medication-overuse headaches and increase the frequency of headaches, ergot poisoning and negative effects on migraine prophylactic medications.
5-HT1 receptor-specific agonists (triptans) Sumatriptan is the drug of choice as it can be administered via orally if patient is able to take, parenterally as an subcutaneous injection (Imitrex) or nasal route as a spray. Usually triptans are well tolerated. Contraindicated in patients with ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or other significant cardiovascular disease. 5-HT1 receptor-specific agonists (triptans)
Sumatriptan is the drug of choice as it can be administered via orally if patient is able to take, parenterally as an subcutaneous injection (Imitrex) or nasal route as a spray. Usually triptans are well tolerated. Contraindicated in patients with ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or other significant cardiovascular disease.
Nonpharmacologic treatment Patient specific triggers should be avoided as much as possible as the first step in the nonpharmacological management. Other commonly used methods, effective in preventing migraine are relaxation training with or without thermal biofeedback, electromyographic biofeedback, and cognitive-behavioral therapy. There are some other therapies, such as acupuncture, hypnosis, transcutaneous electrical nerve stimulation, cervical manipulation, occlusal adjustment, and hyperbaric oxygen. Nonpharmacologic treatment
Patient specific triggers should be avoided as much as possible as the first step in the nonpharmacological management. Other commonly used methods, effective in preventing migraine are relaxation training with or without thermal biofeedback, electromyographic biofeedback, and cognitive-behavioral therapy. There are some other therapies, such as acupuncture, hypnosis, transcutaneous electrical nerve stimulation, cervical manipulation, occlusal adjustment, and hyperbaric oxygen.
Prophylactic measures Consider in patients having more than two headaches per week. These pharmacological agents may not completely prevent migraines, but they may reduce the number or severity of attacks that can turn into status migrainosus. These medications include: Pizotifen, Beta-blockers, Calcium channel blockers, Antidepressants such as tricyclics and monoamine oxidase inhibitors, Anticonvulsants such as divalproex sodium and sodium valproate, Botox, Natural therapies such as magnesium. Prophylactic measures
Consider in patients having more than two headaches per week. These pharmacological agents may not completely prevent migraines, but they may reduce the number or severity of attacks that can turn into status migrainosus. These medications include: Pizotifen, Beta-blockers, Calcium channel blockers, Antidepressants such as tricyclics and monoamine oxidase inhibitors, Anticonvulsants such as divalproex sodium and sodium valproate, Botox, Natural therapies such as magnesium.

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. AUKERMAN G, KNUTSON D, MISER WF, DEPARTMENT OF FAMILY MEDICINE, OHIO STATE UNIVERSITY COLLEGE OF MEDICINE AND PUBLIC HEALTH, COLUMBUS, OHIO. Management of the acute migraine headache. Am Fam Physician [online] 2002 Dec 1, 66(11):2123-30 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12484694
  2. ESTEMALIK EMAD, TEPPER . Preventive treatment in migraine and the new US guidelines. NDT [online] 2013 May [viewed 04 June 2014] Available from: doi:10.2147/NDT.S33769
  3. GILMORE B, MICHAEL M. Treatment of acute migraine headache. Am Fam Physician [online] 2011 Feb 1, 83(3):271-80 [viewed 04 June 2014] Available from: http://www.aafp.org/afp/2011/0201/p271.html
  4. GUIRGUIS-BLAKE J. Effectiveness of acupuncture for migraine prophylaxis. Am Fam Physician [online] 2010 Jan 1, 81(1):29 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20052960
  5. HOLLE D., OBERMANN M.. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders [online] December, 6(6):369-374 [viewed 04 June 2014] Available from: doi:10.1177/1756285613489765
  6. LOGEMANN CD, RANKIN LM. Newer intranasal migraine medications. Am Fam Physician [online] 2000 Jan 1, 61(1):180-6 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10643958
  7. MODI S, LOWDER DM. Medications for migraine prophylaxis. Am Fam Physician [online] 2006 Jan 1, 73(1):72-8 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417067