Is It a Migraine? Risk Factors and Diagnostic Categories

CLINICAL ACTIONS:

Migraine is a complex neurologic disorder including both moderate to severe headache along with a variety of neurologic and systemic symptoms. Common symptoms include hypersensitivity to light and sound, cutaneous pain sensitization, and GI symptoms.

• Migraine symptoms are often described as follows
  • Unilateral (60%)
  • Throbbing (50%)
  • Aggravated by physical activity or head movement (90%)
  • Neck pain
• Aura may include
  • Flashes of light | Partial loss of vision | Parasthesias | Vertigo | Ataxia | Diplopia
  • Symptoms are typically bilateral, sequential (visual, then sensory) and recurrent in nature

Migraine Categories

Migraine with aura (with at least two attacks fulfilling the two following criteria)

• One or more of the following fully reversible aura symptoms
  • Visual
  • Sensory
  • Speech and/or language
  • Motor
  • Brainstem
  • Retinal
• At least three of the following six characteristics
  • At least one aura symptom spreads gradually over ≥5 minutes
  • ≥2 aura symptom in succession
  • Each individual aura symptom lasts 5–60 minutes
  • ≥1 aura symptom is unilateral
  • ≥1 aura symptom is positive for scintillations and pins and needles
  • Aura is accompanied, or followed within 60 minutes, by headache

Note: Not better accounted for by another diagnosis

Migraine without aura (at least 5 attacks fulfilling the following criteria)

• Headache lasting 4-72 hours (untreated or successfully treated)
• Headache has at least two of the following characteristics
  • Unilateral | Pulsating | Moderate/severe intensity | Aggravated by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
• At least one of the following during the headache
  • Nausea and/or vomiting | Photophobia | Phonophobia
• Other disorders ruled out (e.g. meningitis)

Chronic Migraine Definition

• Headache on more than 15 days/month for >3 months
• ≥ 8 days meet diagnostic criteria for migraine with or without aura
• Not better accounted for by another diagnosis

SYNOPSIS:

The WHO lists migraine as the sixth highest cause worldwide of years lost due to disability. Migraine may not always present with typical symptoms and can be bilateral, mild, non-throbbing, with facial pain and hence confused with tension or sinus headache. It may be preceded by prodromal symptoms hours or days before headache. Symptoms can include fatigue, neck stiffness and impaired concentration. Postdromal symptoms occur up to 24 hours after headache may include weakness, fatigue, somnolence, photophobia, impaired concentration, irritability and nausea.

KEY POINTS:

• Prevalence peaks between ages 30 to 39 and is uncommon after the age of 60 and prior to adolescence
• In women, the annual and lifetime prevalence are 18% and 33%
• A minority (<10%) of women have attacks of migraine in association with most of their menstrual cycles
  • Usually without aura
  • Tend to be longer and accompanied by more severe nausea
• 8% of the migraine population has chronic migraine
• Risk factors for chronic migraine
  • Overuse of acute medications
  • Inadequate treatment of acute attack
  • Caffeine consumption
  • Snoring
  • Obesity
  • Female sex
  • Allodynia (perception of pain when non-painful stimuli are applied to the skin)
  • Head injury
  • Low socioeconomic status
  • Depression, anxiety, pain disorders

LEARN MORE – PRIMARY SOURCES:

Lancet: Migraine

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (2018).

AAFP: Approach to Acute Headache in Adults

BMJ: Management of chronic migraine

Related ObG Topics:

Migraine Treatment and Prevention

What are the Consequences of Taking Triptan for Migraine During Pregnancy?

Does Acupuncture Decrease Incidence of Migraines?