Dr. Chamath Fernando Lecturer, Department of Family Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka.

1. Migraine
Natural History
Migraine is a complex disorder characterized by recurrent episodes of headache, most often
unilateral and in some cases associated with visual or sensory symptoms—collectively known as an
aura—that arise most often before the head pain but that may occur during or afterward (see the
image below). Migraine is most common in women and has a strong genetic component.
Migraine headache.Example of a visual migraine aura as described bya person who experiences migraines.This
patientreported that these visual auras preceded her headache by20-30 minutes.
Signs and symptoms
Typical symptoms of migraine include the following:
 Throbbing or pulsatile headache, with moderate to severe pain that intensifies with movement or
physical activity
 Unilateral and localized pain in the frontotemporal and ocular area, but the pain may be felt
anywhere around the head or neck
 Progresses posteriorly and becoming diffuse
 Headache lasts 4-72 hours
 Usually develops over 5-20 minutes and lasts less than 60 minutes
 Nausea (80%) and vomiting (50%), including anorexia and food intolerance, and light-headedness
 Sensitivity to light and sound
Features of migraine aura are as follows:
 May precede or accompany the headache phase or may occur in isolation
 Most commonly visual but can be sensory, motor, or any combination of these
 The most common positive visual phenomenon is the scintillating scotoma, an arc or band of
absent vision with a shimmering or glittering zigzag border
Physical findings during a migraine headache may include the following:
 Cranial/cervical muscle tenderness
 Horner syndrome (ie, relative miosis with 1-2 mm of ptosis on the same side as the headache)
 Conjunctival injection
 Tachycardia or bradycardia
 Hypertension or hypotension
 Hemisensory loss or hemiparetic neurologic deficits (ie, complicated migraine)
 Adie-type pupil (ie, poor light reactivity, with near dissociation from light)
See Clinical Presentation for more detail.

2. Migraine risk factors
Predisposing vascular risk factors for migraine include the following[28] :
• Increased levels of C-reactive protein
• Increased levels of interleukins
• Increased levels of TNF-alpha and adhesion molecules (systemic inflammation markers)
• Oxidative stress and thrombosis
• Increased body weight
• High blood pressure
• Hypercholesterolemia
• Impaired insulin sensitivity
• High homocysteine levels
• Stroke
• Coronary heart disease
Migraine precipitants
Various precipitants of migraine events have been identified, as follows:
• Hormonal changes, such as those accompanying menstruation (common), pregnancy,
and ovulation
• Stress
• Excessive or insufficient sleep
• Medications (eg, vasodilators, oral contraceptives [46] )
• Smoking
• Exposure to bright or fluorescent lighting
• Strong odors (eg, perfumes, colognes, petroleum distillates)
• Head trauma
• Weather changes
• Motion sickness
• Cold stimulus (eg, ice cream headaches)
• Lack of exercise
• Fasting or skipping meals
• Red wine
Certain foods and food additives have been suggested as potential precipitants of migraine,
• Caffeine
• Artificial sweeteners (eg, aspartame, saccharin)
• Monosodium glutamate (MSG)
• Citrus fruits
• Foods containing tyramine (eg, aged cheese)
• Meats with nitrites

3. Diagnosis
The diagnosis of migraine is based on patient history. International Headache Society diagnostic
criteria are that patients must have had at least 5 headache attacks that lasted 4-72 hours (untreated
or unsuccessfully treated) and that the headache must have had at least 2 of the following
characteristics[2]
:
 Unilateral location
 Pulsating quality
 Moderate or severe pain intensity
 Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
In addition, during the headache the patient must have had at least 1 of the following:
 Nausea and/or vomiting
 Photophobia and phonophobia
Finally, these features must not have been attributable to another disorder. Classification of migraine
is as follows:
 Migraine without aura (formerly, common migraine)
 Migraine with aura (formerly, classic migraine)
 Probable migraine without aura
 Probable migraine with aura
 Chronic migraine
 Chronic migraine associated with analgesic overuse
 Childhood periodic syndromes that may not be precursors to or associated with migraine
Migraine variants include the following:
 Childhood periodic syndromes
 Late-life migrainous accompaniments
 Basilar-type migraine
 Hemiplegic migraine
 Status migrainosus
 Ophthalmoplegic migraine
 Retinal migraine
A migraine variant may be suggested by focal neurologic findings, such as the following, that occur
with the headache and persist temporarily after the pain resolves:
 Unilateral paralysis or weakness - Hemiplegic migraine
 Aphasia, syncope, and balance problems - Basilar-type migraine
 Third nerve palsy with ocular muscle paralysis and ptosis, including or sparing the pupillary
response - Ophthalmoplegic migraine
Testing and imaging studies
Selection of laboratory and/or imaging studies to rule out conditions other than migraine headache is
determined by the individual presentation (eg, erythrocyte sedimentation rate and C-reactive protein
levels may be appropriate to exclude temporal/giant cell arteritis). Neuroimaging is not necessary in
patients with a history of recurrent migraine headaches and a normal neurologic examination.

4. The American Headache Society released a list of 5 commonly performed tests or procedures that
are not always necessary in the treatment of migraine and headache, as part of the American Board
of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign. The recommendations
include[3, 4]
:
 Don't perform neuroimaging studies in patients with stable headaches that meet criteria for
migraine.
 Don't perform computed tomography imaging for headache when magnetic resonance imaging is
available, except in emergency settings.
 Don't recommend surgical deactivation of migraine trigger points outside of a clinical trial.
 Don't prescribe opioid or butalbital-containing medications as first-line treatment for recurrent
headache disorders.
 Don't recommend prolonged or frequent use of over-the-counter pain medications for headache.
See Workup for more detail.
Management
Pharmacologic agents used for the treatment of migraine can be classified as abortive (ie, for
alleviating the acute phase) or prophylactic (ie, preventive).
Acute/abortive medications
Acute treatment aims to reverse, or at least stop the progression of, a headache. It is most effective
when given within 15 minutes of pain onset and when pain is mild.[5]
Abortive medications include the following:
 Selective serotonin receptor (5-hydroxytryptamine–1, or 5-HT1) agonists (triptans) e.g.
Sumatryptan 50-100mg
 Ergot alkaloids (eg, Ergotamine tartarate, dihydroergotamine [DHE])
 Analgesics e.g. Paracetamol
 Nonsteroidal anti-inflammatory drugs (NSAIDs mainly Aspirin and also Ibuprofen with PPI)
 Combination products
 Antiemetics e.g. Domperidone, Metaclopromide 10mg
Contraindications for Sumatryptan
 Previous MI
 IHD
 Previous Cerebrovascular accident
 Severe hypertension
Preventive/prophylactic medications
The following may be considered indications for prophylactic migraine therapy:
 Frequency of migraine attacks is greater than 2 per month
 Duration of individual attacks is longer than 24 hours
 The headaches cause major disruptions in the patient's lifestyle, with significant disability that lasts
3 or more days
 Abortive therapy fails or is overused
 Symptomatic medications are contraindicated or ineffective
 Use of abortive medications more than twice a week
 Migraine variants such as hemiplegic migraine or rare headache attacks producing profound
disruption or risk of permanent neurologic injury [6]

5. Prophylactic medications include the following:
 Beta blockers (e.g. Propranolol 20mg bd)
 5HT receptor antagonists – Pizotifen 0.5-1.5mg nocte (also has anti-cholinergic and aniti-histamine
activity)
 Tricyclic antidepressants (Amitryptylline 10-100mg nocte)
 NSAIDs (Aspirin 150-300mg nocte)
 Flunarazine 10mg nocte (Calcium Channel blocker)
 Antiepileptic drugs (Sodium Valproate 300mg bd)
 Calcium channel blockers (Verapamil 240-960mg daily in 3-4 divided doses)
 Selective serotonin reuptake inhibitors (SSRIs)
 Botulinum toxin
Other measures
Treatment of migraine may also include the following:
 Reduction of migraine triggers (eg, lack of sleep, fatigue, stress, certain foods)
 Nonpharmacologic therapy (eg, biofeedback, cognitive-behavioral therapy)
 Integrative medicine (eg, butterbur, riboflavin, magnesium, feverfew, coenzyme Q10)
See Treatment and Medication for more detail.