PrimeView Migraine

1. Prodrome Aura Migraine attack Postdrome
Symptom
severity
Few hours to days 4 to 72 hours
5 to 60 minutes 24 to 48 hours
Diagnosis
Migraine episodes can be divided into
several phases: prodrome (also known
as premonitory), aura, migraine attack
and postdrome.
Prodromal and
postdromal phases can
be accompanied by
various symptoms such
as fatigue and reduced
concentration.
Migraine is typically
diagnosed by the
presence of suggestive
clinical manifestations
only, although ancillary
diagnostic tests may be
required in some
patients to rule out
other conditions.
Patients can be
subclassified as
those with migraine
with aura or those
with migraine
without aura.
For a diagnosis of migraine, patients
must meet the diagnostic criteria in the
International Classification of Headache
Disorders, Third Edition.
Aura is
associated
with transient
neurological
symptoms.
The most
common aura
symptom is
scintillating
scotoma, but
other visual or
sensory
symptoms can
also occur.
Management
Treatment of pain associated with
migraine includes NSAIDs for mild to
moderate pain and triptans for moderate
to severe pain. Preventative therapies
can be used to reduce the frequency
of migraine attacks; however, most
available therapies lack effectiveness.
In general, adverse effects are common
with migraine preventatives, evidence
supporting their use is lacking, and few
comparative trials have been carried out.
CGRP receptor antagonists (gepants) and
monoclonal antibodies targeting the CGRP
pathway have recently been approved
for acute therapy and the prevention of
migraine attacks. These therapies have
demonstrated good efficacy in clinical
trials and are associated with few adverse
effects. The precise mechanism of these
therapies is unknown and requires
further study.
z Many patients with migraine overuse
headache medication or caffeine, which
results in a cycle of withdrawal headaches
that are alleviated by use of headache
medication or caffeine.
Outlook
As many patients do not respond to, or
have adverse effects with, treatments for
migraine, new therapies are desperately
required. These therapies should be able
to consistently render patients pain free
in a timely manner and without headache
recurrence, with little risk of overuse and
good tolerability.
Qualityoflife
Migraine can severely affect patients'
lives owing to the unpredictable nature
of attacks. The unpredictability can be
associated with last-minute cancellations
of various appointments, affecting both
social and work life.
Mechanisms
Symptoms of migraine aura are thought
to be caused by spreading depolarization,
during which almost all cells in a brain
region undergo depolarization and
cause a depolarization wave spreading
in all directions. Activation of trigeminal
nociceptive pathways is also believed
to be involved in migraine. Indeed,
trigeminovascular thalamic neurons that
project to various cortical regions mediate
the sensory–discriminative components
of migraine, such as location, intensity
and quality of pain, in addition to other
symptoms, such as difficulty focusing,
amnesia and sensitivity to light and sound.
Subcortical brain regions, such as the
brainstem and diencephalon, are also
involved in migraine.
z Four rare monogenic migraine
syndromes have been identified:
CADASIL, RVCL-S, FASPS and familial
hemiplegic migraine. In the latter
condition, migraine is associated with
hemiparesis (motor weakness on one side
of the body).
Epidemiology
Ten to 15% of the general population are
migraine patients and had at least one
attack in the previous year. Migraine most
commonly manifests in adolescence,
although it can arise at any age. Fifty
percent of patients have more than 1.5
attacks per month, 25% of patients have
more than one attack weekly and up
to 5% have chronic migraine (migraine
that occurs for ≥15 days per month
for >3 months). Disorders commonly
comorbid with migraine include stroke,
epilepsy, depression, anxiety and
myocardial infarction.
z Migraine is classified as the third most
disabling disease worldwide in terms of
years lived with disability.
Migraineischaracterizedbyepisodesofdisabling
headachesandassociatedsymptomsthatpersist
for4–72hours.Thecharacteristicsofmigrainevary
widelybetweenpatientsandcanvarywithinthe
sameindividual.
Migraine
Written by Louise Adams; designed by Laura Marshall
doi: 10.1038/s41572-022-00335-z; Article citation ID: (2022) 8:1 For the Primer, visit doi: 10.1038/s41572-021-00328-4
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