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Tags : Migraine headaches, neurological condition, Headache pain, Nausea and vomiting, Sensitivity to light and sound, Abdominal pain, Dizziness, vertigo and Fatigue

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History, definitions and diagnosis Migraine 1
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Migraine through history Migraine comes from the Greek word ‘hemicrania’, which referred to pain occurring on one side of the head (‘half skull’)1 The earliest descriptions of migraine are said to be from 3,000 BC2 Hippocrates provided an account of a severe headache that was associated with a visual disturbance, describing the experience as “something shining before him”2 Migraine has been described by physicians through the last two millennia, with some paying greater attention to symptoms other than headache2 Historically, ‘surgical’ techniques have included scalp incisions, application of heated irons, and blood letting2,3 In the less-distant past, treatments have included several chemicals, including trinitrine (nitroglycerin), which is now known to be a vasoactive substance2 2 1. Pearce. Eur Neurol 2005;53(2):109–110;2. Pearce. J Neurol Neurosurg Psychiatry 1986;49(10):1097–1103;3. Koehler & Boes. Brain 2010;133:2489–2500
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Timeline of migraine research 3 CALCRL=calcitonin receptor-like receptor; CGRP=calcitonin gene-related peptide; CSD=cortical spreading depression (or depolarisation); IHS=International Headache Society; PET=positron emission tomography; RAMP1=receptor activity-modifying protein 1; RCP=receptor coupling protein Adapted from: Edvinsson et al. Nat Rev Neurol 2018;14(6):338–350; Tfelt-Hansen & Koehler. Headache 2011;51(5):752–778 First measurement of CGRP released by trigeminal stimulation in humans 1981 1982 Oligaemia in the wake of CSD in rats Neurogenic inflammation theory of migraine 1984 1986 Discovery of the trigeminovascular reflex: a physiological role for CGRP Presence of CGRP confirmed in human cerebral vasculature 1987 1990 First demonstration in people with migraine that CGRP is released during an acute migraine attack 1988 Demonstration that CGRP release by trigeminal activation is inhibited by triptans Characterisation of the multicomponent CGRP receptor that consists of CALCRL, RAMP1 and RCP Characterisation of the gepants 2002 Infusion of CGRP shown to trigger migraine attack in people prone to migraine 1918 1940 Isolation and clinical testing of an ergot alkaloid Identification of pain-sensitive structures in the brain 1941 Lashley’s description of spreading scotoma 1944 Leão’s experiments into CSD 1984 Discovery of CGRP CGRP antibodies made to measure and localise CGRP in the trigeminal–cerebrovascular system, where CGRP was found to be a potent vasodilator 1988 Discovery of proto-typical triptan 1988 New headache classification from IHS 1996 Gene for familial hemiplegic migraine identified 1996 Meningeal sensitisation, central sensitisation and allodynia 1938 Vasodilation in migraine, and ergot therapies 1959 Serotonin – serum (‘sero’) vasoconstrictor (‘tonin’) factor Spreading oligaemia in migraine with aura PET studies highlight the importance of the brainstem Triptan shown to normalise CGRP levels during acute migraine attack 1993 1994 1995 CGRP first proposed to play a role in migraine 1982 1998 1985 2000
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Migraine epidemiology An estimated 1.3 billion individuals were affected by migraine across the globe in 20171 In the WHO global burden of disease study, headache disorder has consistently been the 2nd most prevalent disease in the world1 Women are approximately 3 times more likely than men to have migraine2 Among people aged less than 50 years old, migraine is the most common cause of disability3 Migraine is associated with high levels of disability and comorbidity, including an increased risk of insomnia, depression, and anxiety4 4 WHO=World Health Organization 1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Lancet 2018;392(10159):1789–1858; 2. Gasparini et al. Curr Genomics 2013;14(5):300–315; 3. Steiner et al. J Headache Pain 2018;19(1):17; 4. Buse et al. J Headache Pain 2020;21(1):23 Migraine is a highly prevalent condition
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The burden of migraine Migraine is a burdensome condition, and has a substantial impact on activities of daily living, such as work, school, and social activities1-3 A systematic literature review of the burden of migraine identified several psychosocial difficulties:2 Energy and drive – fatigue, reduced vitality, difficulties with sleep Emotional functioning – depressive symptoms, anxiety, stress, anger Pain – general pain, and the sensation of pain Employment – reduced efficiency at work, restriction in time given to work, partial absence General physical and mental health – general mobility, carrying out daily routine Social functioning – relationships with others, family relationships, leisure activities Global disability – global functioning, quality of life, self-efficacy Many of the psychosocial difficulties identified in the review (e.g., emotional functioning, and employment) appeared to respond well to migraine therapy, particularly to preventive treatment2 5 1. Agosti. Headache 2018;58(Suppl 1):17–32; 2. Raggi et al. J Headache Pain 2012;13(8):595–606; 3. Smitherman et al. Headache 2013;53(3):427–436 Migraine is a highly burdensome condition
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Migraine-related impairment in the AMPP study The AMPP survey of 77,879 households in the USA asked respondents in what way they are “usually affected by severe headaches”:1 No impairment: able to function normally Some impairment: able to function, but with reduced performance Severe impairment: unable to function or requiring bed rest The results showed migraine-related impairment was common among respondents:1 47.7% did no household work 29.1% missed family or social activity 25.3% missed at least 1 day of work/school 6 AMPP=American Migraine Prevalence and Prevention; USA=United States of America 1. Lipton et al. Neurology 2007;68(5):343–349 3. Severe impairment (53.7%) 2. Some impairment (39.1%) 1. No impairment (7.2%) Headache-related impairment during severe headache in the AMPP study1 Migraine is commonly associated with severe impairment or need for bed rest1
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Depression among people with migraine in the AMPP study 7 Low-frequency EM: 0–3 headache days per month; moderate-frequency EM: 4–7 headache days per month; high-frequency EM: 8–14 headache days per month; chronic migraine: ≥15 headache days per month;none or minimum depression: PHQ-9 score 0–4; mild depression: PHQ-9 score 5–9; moderate depression: PHQ-9 score 10–14; moderately severe depression: PHQ-9 score 15–19; severe depression: PHQ-9 score 20–27 AMPP=American Migraine Prevalence and Prevention; EM=episodic migraine; PHQ-9=9-item Patient Health Questionnaire 1. Buse et al. Headache 2020;60:2340–2356 Comorbidity of depression and migraine in AMPP study (n=11,603)1 Rates of comorbidity, including depression, generally increased with headache frequency1
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Migraine stigma and social isolation (from the Eurolite project) 8 Adapted from: Lampl et al. J Headache Pain 2016;17:9 Male Female Avoid telling others Migraine Tension-type headache Family, friends don’t understand Migraine Tension-type headache Employer, colleagues don’t understand Migraine Tension-type headache Difficulties in love life were reported by 17.6% of respondents, and ~1% of respondents reported having fewer children, or had avoided having children altogether, because of migraine
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The economic burden of migraine Direct costs of migraine Examples of direct costs include prescription medication, and hospitalisation1 A study of 215,209 people with migraine found that migraine was associated with $2,571 greater costs per person per year:1 People with migraine: $7,007 Control individuals: $4,436 Estimates of direct migraine costs across the whole of the USA were:1 Outpatient care: $5.21 billion Prescriptions: $4.61 billion Inpatient care: $0.73 billion Emergency department care: $0.52 billion 9 Indirect costs of migraine Examples of indirect costs include lost productivity at work, and workplace absence2 An analysis of 6,516 people with migraine found that migraine was associated with $2,834 greater indirect workplace costs per person per year:2 People with migraine: $4,453 Control individuals: $1,619 The indirect cost of migraine across the whole of the USA was estimated to be $12 billion2 USA=United States of America 1. Hawkins et al. Headache 2008;48(4):553–563; 2. Hawkins et al. J Occup Environ Med 2007;49(4):368–374 Increased knowledge, and access to appropriate migraine management, are likely to help in reducing the economic burden of migraine2
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Migraine criteria, diagnosis and subtypes 10
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What is migraine? What are migraine attacks? Migraine is a chronic neurological disease with episodic attacks of head pain1 If caused by another medical condition, the headache is said to be a secondary headache2 Migraine is characterised, including by International Classification of Headache Disorders, 3rd edition (ICHD-3), from the IHS, by attacks of moderate-to-severe headache and reversible neurological and systemic symptoms:1,2 Photophobia – extreme sensitivity to light Phonophobia – extreme sensitivity to sound Allodynia – pain resulting from a stimulus that would not normally provoke pain (e.g., a light touch of the skin) Nausea and vomiting Other symptoms – including vertigo, dizziness, and cognitive impairment Research into the genetic and biological mechanisms underlying migraine has led to a better understanding of the condition, and to the development of novel therapies and treatments1 11 IHS=International Headache Society 1. Dodick. Lancet 2018;391(10127):1315–1330; 2. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
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ICHD-3 criteria for migraine and migraine attacks 12 aPeople who do not fulfil criteria for chronic migraine ICHD-3=International Classification of Headache Disorders, 3rd edition; MHD=monthly headache day; MMD=monthly migraine day 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Buse et al. Headache 2012;52(10):1456–1470 Chronic migraine1 ≥15 MHDs and ≥8 MMDs >3 months 7.7% ofpeople withmigraine2 Episodic migraine1 During a lifetime, ≥5 migraine attacks lasting 4–72 hoursa Majority ofpeople withmigraine2 Monthly migraine day (MMD)1 ≥2 migraine characteristics, such as: If no aura, ≥1 of the following migraine symptoms: Unilateral Pulsating Moderate/severe Aggravation by, or causing avoidance of, routine physical activity Nausea/vomiting Photophobia/phonophobia Monthly headache day (MHD)1 A day with migraine-type or tension-type headache
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Migraine symptoms and neurobiology CSD, a phenomenon observed in early migraine research, describes a propagated slow wave of depolarisation of neurons and glia, followed by suppression of neural activity and eventual return to baseline1,2 Based on early experiments, and later MRI observations in humans, CSD is hypothesised to be the pathology underlying aura – however, not all people with migraine experience aura3 The vascular theory of migraine proposes that pain results from vasodilation of cranial blood vessels – however, not all data fit the hypothesis that vasodilation can cause migraine pain4,5 The pain in migraine is typically a throbbing, pulsating pain.4 This pulsating pain sensation has been linked to arterial pulsation in some studies, but not in others4 CGRP, a 37-amino acid peptide localised to C- and Aδ-fibres, is a potent vasodilator, and several lines of evidence point towards CGRP playing a crucial role in migraine symptoms6,7 13 CGRP=calcitonin gene-related peptide; CSD=cortical spreading depression; MRI=magnetic resonance imaging 1. Charles & Brennan. Cephalalgia 2009;29(10):1115–1124; 2. Leão. J Neurophysiol 1944;7(6):359–390; 3. Tolner et al. Cephalalgia 2019;39(13):1683–1699; 4. Mason & Russo. Front Cell Neurosci 2018;12:233; 5. Charles & Brennan. Handb Clin Neurol 2010;97:99–108; 6. Russell et al. Physiol Rev 2014;94(4):1099–1142; 7. CGRP Forum website. https://www.cgrpforum.org. Accessed Jan 2020; 8. Burstein et al. J Neurosci 2015;35(17):6619–6629; 9. Goadsby et al. Physiol Rev 2017;97(2):553–622 Migraine is a complex neurological disease with multiple processes, which lead to the varied symptoms that people with migraine may experience (e.g., cognitive, sensory [aura], autonomic, and affective symptoms)8,9
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Migraine with aura, and migraine without aura 14 A person may experience migraine both with and without aura, and the aura experience varies between and within individuals1 Compared with migraine without aura, migraine with aura appears to have:2,3 Greater association with certain comorbid conditions Different alterations of brain structure and function as revealed by imaging studies Differences in heritability4,5 Aura occurs in a minority of people with migraine: ~25%6 Most studies of migraine therapies include mixed populations of migraine with and without aura2,3 This is problematic, because there is evidence that migraine with and without aura respond differently to treatment2 Some have argued that the two conditions – migraine with aura and migraine without aura – should be separated in clinical studies of migraine therapies3 ICHD-3=International Classification of Headache Disorders, 3rd edition 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Hansen & Charles. J Headache Pain 2019;20(1):96; 3. Hauge et al. Cephalalgia 2010;30(9):1041–1048;4. Gervil et al. Ann Neurol 1999;46(4):606–611; 5. Ulrich et al. Ann Neurol 1999;45(2):242–246; 6. Shankar Kikkeri & Nagalli. Migraine with Aura. 2020 Migraine with aura is characterised, according to ICHD-3 criteria, by at least 2 migraine attacks with the presence of the following categories of fully reversible aura symptoms:1 …and at least 3 of the following 6 characteristics:1 At least 1 aura symptom spreads gradually over ≥5 minutes 2 or more aura symptoms occur in succession Each individual aura symptom lasts 5–60 minutes At least 1 aura symptom is unilateral At least 1 aura symptom is positive The aura is accompanied, or followed within 60 minutes, by headache Visual Sensory Speech and/or language Motor Brainstem Retinal
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ICHD-3 diagnostic criteria – episodic migraine with/without aura At least 5 attacks fulfilling criteria B–D Headache attacks lasting 4–72 hours (when untreated or unsuccessfully treated) Headache has at least 2 of the following 4 characteristics: Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of routing physical activity (e.g., walking or climbing stairs) During headache at least 1 of the following: Nausea and/or vomiting Photophobia and phonophobia Not better accounted for by another ICHD-3 diagnosis 15 At least 2 attacks fulfilling criteria B and C At least 1 of the following fully reversible aura symptoms: Visual Sensory Speech and/or language Motor Brainstem Retinal At least 3 of the following 6 characteristics: At least 1 aura symptom spreads gradually over ≥5 minutes 2 or more aura symptoms occur in succession Each individual aura symptom lasts 5–60 minutes At least 1 aura symptom is unilateral At least 1 aura symptom is positive The aura is accompanied, or followed within 60 minutes, by headache Not better accounted for by another ICHD-3 diagnosis See slide notes for further information on diagnostic criteria ICHD-3=International Classification of Headache Disorders, 3rd edition Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211 1.1 Migraine without aura 1.2 Migraine with aura
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ICHD-3 diagnostic criteria – chronic migraine 16 See slide notes for further information on diagnostic criteria ICHD-3=International Classification of Headache Disorders, 3rd edition Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211 Headache (migraine-like or tension-type-like) on 15 days/month for >3 months, and fulfilling criteria B and C Occurring in a patient who has had at least 5 attacks fulfilling criteria B–D for ‘1.1 Migraine without aura’ and/or criteria B and C for ‘1.2 Migraine with aura’ On 8 days/month for >3 months, fulfilling any of the following: Criteria C and D for ‘1.1 Migraine without aura’ Criteria B and C for ‘1.2 Migraine with aura’ Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative Not better accounted for by another ICHD-3 diagnosis 1.3 Chronic migraine The clinical criteria for episodic migraine with and without aura apply to the chronic diagnosis, with the only differentiator being frequency and duration of symptoms
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ICHD-3 diagnostic criteria – status migrainosus 17 If a migraine attack lasts >72 hours, it is diagnosed as ‘status migrainosus’1 Status migrainosus often requires immediate medical attention, because of the length, severity, and persistence of symptoms2 The longer a migraine persists, the greater the risk of dehydration, stroke, aneurysm, permanent vision loss, serious dental problems, coma, and even death2 Treatment approaches for people with status migrainosus include pharmacotherapy and surgery, however, these approaches have only limited success3 More research and specific treatment guidelines are needed to better serve this difficult-to-treat population3 See slide notes for further information on diagnostic criteria aRemissions of up to 12 hours due to medication or sleep are accepted; bmilder cases, not meeting criterion C2, are coded 1.5.1 ‘Probable migraine without aura’ ICHD-3=International Classification of Headache Disorders, 3rd edition 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. The Migraine Institute website. https://www.themigraineinstitute.com/status-migrainosus-migraines/. Accessed May 2020;3. Iljazi et al. Cephalalgia 2020;40(8):818–827 A headache attack fulfilling criteria B and C Occurring in a patient with 1.1 ‘Migraine without aura’ and/or 1.2 ‘Migraine with aura’, and typical of previous attacks except for its duration and severity Both of the following characteristics: Unremitting for >72 hoursa Pain and/or associated symptoms are debilitatingb Not better accounted for by another ICHD-3 diagnosis 1.4.1 Status migrainosus1
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ICHD-3 definitions for episodic and chronic migraine 18 Chronic migraine is defined as having a headache ≥15 days per month for >3 months, of which ≥8 days meet criteria for migraine1,2 For most people with migraine, migraine is episodic – estimates suggest up to 7.7% of people with migraine have chronic migraine2,3 It is estimated that episodic migraine progresses to chronic migraine in approximately 3% of people with migraine annually4 Compared with people with episodic migraine, those with chronic migraine show:2 Higher percentage with severe pain – 92.4% versus 78.1% Greater percentage of occupational disability – 20.0% versus 11.1% Greater healthcare resource use, including visits to primary care providers and headache specialists Higher levels of comorbidities, including depression, anxiety, and obesity 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Katsarava et al. Curr Pain Headache Rep 2012;16(1):86–92; 3. Buse et al. Headache 2012;52(10):1456–1470; 4. Bigal & Lipton. Curr Neurol Neurosci Rep 2011;11:139–148 0 30 8 15 Monthly migraine days Monthly headache days Chronic migraine: Lasting >3 months 30 0 Episodic migraine: People who have had ≥5 attacks of migraine lasting 4–72 hours during lifetime and do not fulfil the criteria for chronic migraine
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ICHD-3 differential diagnosis – tension-type headache At least 10 episodes occurring 1–14 days/month for >3 months fulfilling criteria B–D Lasting from 30 minutes to 7 days Headache has at least 2 of the following 4 characteristics: Bilateral location Pressing or tightening (non-pulsating) quality Mild to moderate intensity Not aggravated by routine physical activity such as walking or climbing stairs Both of the following: No nausea or vomiting No more than 1 of photophobia and phonophobia Not better accounted for by another ICHD-3 diagnosis 19 Headache occurring on >15 days/month for 3 months fulfilling criteria B–D Lasting hours to days, or unremitting At least 2 of the following 4 characteristics: Bilateral location Pressing or tightening (non-pulsating) quality Mild to moderate intensity Not aggravated by routine physical activity such as walking or climbing stairs Both of the following No more than 1 of photophobia, phonophobia or mild nausea Neither moderate or severe nausea of vomiting Not better accounted for by another ICHD-3 diagnosis See slide notes for further information on diagnostic criteria ICHD-3=International Classification of Headache Disorders, 3rd edition Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211 2.2 Frequent episodic tension-type headache 2.3 Chronic tension-type headache
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Attacks fulfilling criteria for ‘3.1 Cluster headache’, and criterion B below Occurring without a remission period, or with remissions lasting <3 months, for at least 1 year ICHD-3 differential diagnosis – cluster headache At least 5 attacks fulfilling criteria B–D Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated) Either or both of the following: At least 1 of the following symptoms or signs, ipsilateral to the headache: Conjunctival injection and/or lacrimation Nasal congestion and/or rhinorrhoea Eyelid oedema Forehead and facial sweating Miosis and/or ptosis A sense of restlessness or agitation Occurring with a frequency between 1 every other day and 8 per day Not better accounted for by another ICHD-3 diagnosis 20 Attacks fulfilling criteria for ‘3.1 Cluster headache’ and occurring in bouts (cluster periods) At least 2 cluster periods lasting from 7 days to 1 year (when untreated) and separated by pain-free remission periods of ≥3 months See slide notes for further information on diagnostic criteria ICHD-3=International Classification of Headache Disorders, 3rd edition Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211 3.1 Cluster headache 3.1.1 Episodic cluster headache 3.1.2 Chronic cluster headache
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ICHD-3 differential diagnosis – medication-associated headache 21 See slide notes for further information on diagnostic criteria ICHD-3=International Classification of Headache Disorders, 3rd edition 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Kristoffersen & Lundqvist. Ther Adv Drug Saf 2014;5(2):87–99 a. Patients should be coded for one or more subtypes of ‘8.2 Medication-overuse headache’ according to the specific medication(s) overused and the criteria for each below. For example, a patient who fulfils the criteria for ‘8.2.2 Triptan-overuse headache’ and the criteria for one of the sub-forms of ‘8.2.3 Non-opioid analgesic-overuse headache’ should receive both these codes. The exception occurs when patients overuse combination-analgesic medications, who are coded ‘8.2.5 Combination analgesic-overuse headache’ and not according to each constituent of the combination analgesic medication b. Patients who use multiple drugs for acute or symptomatic treatment of headache may do so in a manner that constitutes overuse even though no individual drug or class of drug is overused; such patients should be coded ‘8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overused’ c. Patients who are clearly overusing multiple drugs for acute or symptomatic treatment of headache but cannot give an adequate account of their names and/or quantities are coded ‘8.2.7 Medication-overuse headache attributed to unspecified or unverified overuse of multiple drug classes’ until better information is available. In almost all cases, this necessitates diary follow-up Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headachea-c Not better accounted for by another ICHD-3 diagnosis 8.2 Medication-overuse headache1 The prevalence of medication-overuse headache is 1–2% in the general population, higher among women than men, and is highest among those aged in their forties2
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Medication overuse 22 ICHD-3 thresholds for overuse: regular intake of ≥1 opioid or triptan on ≥10 days/month for >3 months, or regular intake of acetaminophen or ≥1 NSAID on ≥15 days/month for >3 months2 ICHD-3=International Classification of Headache Disorders, 3rd edition; NSAID=non-steroidal anti-inflammatory drug Adapted from: 1. Da Silva & Lake. Headache 2014;54(1):211–217; 2. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211 Successful acute treatment of migraine involves treatment and resolution of the migraine attack and symptoms Medication-overuse headache can occur with several classes of migraine therapy, including acetaminophen, caffeine combinations, opioids, barbiturates, NSAIDs, and triptans The vicious cycle of medication overuse1
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Phases of a migraine attack 23
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Proposed phases of a migraine attack 24 Symptoms in bold denote criteria in the ICHD-3 classification ICHD-3=International Classification of Headache Disorders, 3rd edition Adapted from: Dodick. Lancet 2018;391(10127):1315–1330; Cady et al. Headache 2002;42(3):204–216; Goadsby et al. Physiol Rev 2017;97(2):553–622;Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;The American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/timeline-migraine-attack/. Accessed May 2020;Migraine Buddy website. Available at: https://migrainebuddy.com/migraine/2018/11/22/the-stages-of-a-migraine-postdrome-phase. Accessed May 2020 Premonitory Aura Headache Postdrome Fatigue Cognitive difficulties Mood changes Food cravings Neck pain Yawning Visual aura (scotoma, fortification spectrum) Sensory disturbance Speech disturbance Motor symptoms Headache Nausea with or without vomiting Photophobia Phonophobia Osmophobia Feeling tired or weary Difficulty with concentration Neck stiffness Headache 4–72 hrs <12–24 hrs 5–60 minutes A few hoursto days
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The premonitory phase of a migraine attack The headache phase of migraine is preceded by a cluster of symptoms, known as the premonitory symptoms, which can last from a few hours to days1,2 Common premonitory symptoms include:1,3 Fatigue Concentration difficulties Neck pain Mood changes Other premonitory symptoms include nausea, food cravings, and yawning1-3 Research into the neurobiology underlying the premonitory phase of migraine has pointed to early brainstem involvement, as well as the hypothalamus and limbic networks as key2 25 Frequency of the 5 most common premonitory symptoms in a study of 100 children with migraine3 1. Dodick. Lancet 2018;391(10127):1315–1330; 2. Karsan & Goadsby. Front Neurol 2020;11:140;3. Karsan et al. J Headache Pain 2016;17(1):94
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The aura phase of a migraine attack 26 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Viana et al. J Headache Pain 2019;20(1):64 Migraine aura is a complex set of fully reversible visual, sensory, speech/language, motor, brainstem, and retinal symptoms that usually begin before the headache phase of an attack, but can occur during the headache1 Elementary visual symptoms of migraine aura and their description2 Bright light – single area of bright light Foggy/blurred vision Zigzag lines – zigzag or jagged lines Scotoma – single blind area Scotomata – several blind/black areas Small bright dots – small bright dots/stars White dots/round forms – medium sized white dots/round forms Coloured dots/round forms – medium sized coloured dots/round forms Lines (coloured lines) Geometrical shapes “Like looking through heat waves, water or oil” Visual snow – dynamic, continuous, tiny dots usually black/grey on white background or grey/white on black background ‘Bean-like’ forms – ‘bean-like’ forms like a crescent or C-shape Hemianopsia – blindness in half of the visual field Deformed images – deformed images (alteration of lines/angles) Tunnel vision – blindness in the whole periphery Oscillopsia – movement of stationary objects Mosaic vision – seeing images in a mosaic-like pattern Fractured objects Corona effect – an extra edge on objects Anopia – total blindness Micropsia – objects appear smaller or more distant than they actually are Macropsia – objects appear larger or closer than they actually are “Like a negative film” Complex hallucinations – visual perception of something not present (e.g., objects, animals, and persons)
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Migraine headache (head pain) is often unilateral (affecting one side of the head)1 The headache of a migraine is reported by people with migraine to be:1,2 The headache phase of migraine is of moderate-to-severe intensity, and is often accompanied by nausea (with or without vomiting), photophobia, and phonophobia1,2 Unilateral (60%) The headache phase of a migraine attack 27 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Dodick. Lancet 2018;391(10127):1315–1330 Aggravated by physical movement (90% of people with migraine) Throbbing (50%)
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An electronic diary study followed 120 people with migraine over 3 months3 There was no relationship between medication taken for the headache and the duration of the postdrome3 The severity of migraine was not associated with the duration of the postdrome phase3 The postdrome phase of a migraine attack Postdrome is a symptomatic phase, lasting up to 48 hours following the resolution of pain in migraine attacks with or without aura1 Postdrome symptoms overlap with those experienced in the premonitory phase, and include:1,2 Feeling tired or weary Concentration difficulties Neck stiffness Postdrome symptoms can persist for up to 48 hours after the headache phase of migraine1 28 1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Goadsby et al. Physiol Rev 2017;97(2):553–622; 3. Giffin et al. Neurology 2016;87(3):309–313 Postdrome symptoms are common, but poorly studied – more research is needed to understand the link between postdrome and the underlying pathophysiology of migraine1-3 In total, 85% of participants reported ≥1 non-headache symptom in the postdrome phase3
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Migraine is a chronic neurological disease with episodic attacks of head pain 29 Dodick. Lancet 2018;391(10127):1315–1330