Population-based studies have consistently shown that about 5% of men and 15%17% of women suffer migraine attacks. In the United States the estimated annual cost, including costs of direct medical care and lost productivity, exceeds $17 billion. However common, migraine is still underrecognized and undertreated because there are no biological markers to confirm the diagnosis. The need for a reliable diagnostic tool led to the publication of the International Headache Society (IHS) criteria. All of these criteria tend to have high levels of either specificity or sensitivity, but not both. Although imperfect, these criteria are being increasingly accepted as an aid in diagnosis. Clinical practice guidelines aim to state general principles for the improvement of clinical effectiveness and quality of care and to allow informed decision-making by both physicians and patients. It is anticipated that effective guidelines for the diagnosis and treatment of migraine will improve symptom relief, increase quality of life and reduce the economic burden of this condition.
Description
The term migraine refers to periodic, hemicranial, throbbing headaches which usually begin in childhood, adolescence, or early adult life and recur with deminishing frequency during advancing years.
Types:
"Neurologic" or "aura" migraine: Where the patient experiences a vague premonition of attack associated with disturbance of vision which may be bright spots or zig zag lines and giving way to a blind spot in the field of vision. Soon after there may be mnumbness and tingling of the lips, face, hand, slight confusion in thinking, weakness of arm or legmild aphasia, dizziness, drowsiness, uncertainty of gait or confusion. Only a few of these are present in any given patient and tend to occur in the same combination with each attck. They last 5-15 min or more, if these body sensations spread over the body they do so in a matter of minutes (not in seconds as a convulsion). Just as inexplcably they come, they recede and within minutes are followed by a unilateral throbbing headache. This attack is occurs without the neurologic patterns previously mentioned but with the same hemicranial or generalized headache with or with out nausea and vomiting and followed by the same temporal pattern.
Causes
Vasodialation and excessive pulsation of branches of the external carotid aretrery have been observed during headache. As the pulsation decreases as does the pain. Supported further by surgical observations that the extracranial, temporal, and intracranial arteries with stretching of surrounding sensitive structures is beleiver to be the mechanism of most pain in migraine. This is called the vascular theory of migraine which has come to be accepted. But the theory does not explain why these intracranial and extracranial arteries undergo spasms and dialation, nor does it account for the nausea and vomiting (infrequent in all other types of headache except those due to tumor.)
Diagnosis
Migraines are difficult to diagnose for several reasons, some of which are, it is hard to elicit precise information from a patient who is trying to translate symptoms into words.
In describing the quality of pain the patient usually assumes that the word headache should have conveyed enough info to the examiner about the nature of the discomfort. When asked to analogize the sensation to another sensory experience, the patient may make some illusions to tighness, pressureor bursting feeeling. Questions about the intensity of the pain are seldom of much value since they reflect more of the patients attitude towards the conditon and a customary way of reporting things that happen rather than the true severity. As usual the brawny, heraty person tends to minimize discomfort where the neurotic dramatizes it. The symptoms are similar to those of tension headaches, and the manifestation of individual migraine attacks varies considerably between and among individuals. A physical exam of the head itself is seldom useful. A careful history taking, inqueries as to the location of pain and the degree of incompacity to the pateint are better indexes to use. The overall methods used to elicit information and the interpretation of the individual diagnostic criteria and patient responses must be orderly and consistent.
Criteria for diagnosing migraine without aura: 1. One attack every few weeks, more than this is considered exceptional 2. At least 5 attacks fulfilling the following criteria. A. Each attack, untreated or unsuccessfully treated, lasts 2-72 hours.B. The attack has at least 2 of the floowing characteristics:-Unilateral location: Migraines are most commonly unilateral; however thay can be bilateral in 30%40% of cases and sometimes the pain begins on one side and later spreads to the other. Location should therefore be characterized at different phases of the attack, and early or mild attacks should be differentiated from full-blownattacks. Useful questions to ask the patient include: Do you feel pain on one or both sides? If one-sided, is it lways on the same side? If present on both sides, did the pain start on one side? Is it usually maximal on one side? -Pulsating quality: Over 50% of people who suffer migraines report nonthrobbing pain during some attacks, and 30% of patients with tension-type headaches may report pulsating pain. Headache quality may also vary over the duration of the attack. If the pain is throbbing at any phase of the attack, it is recommended that, for consistency,the quality be considered as throbbing overall. Useful questions include: What kind of pain is it — tightening, pressing, throbbing, pounding, pulsating, burning or other? Do different types of pain occur at different times in any one attack? If so, which types? Moderate or severe intensity: The severity of the migraine inhibits or prohibits daily activity. Pain is aggravated by walking up and down stairs or similar routine physical activity: Patients who prefer not to move around should be considered as experiencing aggravation of pain by physical activity. Possibly useful questions about other, less equivocal aggravating factors include Do you avoid movement of even a minor nature (head movement or bending down) during an attack? -During an attack at least 1 of the following symptoms should be present. 1. Nausea or vomiting: It is important that nausea be differentiated from anorexia, which is common among patients with anxiety or tension-type headaches. 2. Photophobia, phonophobia and osmophobiam (aversion to oders) since these are highly sensitive and specific features of migraine. Useful questions to ask the patient include: During a headache, are you unusually sensitive to light, noise or odours? Do you take steps to avoid them? Because there is some degree of overlap of symptoms between migraine and tension-type headache, theseverity of such symptoms should be graded as mild, moderate or severe as with pain severity. C. There is no evidence from the patient's history or physical examination of any other disease that might cause headaches.
Criteria for diagnosing migraine with aura: These diagnostic criteria are the same as those for migraine without aura, bit they include symptoms of neurological dysfunction (including visual disturbance) occurring before or during the attack.
Additional questions : The patient should be questioned further in order to enhance the specificity and sensitivity of the above criteria, and to improve the "pattern recognition" of migraine. Additional questions concerning other typical migraine characteristics should be asked to investigate the following:-The regular or near-regular timing of attacks around menstrual or ovulation periods.-The gradual appearance of headache after sustained exertion -Abatement of headache with sleep -The presence of symptoms such as irritability or other mood variations, hyperactivity, inability to think or concentrate, food cravings and hyperosmia prior to an attack. -The presence of a family history of migraine.-The consistent precipitation of headaches by food, odours, weather changes or stress.- The occurrence of headache at times of let-down, particularly after a high level of activity or stress. Features that should raise concern that a more serious underlying cause may be present, possibly indicating the need for further investigation, should be investigated include the following: -The first or worst headache of the patient's life, particularly if the onset was rapid .-A change in the frequency, severity or clinical features of the attack from what the patient has commonlyexperienced (no longer conforms to the IHS criteria) -The new onset of headache in middle-age or later, or a significant change in a long-standing headache pattern -The occurrence of a new or progressive headache that persists for days -The precipitation of head pain with the Valsalva manoeuvre (by coughing, sneezing or bending down) -The presence of systemic symptoms such as myalgia, fever, malaise, weight loss, scalp tenderness or jawclaudication -The presence of focal neurological symptoms, of any abnormalities found on neurological examination, or ofconfusion, seizures or any impairment in the level of consciousness Physical examination:The general physical examination performed at the first consultation for headache problems should evaluate at least the following: vital signs (blood pressure and heart rate); cardiac status; extracranial structures (sinuses, scalp arteries, cervical paraspinal muscles and temporomandibular joints); and range of motion and the presence of pain in the cervical spine. A screening neurological examination capable of detecting most of the abnormal signs likely to occur in patients with headaches due to intracranial or systemic disease should be performed, including evaluation of neck flexion (for evidence of meningeal irritation) in certain cases; the presence of bruits over the cranium, orbits or neck; and the optic fundi, visual fields, pupillary reactions, sensory function of the fifth cranial nerve, corneal reflexes, motor power in the face and limbs, muscle stretch reflexes, plantar responses and gait. The presence of such abnormalities, unusual in uncomplicated migraine, suggest the need to consider further investigations.
Symptomatic treatment: Patients respond to a variety of medications, and the medication of choice is often individual and idiosyncratic. benefits and hazards of the agents available should be considered as relevant factors in determining the mostappropriate medication. The goals of therapy should be the relief of headache and associated symptoms and a return to normal functioning. Drug therapy is indicated if the headaches threaten to disrupt the patient's ability to function normally. Patients seldom suffer more than a few migraine attacks per month. Although these attacks may be incapacitating and require treatment, and because other types of headache may also occur, patients must be warned that frequent use of symptomatic treatments (analgesics and ergotamine in particular) can lead to medication-induced (rebound) headache and eventually to chronic daily headache. Without appropriate treatment, patients are more likely to consume increasing amounts of less effective compounds, which thus increases the risk of rebound headache. Asking the patient to keep a diary of headache symptoms and medication use may be valuable in preventing this situation.
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