Migraine afflicts one in six people worldwide and results in significant pain, disability, and reductions in quality of life. Chronic migraine affects 2% of the population and is considered by the WHO to be one of the most disabling illnesses.Migraine is defined by the International Classification of Headache Disorders as:

  1. At least five attacks that fulfill criteria
  2. through D B. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
  3. Headache has at least two of the following characteristics:

    1. Unilateral location
    2. Pulsating quality
    3. Moderate or severe pain intensity
    4. Aggravation by or causing avoidance of routine physical activities (e.g., walking or climbing stairs)
  4. During headache at least one of the following occurs:
    1. Nausea and/or vomiting
    2. Photophobia and phonophobia
  5. Not attributed to another disorder
When migraine patients have headaches on fewer than 15 days per month, they are considered to have episodic migraine; when they have headaches on at least 15 days per month, and headaches on at least 8 days each month meet the criteria for migraine, they are considered to have chronic migraine. Approximately one third of patients with migraine have a preceding aura, which develops slowly over 5 to 20 minutes and resolves within 60 minutes. This slow progression of symptom development and the timing of symptom resolution help differentiate migraine aura from stroke. Visual symptoms are the most common and are usually positive symptoms (scintillations) followed by negative symptoms (scotoma). Sensory symptoms are second most common and typically consist of paresthesias in the hand of one extremity with ipsilateral progression up the arm and eventually to the lower face. Less common aura symptoms may include numbness, weakness, speech changes, dizziness, gait instability, ataxia, and loss of vision; however, these less common symptoms significantly increase suspicion for a secondary headache or a less common migraine syndrome (hemiplegic migraine, migraine with brainstem aura, retinal migraine).
Migraine treatment includes abortive headache medications and, when warranted, prophylactic therapy. Prophylactic measures may be initiated in patients who have frequent headaches, insufficient response to acute headache medications, prolonged headaches, migraine that causes significant impact on quality of life, and/or bothersome associated neurologic features, such as may be seen with hemiplegic migraine or migraine with brainstem aura.
The abortive therapy of migraine is heavily reliant on medications. The triptans are arguably the most effective therapy for acute headache relief in the outpatient setting. Several triptans are available as a pill, two are available as orally dissolving tablets, two are available as nasal sprays, and one is available for self-injection. Although there are perhaps subtle differences between the triptans in regard to side effects, elimination halflife, recurrence rate, and overall efficacy, they have more similarities than differences. The amount of triptan that can be safely used is subject to limitations, and multiple contraindications to their use exist that mostly involve vascular diseases and cardiovascular risk factors. Other outpatient acute headache therapies include dihydroergotamine mesylate nasal spray, NSAIDs, antiemetics, butalbital-containing products, and opioid analgesics.
Regardless of therapy, it is important to instruct patients to treat early after the onset of migraine. When migraine is allowed to persist and sensitization occurs, abortive therapies are less successful. Butalbital-containing products and opioids should rarely be used for migraine because of concern for increasing headache frequency and/or severity by causing medicationoveruse headache or opioid tolerance/hyperalgesia.
Prophylactic therapy for migraine may consist of headache trigger avoidance, daily medication, physical therapy, and biobehavioral therapy. Most medications used for the prophylaxis of migraine are antidepressants (TCAs, SNRIs), blood pressure medications (β-blockers, calcium channel blockers), or antiepileptics (topiramate, valproic acid). Other frequently used therapies include riboflavin, magnesium, feverfew, and butterbur. Based upon the results from two large, prospective, blinded, randomized clinical trials, onabotulinumtoxinA is approved by the Food and Drug Administration for the treatment of chronic migraine. As a rule of thumb, prophylactic therapy is considered successful if at least a 50% reduction in headache frequency is appreciated, or if reductions in attack severity are substantial. Physical therapy, biofeedback, relaxation therapy, massage, and acupuncture may also be considered.

Source: Cummings Otolaryngology, 6E (2015)

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