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Migraine headache

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Migraine headaches are "a class of disabling primary headache disorders, characterized by recurrent unilateral pulsatile headaches. The two major subtypes are common migraine (without aura) and classic migraine (with aura or neurological symptoms)."[1] Laymen often use the term for any severe headache, especially with nausea and sensitivity to light and sound, but there are specific criteria. Just as the term is overused in some contexts, however, true migraine has different manifestations, is underdiagnosed, and is sometimes preventable as well as treatable.

Patients with a diagnosis of migraine are called migraneurs.

Classification

  • Common migraine (without aura)
  • Classic migraine (with aura or neurological symptoms)

Diagnosis

Migraines are underdiagnosed[2] and misdiagnosed.[3] About a third of headaches that patients report as being migraines are truly migraines[4]; while about 90% of headaches that are self-reported not to be migraines are truly not migraines.[4] The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria":[5]

  • 5 or more attacks
  • 4 hours to 3 days in duration
  • 2 or more of - unilateral location, pulsating quality, moderate to severe pain, aggravation by or avoidance of routine physical activity
  • 1 or more accompanying symptoms - nausea and/or vomiting, photophobia, phonophobia

For migraine with aura, only two attacks are required to justify the diagnosis.

Additional criteria are available.[6]

POUNDing

The mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.[7]

ID Migraine

The presence of either disability, nausea, or sensitivity to light can diagnose migraine with[8]:

A subsequent systematic review of ID migraine reported similar results.[9]

Treatment

There are two basic problems in migraine management: treating the acute attack, and preventing migraine in chronic migraneurs. Some treatment approaches combine preventive approaches with specific preventive measures. "The addition of combined β blocker plus behavioural migraine management, but not the addition of β blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment" according to a randomized controlled trial. [10]

Abortive treatment

Non-steroidal anti-inflammatory agents

Non-steroidal anti-inflammatory agents (NSAIDs) can help."Oral diclofenac potassium 50 mg is an effective treatment for acute migraine, providing relief from pain and associated symptoms, although only a minority of patients experience pain-free responses" according to a meta-analysis by the Cochrane Collaboration.[11]

Serotonin agonists

High dose acetylsalicylic acid (1000 mg) may be as effective as sumatriptan, especially if the acetylsalicylic acid is combined with metoclopramide to reduce nausea and vomiting, according to a systematic review by the Cochrane Collaboration.[12] One of the trials in the review reported that high dose acetylsalicylic acid (1000 mg), sumatriptan 50 mg and low dose ibuprofen 400 mg are equally effective at reducing pain to mild or none at two hours according to a randomized controlled trial; however, sumatriptan was led to more patients being pain free at two hours (37% versus less than 33% for other groups).[13]

Dopamine antagonists

Phenothiazines, such as prochlorperazine 10 mg parenterally and chlorpromazine 0.04 to 0.1 mg/kg parenterally, are more effective than placebo and more effective than metoclopramide according to a meta-analysis of randomized controlled trials.[14] In addition, prochlorperazine 10 mg intravenously with 12.5 mg diphenhydramine intravenously may be more effective than subcutaneous sumatriptan.[15]

Combination therapy

High dose acetaminophen (1000 mg) combined with metoclopramide is effective and is as effective as oral sumatriptan 100 mg according to a systematic review by the Cochrane Collaboration.[16]

When using intravenous metoclopramide, a 10 mg dose combined with 25 mg of diphenhydramine in 50 ml of saline given over 20 minutes may be optimal.[17]

High dose acetylsalicylic acid (1000 mg) combined with metoclopramide is effective according to a systematic review by the Cochrane Collaboration.[12]

A combination of sumatriptan 85 mg and naproxen sodium 200 mg was better than either drug alone according to a randomized controlled trial funded by the manufacturer of the study drug.[18]

Nonpharmacological treatments

Indirect evidence suggest migraine pain, under certain circumstances, may be worse while laying down.[19][20]

Corticosteroids

Corticosteroids may help prevent recurrence after abortive treatment according to a meta-analyses of randomized controlled trials with number needed to treat of nine[21] or 10[22].

A more recent randomized controlled trial found insignificant benefit, but the study was small and the magnitude of the benefit was similar to the prior meta-analysis meta-analyses.[23]

Investigational treatments

Telcagepant (MK-0974), an oral antagonist of calcitonin gene-related peptide receptor, may be as effective as zolmitriptan but with less drug toxicity according to a randomized controlled trial.[24]

"Sublingual feverfew/ginger appears safe and effective as a first-line abortive treatment" according to a randomized controlled trial.[25]

Preventive treatment

Clinical practice guidelines address preventive treatment.[26]

Perhaps a third of patients meet consensus criteria for preventive treatment.[27]

Systematic reviews addresse options.[28][29]

Tricyclic antidepressants

Tricyclic antidepressants may be effective and may be more effective than second-generation antidepressants according to a systematic review.[30]

Adrenergic beta-antagonists

Placebo is as effective as adding the adrenergic beta-antagonist drug propanolol to patients not adequately controlled on topiramate.In a randomized controlled trial, both groups reduced their days with migraine by half.[31]

Angiotensin inhibition=

Angiotensin-converting enzyme inhibitor and angiotensin II receptor antagonist medications may reduce attacks according to a systematic review.[28]

Anticonvulsants

The anticonvulsant drug topiramate can increase response among patients with migraine according to a randomized controlled trial.[32]> The relative benefit increase was 113.0%. For patients at similar risk to those in this study (23.0% had response), this leads to an absolute benefit increase of 26%. 3.8 patients must be treated for one to benefit (number needed to treat = 3.8). Click here to adjust these results for patients at higher or lower risk of response.

Botulinum toxin

Botulinum toxin may have small benefit according to a meta-analysis[33] that included the PREEMPT 1[34] and PREEMPT 2[35] trials. These trials also showed improvement in the quality of life.[36] However, these studies have been criticized for inability to blind the participants and most subjects having medication overuse headache.[37]

The long term drug toxicity of botulinum toxin is uncertain.[38][39][40]

=Investigational agents

Standards for the conducts of trials of preventive medications have been proposed by the Task Force of the International Headache Society Clinical Trials Subcommittee.[41]

Prognosis

Migraines with auras in mid-life may be associated with stroke[42] and brain infarcts on magnetic resonance imaging[43].

References

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  5. International Headache Society. IHS Classification ICHD-II Migraine headache
  6. Ad Hoc Committee on the Classification of Headache of the National Institute of Neurological Diseases and Blindness. Classification of headache. JAMA (1962) 179:717–8
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