- 1 Classification
- 2 Diagnosis
- 3 Treatment
- 3.1 Abortive treatment
- 3.2 Preventive treatment
- 3.3 =Investigational agents
- 4 Prognosis
- 5 References
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)." 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.
- Common migraine (without aura)
- Classic migraine (with aura or neurological symptoms)
Migraines are underdiagnosed and misdiagnosed. About a third of headaches that patients report as being migraines are truly migraines; while about 90% of headaches that are self-reported not to be migraines are truly not migraines. 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 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.
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.
The presence of either disability, nausea, or sensitivity to light can diagnose migraine with:
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. 
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.
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. 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).
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. In addition, prochlorperazine 10 mg intravenously with 12.5 mg diphenhydramine intravenously may be more effective than subcutaneous sumatriptan.
Perhaps a third of patients meet consensus criteria for preventive treatment.
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.
The anticonvulsant drug topiramate can increase response among patients with migraine according to a randomized controlled trial.> 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 may have small benefit according to a meta-analysis that included the PREEMPT 1 and PREEMPT 2 trials. These trials also showed improvement in the quality of life. However, these studies have been criticized for inability to blind the participants and most subjects having medication overuse headache.
Standards for the conducts of trials of preventive medications have been proposed by the Task Force of the International Headache Society Clinical Trials Subcommittee.
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