Epidemiology

  • Incidence: 5000.00 cases per 100,000 person-years
  • Peak incidence: 30-40 years
  • Sex ratio: more common in males 3:1
Condition Relative
incidence
Tension-type headache3.00
Migraine1
Temporal arteritis0.004
Cluster headache0.002
Paroxysmal hemicrania0.00004
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

Common triggers for a migraine attack
  • tiredness, stress
  • alcohol
  • combined oral contraceptive pill
  • lack of food or dehydration
  • cheese, chocolate, red wines, citrus fruits
  • menstruation
  • bright lights

Clinical features

Migraine is a common type of primary headache. It is characterised typically by:
  • a severe, unilateral, throbbing headache
  • associated with nausea, photophobia and phonophobia
  • attacks may last up to 72 hours
  • patients characteristically go to a darkened, quiet room during an attack
  • 'classic' migraine attacks are precipitated by an aura. These occur in around one-third of migraine patients
  • typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma

Diagnosis

The International Headache Society has produced the following diagnostic criteria for migraine without aura:

PointCriteria
AAt least 5 attacks fulfilling criteria B-D
BHeadache attacks lasting 4-72 hours* (untreated or unsuccessfully treated)
CHeadache has at least two of the following characteristics:
  • 1. unilateral location*
  • 2. pulsating quality (i.e., varying with the heartbeat)
  • 3. moderate or severe pain intensity
  • 4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
DDuring headache at least one of the following:
ENot attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder)

*In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.

Migraine with aura (seen in around 25% of migraine patients) tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma ('jagged crescent'). Sensory symptoms may also occur

If we compare these guidelines to the NICE criteria the following points are noted:
  • NICE suggests migraines may be unilateral or bilateral
  • NICE also give more detail about typical auras:

Auras may occur with or without headache and:
  • are fully reversible
  • develop over at least 5 minutes
  • last 5-60 minutes

The following aura symptoms are atypical and may prompt further investigation/referral;
  • motor weakness
  • double vision
  • visual symptoms affecting only one eye
  • poor balance
  • decreased level of consciousness.

Management

It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines.

Acute treatment
  • first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
  • for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
  • if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan

Prophylaxis
  • prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.
  • NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
  • if these measures fail NICE recommend 'a course of up to 10 sessions of acupuncture over 5-8 weeks' or gabapentin
  • NICE recommend: 'Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people'
  • for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'
  • pizotifen is no longer recommend. Adverse effects such as weight gain & drowsiness are common


SIGN produced guidelines in 2008 on the management of migraine, the following is selected highlights:

Migraine during pregnancy
  • paracetamol 1g is first-line
  • aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester

Migraine and the combined oral contraceptive (COC) pill
  • if patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)

Migraine and menstruation
  • many women find that the frequency and severity of migraines increase around the time of menstruation
  • SIGN recommends that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans are also recommended in the acute situation

Migraine and hormone replacement therapy (HRT)
  • safe to prescribe HRT for patients with a history of migraine but it may make migraines worse


*caution should be exercised with young patients as acute dystonic reactions may develop