1. The Mystery of
Migraines
Andrew Massey, M.D. UKSM-W
May 14, 2013

2. Classification of Headaches
(circa 1977)
1. Vascular headache
a. Classic migraine
b. Common migraine
2. Muscle tension headache
3. Traction and inflammatory headache

3. Classification of Headaches
International Headache Society 1988
• 14 major categories
• 195 separate, individually defined headaches
• 19 migraine types

4. Classification of Headache
International Headache Society 2005
• Part I: The Primary Headaches
• 1. Migraine
• 2. Tension-type headache
• 3. Cluster headache and other trigeminal autonomic cephalalgias
• 4. Other primary headaches
• Part II: The Secondary Headaches
• 5. Headache attributed to head and/or neck trauma
• 6. Headache attributed to cranial or cervical vascular disorder
• 7. Headache attributed to non-vascular intracranial disorder
• 8. Headache attributed to a substance or its withdrawal
• 9. Headache attributed to infection
• 10. Headache attributed to disorder of homoeostasis
• 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or
• other facial or cranial structures
• 12. Headache attributed to psychiatric disorder
• Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches
• 13. Cranial neuralgias and central causes of facial pain
• 14. Other headache, cranial neuralgia, central or primary facial pain

5. Migraine: Subtypes
1.1 Migraine without aura
1.2 Migraine with aura
1.2.1 Typical aura with migraine headache
1.2.2 Typical aura with nonmigraine headache
1.2.3 Typical aura without headache
1.2.4 Familial hemiplegic migraine
1.2.5 Sporadic hemiplegic migraine
1.2.6 Basilar-type migraine
1.3 Childhood periodic syndromes
1.3.1 cyclic vomiting
1.3.2 abdominal migraine
1.3.3 benign paroxysmal vertigo of childhood

6. Migraine: Subtypes
(continued)
1.4 Retinal migraine
1.5 Complications of migraine
1.5.1 Chronic migraine
1.5.2 Status migrainosus
1.5.3 Persistent aura without stroke
1.5.4 Migrainous stroke
1.5.5 Migraine-triggered seizure
1.6 Probable migraine
1.6.1 Probable migraine without aura
1.6.2 Probable migraine with aura
1.6.3 Probable chronic migraine

7. 8. HA attributed to a substance or its withdrawal
8.1 HA induced by acute substance exposure
8.1.4 Alcohol induced headache
8.1.4.1 Immediately induced
8.1.4.2 Delayed induced headache

8. Migraine
• 90% of all headache due to one of 3 disorders:
– Tension-type headache
– Migraine headache
– Cluster headache
• 15% of people in U.S. experience migraine
– 17% of women, 6% of men

9. Migraine: Symptoms
• Pain
– Dull, deep, steady when mild to moderate
– Throbbing or pulsatile when severe
– Worsened by light, noise, motion, sneezing,
straining
– 70% with pain only on one side of the head
• Other symptoms
– Nausea, vomiting, photophobia, phonophobia
– 20% with auras

10. Migraine: Symptoms
• Migraine Aura
– Preceeds or accompanies the headache
– May be sensory, visual, motor, or speech
– Last 5 to 20 minutes (uncommonly 60 minutes)
• Headache may last a few hours to several days
– Usually resolve in sleep
• Postdrome phase
– Patient feels “drained” or exhausted

11. Migraine: Triggers
• Emotional stress, worry
• Medications & chemicals
– Nitroglycerin, hydralazine, estrogens
– Strong perfumes, smoke, organic solvents
• Certain foods or additives
– Nitrites, monosodium glutamate, aspartate, alcohol
• Other triggers
– Fasting, sleep deprivation, physical exertion, weather,
lights, caffeine withdrawal, menstruation

12. Migraine: Diagnostic Criteria
A. At least 5 attacks fulfilling B-D
B. HA lasting 4-72 hours
C. HA has at least two of the following
1. Unilateral location
2. Pulsating quality
3. Moderate or severe intensity
4. Aggravation by walking stairs or similar routine
physical activity
D. Headache not explained by another disorder

13. Diagnosis of headache
1. Take a careful history
2. Do a careful examination

14. History:
30 y.o. British soldier with two year history of
headache and trouble fitting his helmet
Exam:
See next slide 

15. Migraine: Treatment
1. Recognize & avoid triggers
2. Preventive treatment to reduce frequency &
intensity of headaches
3. Acute treatment of migraine

16. Preventive Treatment 1/4
• Medications for control of hypertension
– Beta blockers:
• propranolol, metoprolol, timolol, nadolol, atenolol
– Calcium channel blockers:
• verapamil, nifedipine, nimodipine
– ACE inhibitors or ARBs:
• lisinopril, candesartan

17. Preventive Treatment 2/4
• Antidepressants
– Tricyclics:
• amitriptyline, nortriptyline, protriptyline, doxepin
– Serotonin/norepinephrine reuptake inhibitors:
• venlafaxine

18. Preventive Treatment 3/4
• Anti-Epileptic medications:
– Valproate,
– topiramate,
– gabapentin
• Other agents:
– Botulinum toxin
– Coenzyme Q10
– Nonsteroidal antiinflammatory drugs:
• Naproxen, indomethacin
– Narcotics
– Riboflavin (vitamin B2)

19. Preventive Treatment 4/4
• Nonpharmacologic therapy
– Relaxation training
– Behavioral therapy
– Hypnosis
– Occipital nerve electrical stimulation
– Acupuncture
– Surgery (eg., removal of glabellar muscle)
– Closure of patent foramen ovale (PFO)
– Exercise

20. Acute Treatment of Migraine
• Mild analgesics
– Nonsteroidals: ibuprofen, diclofenac, naproxen
– Acetaminophen
– Aspirin
• Triptans
– Sumatriptan, zolmitriptan, naratriptan, rizatriptan,
almotriptan, eletriptan, frovatriptan
• Ergots
– Ergotamine, dihydroergotamine (DHE)

21. Acute Treatment of Migraine
• Anti-nausea medications
– Metoclopramide, chlorpromazine,
prochlorperazine
• Others
– Benzodiazepines, narcotics, barbiturates
– Steroids (eg., dexamethasone)
• Investigational drugs
– CGRP receptor antagonists
– lasmiditan

22. Acute Treatment of Migraine
• General principles for preventive medications
1. Take early in the attack
2. Non-oral med if prominent nausea &vomiting
3. Consider anti-nausea medication
4. Consider caffeinated beverage
5. Guard against medication overuse headache
a. Expecially with barbiturates or narcotics
b. Increase risk with >2-3 acute treatments per week