Migraine question

satish gore sgore at stanford.edu
Wed Feb 14 18:18:07 EST 2001

Migraine Diagnostic Problem Solving

Migraine prodrome is one of the key clinical features of migraine,
affecting 60% of migraineurs. It behooves the physician to ask
the patient if he or she is experiencing a prodrome, which can occur hours
to days before the onset of the headache, consists of
nonfocal, constitutional symptoms, and can vary widely from patient to
patient in presentation but is often consistent within the
individual patient. Some patients may experience euphoria or extraordinary
fatigue, may yawn frequently, or will have specific
food cravings as a prodrome.

Medication should be started at the beginning of the prodrome, as this is
when hypothalamic changes are occurring in the brain
under dopaminergic influence. The prodrome is unique to migraine (it is
not seen in other neurologic syndromes) and represents
an important diagnostic feature.[12]

Migraine aura. Approximately 20% of migraineurs experience an aura
associated with their headache, which may reflect a
wide range of neural deficits. Most often the aura is visual
(scintillations, scotomas); it also often has a hemianoptic distribution.
usually develops and fades within 30 minutes. If it persists longer than
an hour, it should be evaluated as an ischemic attack.[1]

Migraine without aura. The IHS criteria for clinical diagnosis of migraine
without aura require at least 5 attacks with
headaches lasting between 4 and 72 hours. The headaches are unilateral
with a pulsating quality and are of moderate to severe
intensity. These headaches are aggravated by routine physical activity.
During the headache, patients experience at least 1 of the
following symptoms: nausea, vomiting, photophobia, or phonophobia.[1]

Migraine with aura. It is easier to diagnose migraine with aura than those
cases without aura. The IHS criteria for diagnosis
require patients to have had at least 2 attacks with at least 3 of the
following characteristics:

     at least 1 fully reversible aura symptom indicating focal cerebral
cortical and/or brain stem dysfunction;
     at least 1 aura symptom developing gradually over 4 minutes, or at
least 2 symptoms occurring in succession;
     no aura symptom lasting more than 60 minutes (if more than 1 aura
symptom is present, the expected duration is
     proportionally increased); and/or
     migraine headache follows aura within 60 minutes (but may also begin
before or simultaneously with aura).[1]

Migraine headache As stated above, the migraine headache is usually
unilateral with throbbing pain. However, 40% of
migraineurs experience bilateral pain, and this presentation can confound
diagnosis. The pain is usually aggravated by physical
activity, loud noise, and bright lights. Its onset is gradual, and
patients may sleep through the initial portion of the headache. The
headache peaks and then subsides over the course of 4 to 72 hours. Nausea
occurs in up to 90% of patients and vomiting in
approximately one third.[10]

Migraine postdrome As the pain wanes, the patient will feel tired,
irritable, and listless. Many patients describe the postdrome
as a sensation of having been "hit by a truck."[10]

Other Types of Headache

To make an accurate diagnosis of migraine, it is important to be able to
identify other types of headaches.

Tension-type headache. Tension-type headache is very common and may last
from 30 minutes to 7 days per episode. It is
characterized by headache pain and 2 of the following symptoms[1]:

     a pressing/tightening, nonpulsating quality (this is the so-called
"vice-grip" headache or muscle-contraction headache);
     bilateral location;
     lack of aggravation by routine physical activity; and/or
     mild or moderate intensity that may inhibit but not prohibit

Alternatively, tension-type headache may be diagnosed if there is head
pain in the absence of nausea, vomiting, photophobia, and
phonophobia (although one of the latter qualities may be present).
Tension-type headache is defined as occurring fewer than 15
days per month.

Rebound headache. Rebound headache is characterized by a diffuse,
bilateral headache that occurs every day or nearly every
day. It is aggravated by mild physical or mental exertion. Many patients
awaken with an early-morning headache and experience
restlessness, nausea, forgetfulness, asthenia, and depression.[1]

Rebound headache may occur in response to withdrawal of an ergotamine, a
barbiturate, or codeine, and as tolerance develops
to an acute or abortive migraine medication. One clue to rebound headache
is a patient's failure to respond to preventive migraine
medication.[1] It is critical to ask headache patients about their use of
analgesic medications to determine if they are suffering
from rebound headache. Many may be ashamed to admit to overuse of

Cluster headache. Cluster headache is characterized by severe unilateral
orbital, supraorbital, and/or temporal pain lasting 15 to
180 minutes. At least 1 of the following symptoms is also present on the
headache side:

     conjunctival injection;
     facial sweating;
     nasal congestion;
     rhinorrhea; and/or
     eyelid edema.[1]

Attacks may occur anywhere from once a day to 8 times a day in


The diagnosis of migraine headaches is based on symptoms and history as
reported by the patient. There is no blood test or x-ray
to confirm the diagnosis. Symptoms may vary from one attack to another,
and migraine may be comorbid with other conditions.

Information on the family history of migraine may be lacking or
incomplete. Patients with migraine may also suffer from
tension-type or drug-induced rebound headaches. Patient evaluation can be
time-consuming and labor intensive, requiring
significant education of the patient regarding optimal management of this
benign but very disabling condition. Patients need to be
educated that migraine is a genetic, biologically based disorder as well
as an eminently treatable disorder.

This is from medscape(c) website, may be a lil technical. but hope this
there are no clear answers to ur question,
satish gore

MS wrote:

> Can anyone explain whether migraine involves vasoconstriction and/or
> vasodilation? Also, what is the mechanism of anti-migraine medication?
> Thanks.

Dr Satishchandra gore.
telephones: Home 650 566 1230 Lab: 650 724 5178
Post doctoral fellow @ University of stanford medical center

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