Migraine

Definition/diagnostic criteria Migraine is a primary headache disorder characterised by recurrent episodes of headache, most often unilateral and in some cases associated with visual or sensory symptoms—collectively known as an aura—that arise most often before the head pain but that may occur during or afterward. The International Classification of Headache Disorders (ICHD-3) criteria define migraines as having at least five attacks lasting 4-72 hours, featuring at least two of the following: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by or causing avoidance of routine physical activity, plus at least one of the following: nausea and/or vomiting, or photophobia and phonophobia.

Epidemiology Migraine affects approximately 15% of the UK population, with a higher prevalence in women (22%) than in men (8%). The peak age of onset is in the early 30s.

Diagnosis

Clinical features: Migraine diagnosis is predominantly clinical. Common features include unilateral, throbbing headaches, sensitivity to light or sound, nausea, and sometimes vomiting. Some patients experience aura, manifesting as visual disturbances, sensory changes, or speech difficulties.

Investigations: Routine investigations are not necessary for a typical presentation of migraine. However, neuroimaging may be considered in atypical cases, such as those with sudden onset, a marked change in the pattern of headaches, or neurological signs.

Typical abnormalities: There are no specific abnormalities for migraine on routine investigations. MRI or CT scans are normal in typical migraine but are used to exclude other pathologies.

Treatment Treatment options include acute and prophylactic treatments. Acute treatments consist of analgesics like paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or triptans (e.g. sumatriptan). An anti-emetic may also be useful acutely. Prophylactic treatments are considered when migraine is occurring frequently and impacting significantly on quality of life, and may include beta-blockers (e.g, propranolol), topiramate or amitriptyline.

For menstrual migraine unresponsive to standard treatment, consider prophylactic triptans. In migraine with aura, combined hormonal contraceptive use may increase the risk of vascular events and should be avoided.

Prognosis Migraine is a chronic condition with variable prognosis. While some individuals may experience a decline in frequency and severity of attacks over time, others may have persistent, frequent episodes. Effective management can significantly improve quality of life and reduce disability.