Migraine 1 Migraine through history Migraine comes from the Greek word hemicrania which referred to pain occurring on one side of the head half skull 1 The earliest descriptions of migraine are said to be from 3000 BC ID: 911079
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Slide1
History, definitions and diagnosis
Migraine
1
Slide2Migraine through history
Migraine comes from the Greek word ‘
hemicrania
’, which referred to pain occurring on one side of the head (‘half skull’)
1The earliest descriptions of migraine are said to be from 3,000 BC2Hippocrates provided an account of a severe headache that was associated with a visual disturbance, describing the experience as “something shining before him”2Migraine has been described by physicians through the last two millennia, with some paying greater attention to symptoms other than headache2Historically, ‘surgical’ techniques have included scalp incisions, application of heated irons, and blood letting2,3In the less-distant past, treatments have included several chemicals, including trinitrine (nitroglycerin), which is now known to be a vasoactive substance2
2
1. Pearce. Eur Neurol 2005;53(2):109–110;2. Pearce. J Neurol Neurosurg Psychiatry 1986;49(10):1097–1103;3. Koehler & Boes. Brain 2010;133:2489–2500
Slide3Timeline of migraine research
3
CALCRL=calcitonin receptor-like receptor;
CGRP=calcitonin gene-related peptide;
CSD=cortical spreading depression (or depolarisation); IHS=International Headache Society; PET=positron emission tomography; RAMP1=receptor activity-modifying protein 1; RCP=receptor coupling proteinAdapted from: Edvinsson et al. Nat Rev Neurol 2018;14(6):338–350; Tfelt-Hansen & Koehler. Headache 2011;51(5):752–778
First measurement of CGRP released by trigeminal stimulation in humans
1981
1982
Oligaemia in the wake of CSD in rats
Neurogenic inflammation theory of migraine
1984
1986
Discovery of the trigeminovascular reflex: a physiological role for CGRP
Presence of CGRP confirmed in human cerebral vasculature
1987
1990
First demonstration in people with migraine that CGRP is released during an acute migraine attack
1988
Demonstration that CGRP release by trigeminal activation is inhibited by triptans
Characterisation of the multicomponent CGRP receptor that consists of CALCRL, RAMP1 and RCP
Characterisation of the gepants
2002
Infusion of CGRP shown to trigger migraine attack in people prone to migraine
1918
1940
Isolation and clinical testing of an ergot alkaloid
Identification of
pain-sensitive structures in the brain
1941
Lashley’s description of spreading scotoma
1944
Leão’s experiments into CSD
1984
Discovery
of CGRP
CGRP antibodies made to measure and localise CGRP in the trigeminal–cerebrovascular system, where CGRP was found to be a potent vasodilator
1988
Discovery
of proto-
typical
triptan
1988
New headache classification from IHS
1996
Gene for
familial hemiplegic
migraine identified
1996
Meningeal sensitisation,
central sensitisation and allodynia
1938
Vasodilation in migraine,
and ergot therapies
1959
Serotonin – serum
(‘sero’) vasoconstrictor (‘tonin’) factor
Spreading oligaemia in migraine with aura
PET studies highlight the importance of the brainstem
Triptan shown to normalise CGRP levels during acute migraine attack
1993
1994
1995
CGRP first proposed to play a role in migraine
1982
1998
1985
2000
Slide4Migraine epidemiology
An estimated 1.3 billion individuals were affected by migraine across the globe in 2017
1
In the WHO global burden of disease study, headache disorder has consistently been the 2
nd most prevalent disease in the world1Women are approximately 3 times more likely than men to have migraine2 Among people aged less than 50 years old, migraine is the most common cause of disability3Migraine is associated with high levels of disability and comorbidity, including an increased risk of insomnia, depression, and anxiety44
WHO=World Health Organization1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Lancet 2018;392
(10159):1789–1858; 2. Gasparini et al. Curr Genomics 2013;14(5):300–315; 3. Steiner et al. J Headache Pain 2018;19(1):17; 4. Buse et al. J Headache Pain 2020;21(1):23
Migraine is a highly prevalent condition
Slide5The burden of migraine
Migraine is a burdensome condition, and has a substantial impact on activities of daily living, such as work, school, and social activities
1-3
A systematic literature review of the burden of migraine identified several psychosocial difficulties:
2Energy and drive – fatigue, reduced vitality, difficulties with sleepEmotional functioning – depressive symptoms, anxiety, stress, angerPain – general pain, and the sensation of painEmployment – reduced efficiency at work, restriction in time given to work, partial absenceGeneral physical and mental health – general mobility, carrying out daily routineSocial functioning – relationships with others, family relationships, leisure activities Global disability
– global functioning, quality of life, self-efficacyMany of the psychosocial difficulties identified in the review (e.g., emotional functioning, and employment) appeared to respond well to migraine therapy, particularly to preventive treatment2
51. Agosti. Headache 2018;58(Suppl 1):17–32; 2. Raggi et al. J Headache Pain 2012;13(8):595–606; 3. Smitherman et al. Headache 2013;53(3):427–436
Migraine is a highly burdensome condition
Slide6Migraine-related impairment in the
AMPP
study
The AMPP survey of 77,879 households in the USA asked respondents in what way they are “usually affected by severe headaches”:
1 No impairment: able to function normally
Some impairment: able to function, but with reduced performanceSevere impairment: unable to function or requiring bed rest
The results showed migraine-related impairment was common among respondents:147.7% did no household work29.1% missed family or social activity25.3% missed at least 1 day of work/school 6
AMPP=American Migraine Prevalence and Prevention; USA=United States of America1. Lipton et al. Neurology 2007;68(5):343–349
3. Severe
impairment
(53.7%)
2. Some
impairment
(39.1%)
1. No impairment
(7.2%)
Headache-related impairment during severe headache in the AMPP study
1
Migraine is commonly associated with severe impairment or need for bed rest
1
Slide7Depression among people with migraine in the AMPP study
7
Low-frequency EM: 0–3 headache days per month; moderate-frequency EM: 4–7 headache days per month;
high-frequency EM: 8–14 headache days per month; chronic migraine: ≥15 headache days per month;
none or minimum depression: PHQ-9 score 0–4; mild depression: PHQ-9 score 5–9; moderate depression: PHQ-9 score 10–14; moderately severe depression: PHQ-9 score 15–19; severe depression: PHQ-9 score 20–27AMPP=American Migraine Prevalence and Prevention; EM=episodic migraine; PHQ-9=9-item Patient Health Questionnaire 1. Buse et al. Headache 2020;60:2340–2356
None or minimum depression
Mild
depression
Moderate depression
Moderately severe depression
Severe depression
Comorbidity of depression and migraine in AMPP study (n=11,603)
1
Rates of comorbidity, including depression, generally increased with headache frequency
1
Slide8Migraine stigma and social isolation (from the
Eurolite
project)
8
Adapted from:
Lampl et al. J Headache Pain 2016;17:9
Male
Female
Avoid telling others
Migraine
Tension-type headache
Family, friends don’t understand
Migraine
Tension-type headache
Employer, colleagues don’t understand
Migraine
Tension-type headache
Difficulties in love life
were reported by 17.6% of respondents, and ~1% of respondents reported
having fewer children
, or had avoided having children altogether, because of migraine
Slide9The economic burden of migraine
Direct costs of migraine
Examples of direct costs include prescription medication, and hospitalisation
1
A study of 215,209 people with migraine found that migraine was associated with $2,571 greater costs per person per year:1People with migraine: $7,007Control individuals: $4,436Estimates of direct migraine costs across the whole of the USA were:1Outpatient care: $5.21 billionPrescriptions: $4.61 billionInpatient care: $0.73 billionEmergency department care: $0.52 billion9
Indirect costs of migraine
Examples of indirect costs include lost productivity at work, and workplace absence2An analysis of 6,516 people with migraine found that migraine was associated with $2,834 greater indirect workplace costs per person per year:2People with migraine: $4,453 Control individuals: $1,619The indirect cost of migraine across the whole of the USA was estimated to be $12 billion2
USA=United States of America1. Hawkins et al. Headache 2008;48(4):553–563; 2. Hawkins et al. J Occup Environ Med 2007;49(4):368–374
Increased knowledge, and access to appropriate migraine management,
are likely to help in reducing the economic burden of migraine
2
Slide10Migraine criteria, diagnosis and subtypes
10
Slide11What is migraine? What are migraine attacks?
Migraine is a chronic neurological disease with episodic attacks of head pain
1
If caused by another medical condition, the headache is said to be a secondary headache
2Migraine is characterised, including by International Classification of Headache Disorders, 3rd edition (ICHD-3), from the IHS, by attacks of moderate-to-severe headache and reversible neurological and systemic symptoms:1,2Photophobia – extreme sensitivity to lightPhonophobia – extreme sensitivity to soundAllodynia – pain resulting from a stimulus that would not normally provoke pain (e.g., a light touch of the skin)
Nausea and vomitingOther symptoms – including vertigo, dizziness, and cognitive impairmentResearch into the genetic and biological mechanisms underlying migraine has led to a better understanding of the condition, and to the development of novel therapies and treatments
111
IHS=International Headache Society1. Dodick. Lancet 2018;391(10127):1315–1330; 2. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
Slide12ICHD-3 criteria for migraine and migraine attacks
12
a
People who do not fulfil criteria for chronic migraine
ICHD-3=International Classification of Headache Disorders, 3
rd edition;
MHD=monthly headache day; MMD=monthly migraine day1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Buse
et al. Headache 2012;52(10):1456–1470
Chronic
migraine
1
≥15 MHDs
and
≥8 MMDs
>3 months
7.7% of
people with
migraine
2
Episodic
m
igraine
1
During a lifetime,
≥5 migraine attacks lasting 4–72 hours
a
Majority of
people with
migraine
2
Monthly migraine day (MMD)
1
≥2 migraine characteristics, such as:
If no aura, ≥1 of the following migraine symptoms:
Unilateral
Pulsating
Moderate/severe
Aggravation by, or causing
avoidance of, routine physical activity
Nausea/vomiting
Photophobia/phonophobia
Monthly headache day (MHD)
1
A day with migraine-type
or tension-type headache
Slide13Migraine symptoms and neurobiology
CSD, a phenomenon observed in early migraine research, describes a propagated slow wave of depolarisation of neurons and glia, followed by suppression of neural activity and eventual return to baseline
1,2
Based on early experiments, and later MRI observations in humans, CSD is hypothesised to be the pathology underlying aura – however, not all people with migraine experience aura3The vascular theory of migraine proposes that pain results from vasodilation of cranial blood vessels – however, not all data fit the hypothesis that vasodilation can cause migraine pain4,5The pain in migraine is typically a throbbing, pulsating pain.4 This pulsating pain sensation has been linked to arterial pulsation in some studies, but not in others4CGRP, a 37-amino acid peptide localised to C- and Aδ-fibres, is a potent vasodilator, and several lines of evidence point towards CGRP playing a crucial role in migraine symptoms
6,7
13
CGRP=calcitonin gene-related peptide; CSD=cortical spreading depression; MRI=magnetic resonance imaging
1. Charles & Brennan. Cephalalgia 2009;29(10):1115–1124; 2.
Leão
. J
Neurophysiol
1944;7(6):359–390;
3.
Tolner
et al. Cephalalgia 2019;39(13):1683–1699; 4. Mason & Russo. Front Cell
Neurosci 2018;12:233; 5. Charles & Brennan. Handb Clin Neurol 2010;97:99–108; 6. Russell et al. Physiol Rev 2014;94(4):1099–1142; 7. CGRP Forum website. https://www.cgrpforum.org. Accessed Jan 2020;
8. Burstein et al. J Neurosci 2015;35(17):6619–6629; 9. Goadsby et al. Physiol Rev 2017;97(2):553–622
Migraine is a
complex neurological disease with multiple processes,
which lead to the varied symptoms that people with migraine may experience
(e.g., cognitive, sensory [aura], autonomic, and affective symptoms)8,9
Slide14Migraine with aura, and migraine without aura
14
A person may experience migraine both with and without aura, and the aura experience varies between and within individuals
1
Compared with migraine without aura, migraine with aura appears to have:2,3Greater association with certain comorbid conditions Different alterations of brain structure and function as revealed by imaging studiesDifferences in heritability4,5Aura occurs in a minority of people with migraine: ~25%6Most studies of migraine therapies include mixed populations of migraine with and without aura2,3This is problematic, because there is evidence that migraine with and without aura respond differently to treatment
2Some have argued that the two conditions – migraine with aura and migraine without aura – should be separated in clinical studies of migraine therapies3
ICHD-3=International Classification of Headache Disorders, 3rd edition1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Hansen & Charles. J Headache Pain 2019;20(1):96; 3. Hauge et al. Cephalalgia 2010;30(9):1041–1048;4. Gervil et al. Ann Neurol 1999;46(4):606–611; 5. Ulrich et al. Ann
Neurol 1999;45(2):242–246; 6. Shankar Kikkeri & Nagalli. Migraine with Aura. 2020
Migraine with aura is characterised, according to ICHD-3 criteria, by at least 2 migraine attacks with the presence of the following categories of fully reversible aura symptoms:
1
…and at least 3 of the following 6 characteristics:
1
At least 1 aura symptom spreads gradually over ≥5 minutes
2 or more aura symptoms occur in succession
Each individual aura symptom lasts 5–60 minutes
At least 1 aura symptom is unilateral
At least 1 aura symptom is positive
The aura is accompanied, or followed within 60 minutes, by headache
Visual
Sensory
Speech and/or language
Motor
Brainstem
Retinal
Slide15ICHD-3 diagnostic criteria – episodic migraine with/without aura
At least 5 attacks fulfilling criteria B–D
Headache attacks lasting 4–72 hours (when untreated or unsuccessfully treated)
Headache has at least 2 of the following 4 characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routing physical activity (e.g., walking or climbing stairs)
During headache at least 1 of the following:
Nausea and/or vomiting
Photophobia and phonophobia
Not better accounted for by another ICHD-3 diagnosis
15
At least 2 attacks fulfilling criteria B and C
At least 1 of the following fully reversible aura symptoms:
Visual
Sensory
Speech and/or language
Motor
Brainstem
Retinal
At least 3 of the following 6 characteristics:
At least 1 aura symptom spreads gradually over ≥5 minutes
2 or more aura symptoms occur in succession
Each individual aura symptom lasts 5–60 minutes
At least 1 aura symptom is unilateral
At least 1 aura symptom is positive
The aura is accompanied, or followed within 60 minutes, by headache
Not better accounted for by another ICHD-3 diagnosis
See slide notes for further information on diagnostic criteria
ICHD-3=International Classification of Headache Disorders, 3
rd
edition
Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
1.1 Migraine without aura
1.2 Migraine with aura
Slide16ICHD-3 diagnostic criteria – chronic migraine
16
See slide notes for further information on diagnostic criteria
ICHD-3=International Classification of Headache Disorders, 3
rd editionHeadache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
Headache (migraine-like or tension-type-like) on 15 days/month for >3 months, and fulfilling criteria
B and C
Occurring in a patient who has had at least 5 attacks fulfilling criteria B–D for ‘1.1 Migraine without aura’ and/or criteria B and C for ‘1.2 Migraine
with aura’
On 8 days/month for >3 months, fulfilling any
of the following:
Criteria C and D for ‘1.1 Migraine without aura’
Criteria B and C for ‘1.2 Migraine with aura’
Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
Not better accounted for by another ICHD-3
diagnosis
1.3 Chronic migraine
The clinical criteria for episodic migraine with and without aura apply to the chronic diagnosis, with the only differentiator being frequency and duration of symptoms
Slide17ICHD-3 diagnostic criteria – status migrainosus
17
If a migraine attack lasts >72 hours, it is diagnosed as ‘status migrainosus’
1
Status migrainosus often requires immediate medical attention, because of the length, severity, and persistence of symptoms2The longer a migraine persists, the greater the risk of dehydration, stroke, aneurysm, permanent vision loss, serious dental problems, coma, and even death2Treatment approaches for people with status migrainosus include pharmacotherapy and surgery, however, these approaches have only limited success3More research and specific treatment guidelines are needed to better serve this difficult-to-treat population3
See slide notes for further information on diagnostic criteriaaRemissions
of up to 12 hours due to medication or sleep are accepted; bmilder cases, not meeting criterion C2, are coded 1.5.1 ‘Probable migraine without aura’ ICHD-3=International Classification of Headache Disorders, 3rd edition1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. The Migraine Institute website. https://www.themigraineinstitute.com/status-migrainosus-migraines/. Accessed May 2020;
3. Iljazi et al. Cephalalgia 2020;40(8):818–827
A headache attack fulfilling criteria B and C
Occurring in a patient with 1.1 ‘Migraine without aura’ and/or 1.2 ‘Migraine with aura’, and typical of previous attacks except for its duration and severity
Both of the following characteristics:
Unremitting for >72
hours
a
Pain and/or associated symptoms are
debilitating
b
Not better accounted for by another ICHD-3 diagnosis
1.4.1 Status migrainosus
1
ICHD-3 definitions for episodic and chronic migraine
18
Chronic migraine is defined as having a headache ≥15 days per month for >3 months, of which ≥8 days meet criteria for migraine
1,2
For most people with migraine, migraine is episodic – estimates suggest up to 7.7% of people with migraine have chronic migraine
2,3
It is estimated that episodic migraine progresses to chronic migraine in approximately 3% of people with migraine annually
4
Compared with people with episodic migraine, those with chronic migraine show:
2
Higher percentage with severe pain – 92.4% versus 78.1%
Greater percentage of occupational disability – 20.0% versus 11.1%
Greater healthcare resource use, including visits to primary care providers and headache specialists
Higher levels of comorbidities, including depression, anxiety, and obesity
1. Headache Classification Committee of the International Headache Society (
IHS
). Cephalalgia 2018;38(1):1–211;
2.
Katsarava et al. Curr Pain Headache Rep 2012;16(1):86–92; 3. Buse et al. Headache 2012;52(10):1456–1470;
4. Bigal & Lipton. Curr Neurol Neurosci Rep 2011;11:139–148
0
30
8
15
Monthly migraine days
Monthly headache days
Chronic migraine:
Lasting >3 months
30
0
Episodic migraine:
People who have had ≥5 attacks of migraine lasting 4–72 hours during lifetime and do not fulfil the criteria for chronic migraine
Slide19ICHD-3 differential diagnosis – tension-type headache
At least 10 episodes occurring 1–14 days/month for >3 months fulfilling criteria B–D
Lasting from 30 minutes to 7 days
Headache has at least 2 of the following 4 characteristics:
Bilateral location
Pressing or tightening (non-pulsating) quality
Mild to moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs
Both of the following:
No nausea or vomiting
No more than 1 of photophobia and phonophobia
Not better accounted for by another ICHD-3 diagnosis
19
Headache occurring on >15 days/month for 3 months fulfilling criteria B–D
Lasting hours to days, or unremitting
At least 2 of the following 4 characteristics:
Bilateral location
Pressing or tightening (non-pulsating) quality
Mild to moderate intensity
Not aggravated by routine physical activity such as walking or climbing stairs
Both of the following
No more than 1 of photophobia, phonophobia or mild nausea
Neither moderate or severe nausea of vomiting
Not better accounted for by another ICHD-3 diagnosis
See slide notes for further information on diagnostic criteria
ICHD-3=International Classification of Headache Disorders, 3
rd
edition
Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
2.2 Frequent episodic tension-type headache
2.3 Chronic tension-type headache
Slide20Attacks fulfilling criteria for ‘3.1 Cluster headache’,
and criterion B below
Occurring without a remission period, or with remissions lasting <3 months, for at least 1
year
ICHD-3 differential diagnosis – cluster headache
At least 5 attacks fulfilling criteria B–D
Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)
Either or both of the following:
At least 1 of the following symptoms or signs, ipsilateral to the headache:
Conjunctival injection and/or lacrimation
Nasal congestion and/or
rhinorrhoea
Eyelid
oedema
Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Occurring with a frequency between 1 every other day and 8 per day
Not better accounted for by another ICHD-3 diagnosis
20
Attacks fulfilling criteria for ‘3.1 Cluster headache’ and occurring in bouts (cluster periods)
At least 2 cluster periods lasting from 7 days to 1 year (when untreated) and separated by pain-free remission periods of ≥3 months
See slide notes for further information on diagnostic criteria
ICHD-3=International Classification of Headache Disorders, 3
rd editionHeadache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
3.1 Cluster headache
3.1.1 Episodic cluster headache
3.1.2 Chronic cluster headache
Slide21ICHD-3 differential diagnosis – medication-associated headache
21
See slide notes for further information on diagnostic criteria
ICHD-3=International Classification of Headache Disorders, 3
rd edition1. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2. Kristoffersen & Lundqvist. Ther Adv Drug Saf 2014;5(2):87–99
a. Patients should be coded for one or more subtypes of ‘8.2 Medication-overuse headache’ according to the specific medication(s) overused and the criteria for each below. For example, a patient who fulfils the criteria for ‘8.2.2 Triptan-overuse headache’ and the criteria for one of the sub-forms of ‘8.2.3 Non-opioid analgesic-overuse headache’ should receive both these codes. The exception occurs when patients overuse combination-analgesic medications, who are coded ‘8.2.5 Combination analgesic-overuse headache’ and not according to each constituent of the combination analgesic medication
b. Patients who use multiple drugs for acute or symptomatic treatment of headache may do so in a manner that constitutes overuse even though no individual drug or class of drug is overused; such patients should be coded ‘8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overused’
c. Patients who are clearly overusing multiple drugs for acute or symptomatic treatment of headache but cannot give an adequate account of their names and/or quantities are coded ‘8.2.7 Medication-overuse headache attributed to unspecified or unverified overuse of multiple drug classes’ until better information is available. In almost all cases, this necessitates diary follow-up
Headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder
Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of
headache
a
-c
Not better accounted for by another ICHD-3 diagnosis
8.2 Medication-overuse headache
1
The prevalence of medication-overuse headache is
1–2% in the general population
, higher among women than men, and is highest among those aged in their forties
2
Slide22Short-term pain relief
Rebound headache
Higher
medication dose
Medication overuse
22
ICHD-3 thresholds for overuse:
regular intake of ≥1 opioid or triptan on ≥10 days/month for >3 months,
or regular intake of acetaminophen or ≥1 NSAID on ≥15 days/month for >3 months
2
ICHD-3=International Classification of Headache Disorders, 3
rd
edition;
NSAID=non-steroidal anti-inflammatory drug
Adapted from: 1. Da Silva & Lake
.
Headache 2014;54(1):211–217;
2.
Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211
Medication
Headache
Pain relief
Successful acute treatment
of migraine involves treatment and resolution of the migraine attack and symptoms
Medication-overuse headache
can occur with several classes of migraine therapy, including acetaminophen, caffeine combinations, opioids, barbiturates, NSAIDs, and triptans
The vicious cycle of medication overuse
1
Slide23Phases of a migraine attack
23
Slide24Proposed phases of a migraine attack
24
Symptoms in
bold
denote criteria in the ICHD-3 classification
ICHD-3=International Classification of Headache Disorders, 3
rd
edition
Adapted from:
Dodick
. Lancet 2018;391(10127):1315–1330; Cady et al. Headache 2002;42(3):204–216;
Goadsby
et al.
Physiol
Rev 2017;97(2):553–622;
Headache Classification Committee of the International Headache Society (
IHS
). Cephalalgia 2018;38(1):1–211;
The American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/timeline-migraine-attack/. Accessed May 2020;
Migraine Buddy website. Available at: https://migrainebuddy.com/migraine/2018/11/22/the-stages-of-a-migraine-postdrome-phase. Accessed May 2020
Premonitory
Aura
Headache
Postdrome
Fatigue
Cognitive difficulties
Mood changes
Food cravings
Neck pain
Yawning
Visual aura (scotoma, fortification spectrum)
Sensory disturbance
Speech disturbance
Motor symptoms
Headache
Nausea with or without vomiting
Photophobia
Phonophobia
Osmophobia
Feeling tired
or weary
Difficulty with concentration
Neck stiffness
Headache
4–72 hrs
<12–24 hrs
5–60
minutes
A few hours
to days
Slide25The premonitory phase of a migraine attack
The headache phase of migraine is preceded by a cluster of symptoms, known as the premonitory symptoms, which can last from a few hours to days
1,2
Common premonitory symptoms include:
1,3FatigueConcentration difficultiesNeck painMood changesOther premonitory symptoms include nausea, food cravings, and yawning1-3Research into the neurobiology underlying the premonitory phase of migraine has pointed to early brainstem involvement, as well as the hypothalamus and limbic networks as key225
Frequency of the 5 most common premonitory symptoms in a study of 100 children with migraine3
1. Dodick. Lancet 2018;391(10127):1315–1330; 2. Karsan & Goadsby. Front Neurol 2020;11:140;3.
Karsan et al. J Headache Pain 2016;17(1):94
Slide26The aura phase of a migraine attack
26
1. Headache Classification Committee of the International Headache Society (
IHS
). Cephalalgia 2018;38(1):1–211;
2. Viana et al. J Headache Pain 2019;20(1):64
Migraine aura is a complex set of
fully reversible visual, sensory, speech/language, motor, brainstem, and retinal symptoms
that usually begin before the headache phase of an attack, but can occur during the headache
1
Elementary visual symptoms of migraine aura and their description
2
Bright light
– single area of bright light
Foggy/blurred vision
Zigzag lines
– zigzag or jagged lines
Scotoma
– single blind area
Scotomata
– several blind/black areas
Small bright dots
– small bright dots/stars
White dots/round forms
– medium sized white dots/round forms
Coloured dots/round forms
– medium sized coloured dots/round forms
Lines (coloured lines)
Geometrical shapes
“Like looking through heat waves, water or oil”
Visual snow
– dynamic, continuous, tiny dots usually black/grey on white background or grey/white on black background
‘Bean-like’ forms
– ‘bean-like’ forms like a crescent or C-shape
Hemianopsia
– blindness in half of the visual field
Deformed images
– deformed images (alteration of lines/angles)
Tunnel vision
– blindness in the whole periphery
Oscillopsia
– movement of stationary objects
Mosaic vision
– seeing images in a mosaic-like pattern
Fractured objects
Corona effect
– an extra edge on objects
Anopia
– total blindness
Micropsia
– objects appear smaller or more distant than they actually are
Macropsia
– objects appear larger or closer than they actually are
“Like a negative film”
Complex hallucinations
– visual perception of something not present (e.g., objects, animals, and persons)
Slide27Migraine headache (head pain) is often unilateral (affecting one side of the head)
1The headache of a migraine is reported by people with migraine to be:1,2
The headache phase of migraine is of moderate-to-severe intensity, and is often accompanied by nausea (with or without vomiting), photophobia, and phonophobia
1,2
Unilateral
(60%)
The headache phase of a migraine attack
27
1.
Headache Classification Committee of the International Headache Society (
IHS
). Cephalalgia 2018;38(1):1–211;
2.
Dodick
. Lancet 2018;391(10127):1315–1330
Aggravated by physical movement
(90%
of people with migraine
)
Throbbing
(50%)
Slide28An electronic diary study followed 120 people with migraine over 3 months
3There was no relationship between medication taken for the headache and the duration of the postdrome
3
The severity of migraine was not associated with the duration of the postdrome phase
3The postdrome phase of a migraine attack
Postdrome is a symptomatic phase, lasting up to 48 hours following the resolution of pain in migraine attacks with or without aura1Postdrome symptoms overlap with those experienced in the premonitory phase, and include:
1,2Feeling tired or wearyConcentration difficulties Neck stiffnessPostdrome symptoms can persist for up to 48 hours after the headache phase of migraine1
281. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1–211;2.
Goadsby
et al.
Physiol
Rev 2017;97(2):553–622; 3.
Giffin
et al. Neurology 2016;87(3):309–313
Postdrome symptoms are common, but poorly studied – more research is needed to understand the link between postdrome and the underlying pathophysiology of migraine
1-3
In total, 85% of participants reported ≥1 non-headache symptom in the postdrome phase
3
Slide29Migraine is a chronic neurological disease with episodic attacks of head pain
29
Dodick
. Lancet 2018;391(10127):1315–1330