History, definitions and diagnosis - PowerPoint Presentation

Slide1

History, definitions and diagnosis

Migraine

1

Slide2

Migraine 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

Slide3

Timeline 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

Slide4

Migraine 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

Slide5

The 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

Slide6

Migraine-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

Slide7

Depression 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

Slide8

Migraine 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

Slide9

The 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

Slide10

Migraine criteria, diagnosis and subtypes

10

Slide11

What 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

Slide12

ICHD-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

Slide13

Migraine 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

Slide14

Migraine 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

Slide15

ICHD-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

Slide16

ICHD-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

Slide17

ICHD-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

Slide18

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

Slide19

ICHD-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

Slide20

Attacks 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

Slide21

ICHD-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

Slide22

Short-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

Slide23

Phases of a migraine attack

23

Slide24

Proposed 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

Slide25

The 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

Slide26

The 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)

Slide27

Migraine 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%)

Slide28

An 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

Slide29

Migraine is a chronic neurological disease with episodic attacks of head pain

29

Dodick

. Lancet 2018;391(10127):1315–1330