Headaches are common, but there are different forms of headaches. Migraine is a leading cause of disability in American women aged 15-49 and affecting 12% of adults, more women than men.
Note this website is not a substitute for usual health care – consult your healthcare provider.
Below videos and material from CMAJ March 2023.
The tendency to have migraine headaches can be inherited.
Migraine screener – PIN: 2 of: photophobia, functional impairment, nausea. An attack can start with warning symptoms – called a prodrome, then an aura, which can be a smell, particular taste, or even have symptoms resembling a minor stroke, headache, postdrome, and interictal (between attacks). These phases can occur one after another or together.
People who experience migraines have a hyperexcitable nervous system. The trigeminal nerve – a nerve that sends signals to dura and cerebral arteries – is activated. Substances are released that dilate arteries and cause inflammation of the dura.
One substance, calcitonin gene-related peptide, CGRP – a neuropeptide, signals the trigeminal nucleus caudalis. Pain signals from here and nerves in C1-2, then travel to the pain processing areas of the brain: brain stem, thalamus, hypothalamus, basal ganglia, and cortex). CGRP increases in a migraine attack. Newer drugs work on blocking the action of this neuropeptide.
Types of MIgraine
Migraine with aura – at least 1 aura symptom spreads gradually over 5 or more minutes, or, 2 or more auras in succession – each lasting 5 to 50 minutes, at least one of them unilateral, aura followed within 60 minutes by a headache.
Migraine without aura
Chronic migraine – migraine for 15 or more days per month for at least 3 months (7 of these days could also be a tension headache).
Migraine complications
Probable migraine
Episodic migraine
Investigations
If the migraines have been present and unchanging for a while, and the neurological exam is normal, then the likelihood of finding something wrong on an MRI is the same as doing MRI’s on the general population.
MRI’s should be done if there are red flags:
Systemic signs, symptoms, or disease – fever, weight loss, HIV, immunosuppression, malignancy, pregnancy, or postpartum. Look for metastases, CNS infection, cerebral venous sinus thrombosis CVST, idiopathic intracranial hypertension, reversible cerebral vasoconstriction syndrome RCVS.
Neurologic symptoms or signs – deficits or prolonged CNS symptoms, or both. (Neoplasia, inflammation, infection, or vascular CNS disease).
Late onset – after 50 years of age.
Sudden onset – Thunderclap headache with onset to max intensity in less 60sec. SAH, CVST, RCVS, arterial dissection.
Papilledema – CT or MRI with venogram
Postural aggravation – triggered by standing or lying down
Precipitated by valsalva (coughing, exercise, or intercourse).
Pattern change or progression.
Migraines always on the same side – side-locked. (pituitary tumors, intracranial dissections, infections).
Management
If there is mild disability, then over the counter analgesics can be tried, repeated in 2 to 24 hours. Medication.
Triptans – contraindicated in heart disease or stroke or other vascular diseases.
Dihydroergotamine can be used for severe attacks, but it has many drug interactions and can high risk of heart side effects.
Opioids should be avoided when treating migraines.
New meds include lasmiditan and gepants. They are helpful when triptans are contraindicated.
Neuromodulation devices – non invasive and minimal side effects.
Peripheral nerve blocks with local anesthetic infiltrating various nerve branches of the trigemino-cervical system.
Headaches may be associated with widespread Pain, Fatigue, Fibromyalgia and Irritable Bowel Syndrome
If you are interested in this approach, you could try his next video below