Diagnosis and Treatment of Migraine

doi:10.4065/77.3.255

Mayo Clinic Proceedings

Volume 77, Issue 3, March 2002, Pages 255-261

https://doi.org/10.4065/77.3.255 Get rights and content

Despite recent advances in understanding the pathophysiology and treatment of migraine, considerable uncertainty remains surrounding the diagnosis and treatment of this disorder. This uncertainty is reflected in studies that show both underdiagnosis and undertreatment of migraine. While the diagnosis can be assisted by criteria from the International Headache Society, other approaches may be useful in clinical practice. Treatment of migraine must be based on an individualized patient strategy that integrates education, patient participation, and effective use of pharmacological interventions. Many patients, despite self-treatment with simple analgesics, continue to suffer considerable disability associated with their migraines. Triptans, which are more effective at relieving migraine symptoms and maintaining patient function than are nonspecific therapies, are used in only a minority of patients with migraine. Treatment goals of rapid, complete relief with no recurrence and minimal adverse effects can be achieved when effective therapy is matched to individual patient goals. For prophylaxis, anticonvulsant drugs emerging as effective options are being added to the armamentarium with traditional compounds such as tricyclic antidepressants and β-blockers.

Section snippets

DIFFERENTIAL DIAGNOSIS OF MIGRAINE

In 1988, the International Headache Society (IHS) developed criteria for headache and facial pain disorders, including migraine (Table 1).⁸ These guidelines have proved invaluable in organizing headache research, and they form the basis for the category of headache in the International Classification of Diseases.⁹ Many primary care clinicians are unfamiliar with or do not implement these criteria and may prefer assessment tools more applicable to clinical practice.

MEASURES OF EFFECT OF HEADACHES ON DAILY FUNCTION

Headaches that interfere with daily living warrant medical attention and effective treatment. To address this issue, work has focused on measures of migraine disability, specifically the Migraine Disability Assessment,¹³ the Headache Intensity Test,¹⁴ and the Headache Disability Inventory.¹⁵ The Migraine Disability Assessment is a 5-item questionnaire designed to assess headache-related disability for use in routine clinical practice. Scores are divided into grades I through IV with I

APPROACHES TO TREATMENT

Migraine treatment begins with the patient's headache history. The history not only provides valuable information about severity, duration, premonitory symptoms, and possible precipitating factors but also involves patients in the management of their condition. Understanding the pattern of headache activity is essential to determining treatment needs. This understanding can be facilitated with use of a headache diary. Sample diaries are readily available from various sources, including the

PROPHYLAXIS

Although intermittent therapy for acute migraine episodes can be effective in many patients, some are candidates for prophylaxis. Patients requiring acute therapy more than 2 days per week should be considered for prophylaxis. In addition, if patients are having 2 or more migraines a month that cannot be adequately controlled with abortive medication, prophylaxis may be necessary. When headaches interfere substantially with a patient's ability to function; when acute medications are

CONCLUSION

Recent decades have seen considerable advances in the understanding and treatment of migraine, although this disorder remains underdiagnosed and undertreated. More efficient recognition schemes for migraine are emerging that will facilitate identification of patients with medically relevant headaches. Triptans with models of early intervention are redefining treatment opportunities and establishing treatment outcomes that can meet patient desires.

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Cited by (40)

The role of nutrients in the pathogenesis and treatment of migraine headaches: Review
2018, Biomedicine and Pharmacotherapy
Citation Excerpt :
Migraine drug treatments aim to prevent headache attack or reduce the intensity and frequency of attacks, particularly when they are characterized by intense pain. Triptans can be considered as important drugs for acute treatment; they effect serotonin (5-HT) 1B/D/F receptors located on presynaptic trigeminal nerve endings of vascular smooth muscle and the central nervous system (CNS) [14–16]. In addition to tryptan, various other drugs including beta blockers, tricyclic antidepressants, calcium channel blockers, NSAIDs, and anticonvulsants are used in treating migraine [16,17].
Migraine as a disabling neurovascular disease affects 6% of men and 18% of women worldwide. The deficiency of many nutrients including magnesium, niacin, riboflavin, cobalamin, coenzymes Q10, carnitine, α-lipoic acid and vitamin D is associated with migraine. Some researchers postulate that mitochondrial dysfunction and impaired antioxidant status can cause migraine. Also increase in homocysteine level can lead to migraine attacks; therefore, some Nutraceuticals play a vital role in migraine prevention. Thus, the aim of the current study was to review randomized controlled trials (RCT) assessing the effect of nutritional supplements on migraine patients.
English articles in the following databases were searched: MEDLINE, AMED, EMBASE and Cochrane Library. In this manuscript, RCTs published during 1990–2017 were reviewed.
Evidences indicate that supplementation with magnesium, carnitine, riboflavin, niacin, CoQ10, vitamin D, Vitamin B₁₂ and alpha lipoic acid have prophylactic and therapeutic effects on migraine patients.
Due to the possible side effects of pharmacological drugs and drug addictions, the use of nutrient compounds alone or in combination with routine cures have been proposed. However, further constructive studies are required.
Acute and Preventative Treatment of Episodic Migraine
2015, Headache and Migraine Biology and Management
Based on scientific evidence and clinical experience, acute and preventive pharmacological treatments of episodic migraine are reviewed, summarized, and evaluated in this chapter. A practical formula (the “5 Ps”) is described that guides clinicians through the process of eliciting the necessary information from patients for creating a beneficial treatment strategy. Attack-based and phase-based treatment approaches are outlined and explained to maximize the effectiveness of interventions over extended periods of time. The procedure of staging patients based on the progression of migraine (infrequent episodic, frequent episodic, very frequent episodic, and chronic migraine) and the implications of this process in long-term management are featured.
Headache and Facial Pain: Differential Diagnosis and Treatment
2013, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
The third most common aura is a motor aura that presents with motor weakness of the upper and lower extremities or a dysphasic speech disturbance. The differential diagnoses in patients presenting with possible migraine include temporal arteritis, acute glaucoma, meningitis, transient ischemic attacks, and subarachnoid hemorrhage.13 If a patient has one or more “red flags” for a secondary headache disorder (see “Secondary Headaches”), then the physician is obligated to do a workup that should include either a magnetic resonance imaging (MRI) or computed tomographic (CT) scan of the head to rule out other structural conditions.
Headaches affect 90% of the population sometime during their life. Most are benign and fleeting, some are serious and life-threatening, and others require ongoing medical consultation and treatment. A careful history and physical is necessary to establish a differential diagnosis and to guide the choice of testing to make an accurate diagnosis. The most common types of headaches are discussed in this review. They are divided into primary and secondary headache disorders as classified by the International Headache Society. Primary headache disorders include migraine without and with aura, cluster and tension-type headaches. Secondary headaches are those that occur as a result of some other disorder and include brain tumors, rhinosinusitis, diseases of intracranial and extracranial vasculature, and temporomandibular joint disease.
Clumsiness and Difficulty Walking (Brain Tumor)
2006, Essential Family Medicine
Clumsiness and difficulty walking (brain tumor)
2006, Essential Family Medicine: Fundamentals and Case Studies, Third Edition
Early intervention in migraine with sumatriptan tablets 50 mg versus 100 mg: A pooled analysis of data from six clinical trials
2005, Clinical Therapeutics
In clinical trials evaluating sumatriptanin the treatment of moderate or severe migraine pain, the 50- and 100-mg doses have been comparably effective and well tolerated.
To assess the dose-efficacy relationshipof sumatriptan tablets given early for mild pain, data from 6 randomized, double-blind, placebo-controlled, early-intervention studies of sumatriptan tablets 50 mg and 100 mg (5 of which have been published) were pooled for analysis. These constitute all the studies conducted to date of sumatriptan tablets prospectively given early for mild pain.
The primary efficacy end point in all the studies was the proportion of patients reporting a pain-free result (ie, mild, moderate, or severe pain reduced to none) 2 hours postdose. Other efficacy end points included the proportion of patients who were migraine free (ie, no pain and no associated symptoms of nausea, vomiting, photophobia, or phonophobia) 2 hours postdose; the proportion reporting worsening of pain (ie, moderate or severe pain) 2 hours postdose; and the proportion with a sustained pain-free result (ie, pain free from 2–24 hours postdose with no use of a second dose of study medication or of rescue medication). Tolerability was assessed by evaluating the incidence of individual adverse events. The investigators assessed each adverse event's relationship to study medication.
The number of patients in the intent-to-treat population was 2297 (771 sumatriptan 50 mg, 759 sumatriptan 100 mg, 767 placebo). Patients' mean age ranged from 39.4 to 39.8 years across groups, and most patients were female (90%–92%) and white (89%–90%). A pain-free result 2 hours post dose was reported by significantly more patients who took either dose of sumatriptan tablets compared with placebo and by significantly more patients who took the 100-mg dose compared with the 50-mg dose (50 mg, 49%; 100 mg, 58%; placebo, 24%; P < 0.001, both sumatriptan doses vs placebo, and 100 mg vs 50 mg). A similar pattern was observed for migraine-free results 2 hours postdose (50 mg, 42%; 100 mg, 47%; placebo, 20%; P < 0.05, both sumatriptan doses vs placebo, and 100 mg vs 50 mg), worsening of pain 2 hours postdose (50 mg, 26%; 100 mg, 21%; placebo, 46%; P < 0.05, both sumatriptan doses vs placebo, and 100 mg vs 50 mg), and sustained pain-free results from 2 through 24 hours postdose (50 mg, 30%; 100 mg, 35%; placebo, 12%; P < 0.05, both sumatriptan doses vs placebo, and 100 mg vs 50 mg). Both doses of sumatriptan were well tolerated, and no dose-related trends in the incidence of individual drug-related adverse events were observed.
In this analysis of pooled data from6 clinical trials, sumatriptan tablets 50 mg and 100 mg administered early in a migraine attack while the pain was mild were well tolerated and significantly more effective than placebo. The 100-mg dose of sumatriptan was significantly more effective than the 50-mg dose.

View all citing articles on Scopus

¹: Dr Dodick has consulted for, lectured at events, or conducted research sponsored by Allergan, AstraZeneca Pharmaceuticals LP, Abbott Laboratories, Inc, Merck & Co, Inc, Pfizer, Inc, Glaxo-SmithKline, Ortho-McNeil Pharmaceutical, Pharmacia Corporation, Almirall Prodesfarma, and Eli Lilly and Company.

²: Dr Cady has served as a member of the advisory board and speakers bureau and has received research grants from Astra-Zeneca Pharmaceuticals LP, GlaxoSmithKline, Merck & Co, Inc, and Pfizer, Inc; he has received research grants from Pozen, Winston Labs, and Allergan, where he has also served on the advisory board: and he has served as a member of the advisory board for Abbott Laboratories, Inc, and Elan Corporation.

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ReviewDiagnosis and Treatment of Migraine

Section snippets

DIFFERENTIAL DIAGNOSIS OF MIGRAINE

MEASURES OF EFFECT OF HEADACHES ON DAILY FUNCTION

APPROACHES TO TREATMENT

PROPHYLAXIS

CONCLUSION

Mayo Clin Proc

Lancet

Clin Ther

The trigeminovascular system and migraine: studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats

Ann Neurol

Shared mechanisms in affective illness, epilepsy, and migraine

Neurology

Circadian rhythms and migraine

Cleve Clin J Med

Migraine in the United States: a review of epidemiology and health care use

Neurology

The prevalence and characteristics of migraine in a population-based cohort: the GEM study

Neurology

Prevalence of migraine headache in the United States: relation to age, income, race, and other sociodemographic factors

JAMA

Migraine's impact today: burden of illness, patterns of care

Postgrad Med

Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain

Cephalalgia

Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology [published correction appears in Neurology. 2000;56:142]

Neurology

Diagnosis of headache

2000 Wolfe Award: sumatriptan for the range of headaches in migraine sufferers: results of the Spectrum Study

Headache

Reliability of the migraine disability assessment score in a population-based sample of headache sufferers

Cephalalgia

Practical implications of item response theory and computerized adaptive testing: a brief summary of ongoing studies of widely used headache impact scales

Med Care

Headache Disability Inventory (HDI): short-term test-retest reliability and spouse perceptions

Headache

Patient-centered strategies for the effective management of migraine

Review
Diagnosis and Treatment of Migraine