Migraine: clinical aspects

Simy Parikh MD (Dr. Parikh of The Jefferson Headache Center at Thomas Jefferson University has no relevant financial relationships to disclose.)
Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.

)
Originally released May 4, 2019; expires May 4, 2022

Overview

This discussion of the clinical aspects of migraine reviews key features in assessing and diagnosing migraine in the clinical setting. The article focuses on the spectrum of symptoms and phases that encompass migraine, migraine complications, migraine comorbidities, and the need for further workup. Discussion of pharmacological migraine management is outside the scope of this review.

Key points

 

• Attacks of head pain are a key characteristic of migraine; however, the clinical features of migraine extend to an array of non-nociceptive psychological, gastrointestinal, neurologic or autonomic, and constitutional symptoms that are not specified in formal diagnostic criteria.

 

Status migrainosus, persistent aura without infarction, migrainous infarction, and migraine aura-triggered seizure are migraine complications.

 

• SNOOP4 (ie, Systemic symptoms or secondary risk factors, Neurologic deficits, sudden Onset of symptoms, Older age, Positional quality, Papilledema, change from Prior symptoms, and certain Precipitating triggers) is a common acronym used to distinguish clinical features for which a person with migraine would need further diagnostic assessment to rule out headache associated with cerebrospinal fluid pressure changes, infections, malignancies, strokes, and vascular or mass lesions.

 

• The routine use of neuroimaging is not warranted in most adult patients with recurrent headaches that have been defined as migraine.

 

• There is an increased incidence of stroke in young women with migraine with aura, especially those who smoke or use oral contraceptives; this increased risk is present independently of other known cardiovascular risk factors.

 

• Patients who have migraine with or without aura have an increased likelihood of developing a specific group of episodic syndromes typically manifesting in childhood; these include abdominal migraine, cyclic vomiting syndrome, benign paroxysmal vertigo, and benign paroxysmal torticollis.

Historical note and terminology

The term “migraine” can be traced back to the Greek word “hemicrania,” which means “half head” and corresponds to the unilateral head pain that is often associated with migraine (Pearce 1986). Although the concept of migraine was originally based on a disturbance of the “four humours" of ancient Greek medicine, understanding of migraine has since evolved (Pearce 1986). Now, migraine is understood as a biological process and primary disorder of the nervous system that leads to a wide spectrum of symptoms and clinical manifestations.

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