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  • Updated 08.22.2021
  • Released 05.04.2019
  • Expires For CME 08.22.2024

Migraine: clinical aspects

Introduction

Overview

This discussion of the clinical aspects of migraine reviews key aspects of 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.

• Migraine is a disease, which can be divided into the ictal, symptomatic state, and the interictal, asymptomatic state. Counselling patients on the ictal phases and their symptoms is recommended to improve patient recognition of the features of their disease. A focus on protective factors rather than trigger avoidance during the interictal phase is recommended to improve patient functionality.

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

• The pathophysiology of migraine involves peripheral and central sensitization. Aspects of migraine pathophysiology correlate with the symptom progression during a migraine attack.

• 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 (44). Although the concept of migraine was originally based on a disturbance of the “four humors" of ancient Greek medicine and, later, as a disease of blood vessels, understanding of migraine has since evolved (44). Now, migraine is understood as a biological process and primary disorder of the neurovascular system, which results in a wide spectrum of symptoms and clinical manifestations.

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