Migraine (Classification)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Aggravating factors

Migraine may be aggravated by a number of factors. That is, in a person who already meets criteria for migraine, particular factors may be associated with a relatively long term (usually weeks to months) increase in the severity or frequency of attacks.

Examples of commonly reported aggravating factors include:

• Psychosocial stress,
• Frequent intake of alcoholic beverages,
• Other environmental factors.

Trigger factors (precipitating factors)

Trigger factors increase the probability of a migraine attack in the short term (usually <48 hours) in a person with migraine. Though some trigger factors have been reasonably well studied epidemiologically (e.g., menstruation) or in clinical trials (e.g., chocolate, aspartame), causal attribution in individual patients may be difficult.

Migraine without aura

Previously used terms: Common migraine, hemicrania simplex

Description:

Recurrent headache disorder manifesting in attacks lasting 4-72 hours.

Typical characteristics of the headache are;

1. Unilateral location,
2. Pulsating quality,
3. Moderate or severe intensity,
4. Aggravation by routine physical activity
5. Association with nausea and/or photophobia and phonophobia.

Migraine with aura

Previously used terms: Classic or classical migraine, ophthalmic, hemiparaesthetic, hemiplegic or aphasic migraine, migraine accompagnée, complicated migraine

Typical aura with migraine headache

This is the most common migraine syndrome associated with aura. The diagnosis is usually evident after a careful history alone though there are rare secondary mimics including carotid dissection, arteriovenous malformation and seizure.

Typical aura consisting of visual and/or sensory and/or speech symptoms. Gradual development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterize the aura which is associated with a headache fulfilling criteria for Migraine without aura.

Additional loss or blurring of central vision may occur.

Typical aura with non-migraine headache

Typical aura consisting of visual and/or sensory and/or speech symptoms. Gradual development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterize the aura which is associated with a headache that does not fulfill criteria for Migraine without aura.

Additional loss or blurring of central vision may occur.

Typical aura without headache

Typical aura consisting of visual and/or sensory symptoms with or without speech symptoms. Gradual development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterize the aura which is not associated with headache.

Additional loss or blurring of central vision may occur.

Familial hemiplegic migraine (FHM)

Migraine with aura including motor weakness and at least one first or second degree relative has migraine aura including motor weakness.

It may be difficult to distinguish weakness from sensory loss but new genetic data have allowed a more precise definition of Familial hemiplegic migraine than previously.

Familial hemiplegic migraine is very often mistaken for epilepsy, and (unsuccessfully) treated as such.

Sporadic hemiplegic migraine

Migraine with aura including motor weakness but no first or second degree relative has aura including motor weakness.

Epidemiological studies have shown that sporadic cases occur with approximately the same prevalence as familial cases. The attacks have the same clinical characteristics as those in Familial hemiplegic migraine.

Sporadic cases always require neuroimaging and other tests to rule out other cause.

A lumbar puncture is also necessary to rule out pseudomigraine with temporary neurological symptoms and lymphocytic pleocytosis.

This condition is more prevalent in males and often associated with transient hemiparesis and aphasia.

Basilar type migraine

Migraine with aura symptoms clearly originating from the brain stem and/or from both hemispheres simultaneously affected, but no motor weakness. Basilar type attacks are mostly seen in young adults. Many patients who have basilar type attacks also report attacks with typical aura

Childhood periodic syndromes that are commonly precursors of migraine

Cyclical vomiting

Recurrent episodic attacks, usually stereotypical in the individual patient, of vomiting and intense nausea. Attacks are associated with pallor and lethargy.

There is complete resolution of symptoms between attacks. In particular, history and physical examination do not show signs of gastrointestinal disease

Abdominal migraine

An idiopathic recurrent disorder seen mainly in children and characterized by episodic midline abdominal pain manifesting in attacks lasting 1-72 hours with normality between episodes.

The pain is of moderate to severe intensity and associated with vasomotor symptoms, nausea and vomiting.

Pain is severe enough to interfere with normal daily activities.

Children may find it difficult to distinguish anorexia from nausea. The pallor is often accompanied by dark shadows under the eyes. In a few patients flushing is the predominant vasomotor phenomenon.

Most children with abdominal migraine will develop migraine headache later in life.

Benign paroxysmal vertigo of childhood

This probably heterogeneous disorder is characterized by recurrent brief episodic attacks of vertigo occurring without warning and resolving spontaneously in otherwise healthy children. Often associated with nystagmus or vomiting; unilateral throbbing headache may occur in some attacks.

Increased risk for stroke in migraine patients has been demonstrated in women under age 45 in several studies. Evidence for an association between migraine and stroke in older women and in men is inconsistent.

Retinal migraine

Described as repeated attacks of monocular visual disturbance, including scintillations, scotomata or blindness, associated with migraine headache.

Diagnostic Criteria of Retinal Migraine

1. Normal ophthalmological examination between attacks,
2. Not attributed to another disorder,
3. At least 2 attacks fulfilling criteria 4 and 5,
4. Fully reversible monocular positive and/or negative visual phenomena (e.g., scintillations, scotomata or blindness) confirmed by examination during an attack or (after proper instruction) by the patient’s drawing of a monocular field defect during an attack,
5. Headache fulfilling criteria 1, 4 and 5 for migraine without aura begins during the visual symptoms or follows them within 60 minutes.

Complications of migraine

Chronic migraine

Migraine headache occurring on 15 or more days per month for more than 3 months in the absence of medication overuse.

Status migrainosus

A debilitating migraine attack lasting for more than 72 hours (Interruption during sleep is disregarded. Short lasting relief due to medication is also disregarded).

Persistent aura without infarction

Aura symptoms persist for more than 1 week without radiographic evidence of infarction. Persisting aura symptoms are rare, but often bilateral and may last for months or years. Reliably effective treatment is not known though acetazolamide and valproic acid have helped in a few cases.

Migrainous infarction

One or more migrainous aura symptoms associated with an ischaemic brain lesion in appropriate territory demonstrated by neuroimaging.

Ischaemic stroke in a migraine sufferer may be categorized as cerebral infarction of other cause coexisting with migraine, cerebral infarction of other cause presenting with symptoms resembling migraine with aura, or cerebral infarction occurring during the course of a typical migraine with aura attack.

Migraine triggered seizures

A seizure triggered by a migraine aura.

Migraine and epilepsy are prototypical examples of paroxysmal brain disorders. While migraine like headaches are quite frequently seen in the postictal period, sometimes a seizure occurs during or following a migraine attack. This phenomenon, sometimes referred to as migralepsy, has been described in patients with migraine with aura.

Probable migraine

Previously described as migrainous disorder.

Probable migraine without aura

Diagnosis of probable migraine without an aura can be made if the patient fulfills the criteria for chronic migraine or status migrainosus.