Migraine classification

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

Classification

Migraines have been classified by the International Headache Society which periodically revises their classification.

Defining Severity of Pain

In addition to classifying the type of headache, the International Headache Society defines intensity of pain on a verbal 4 point scale:

• 0 no pain
• 1 mild pain 'does not interfere with usual activities'
• 2 moderate pain 'inhibits, but does not wholly prevent usual activities'
• 3 severe pain 'prevents all activities'

Migraine Without Aura

Aslo known as common migraine or hemicrania simplex is a recurrent headache that lasts 4-72 hours. It is characterized by unilateral location, pulsating quality, moderate to severe intensity, worsens with physical activity and can be associated to nauseas, vomiting and photophobia. In order to diagnose migraine without aura, there must have been at least five attacks not attributable to another cause that fulfill the following criteria

1. Headache attacks lasting 4-72 hours

2. At least two of the following characteristics

• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity

3. During the headache there must be at least one of the following associated symptom clusters

• Nausea and/or vomiting
• Photophobia and phonophobia

When these criteria are not fully met, the problem may be classified as "probable migraine without aura" but other diagnoses such as "episodic tension type headache" must also be excluded.

Migraine With Aura

Also known as classic migraine, is the second most commonly seen form of migraine: patients who primarily suffer from migraine with aura may also have attacks of migraine without aura. Migraine with aura is a recurrent condition in which the attacks are manifested as reversible focal neurologic signs that progress over 5-20 minutes, lasting for less than 60 minutes. After the aura symptoms the headache with the same description as the headache in migraine without aura starts. Less commonly, the aura may occur without a subsequent headache or the headache may be non-migrainous in type. In order to diagnose migraine with aura, there must have been at least two attacks not attributable to another cause that fulfill the following criteria.

1. Aura consisting of at least one of the following, but no muscle weakness or paralysis

• Fully reversible visual symptoms (e.g. flickering lights, spots, lines, loss of vision)

• Fully reversible sensory symptoms (e.g. pins and needles, numbness)

• Fully reversible dysphasia

2. Aura has at least two of the following characteristics

• Visual symptoms affecting just one side of the field of vision and/or sensory symptoms affecting just one side of the body

• At least one aura symptom develops gradually over more than 5 minutes and/or different aura symptoms occur one after the other over more than 5 minutes

• Each symptom lasts from 5-60 minutes

Where these criteria are not fully met, a diagnosis of "probable migraine with aura" may be considered, although other neurological causes must also be excluded.

If the picture complies with the criteria but includes one-sided muscular weakness or paralysis, a diagnosis of "sporadic hemiplegic migraine" or "familial hemiplegic migraine" should be considered.

Typical Aura With Migraine Headache

Is a typical aura involving visual and/or sensory and/or speech symptoms, lasting no more than 60 minutes. The aura is characterized by complete reversibility of the symptoms, which is associated with headache fulfilling the criteria for migraine without aura. It begins during the aura or follow the aura within 60 minutes and is not attributed to another disorder.

Typical Aura with non-Migraine headache

Is a typical aura involving visual and/or sensory and/or speech symptoms, lasting no more than 60 minutes. The aura is characterized by complete reversibility of the symptoms, which is associated with headache that does not fulfil the criteria for migraine without aura.

Typical Aura without headache

Is a typical aura involving visual and/or sensory and/or speech symptoms, lasting no more than 60 minutes. The aura is characterized by complete reversibility of the symptoms, which is not associated with headache.

Familial Hemiplejic Migraine (FHM)

Familial hemiplegic migraine (FHM) is a type of migraine with a possible polygenetic component. These migraine attacks may last 4-72 hours and are apparently caused by ion channel mutations, three types of which have been identified to date. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties.

Sporadic Hemiplejic Migraine

Sporadic hemiplegic migraine (SHM) have migraine attacks that may last 4-72 hours. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties without a first or second relative with hemiplegic migraine.

Basilar-Type Migraine

Basilar type migraine (BTM), formerly known as basilar artery migraine (BAM) or basilar migraine (BM), is an uncommon type of complicated migraine with aura. In the majority of migraineurs the aura progress gradually for 5 minutes or more, lasting 5 - 120 minutes and the headache starts after the onset of the aura. The symptoms are originated from the brain stem and/or from both hemispheres simultaniously attacked, without weakness. It always present 2 or more brain stem related aura symptoms (eg. Dysarthria, vertigo, hypoacusis, diplopia, ataxia, decreased level of consciousness) . Serious episodes of BTM can lead to stroke, coma, or even death. The use of triptans and other vasoconstrictors as abortive treatments in BTM is contraindicated. Abortive treatments for BTM often focus on vasodilation and restoration of normal blood flow to the vertebrobasilar territory and subsequent return of normal brain stem function.

Childhood Periodic Syndromes That Are Commonly Precursors Of Migraine

Cyclical Vomiting

Are recurrent episodic attacks that last from 1 hour to 5 days of nausea and vomiting at least 4 times per hour, free of symptoms between attacks and it is not attributed to another disorder.

Abdominal migraine

Is a recurrent disorder of unknown origin which occurs mainly in children. It is characterised by episodes of moderate to severe central abdominal pain lasting 1-72 hours. There is usually associated nausea and vomiting but the child is entirely well between attacks. In order to diagnose abdominal migraine, there must be at least five attacks, not attributable to another cause, fulfilling the following criteria

1. Attacks lasting 1-72 hours when untreated

2. Pain must have ALL of the following characteristics

• Location in the midline, around the umbilicus or poorly localised

• Dull or 'just sore' quality

• Moderate or severe intensity

3. During an attack there must be at least two of the following

• Loss of appetite

• Nausea

• Vomiting

• Pallor

Most children with abdominal migraine will develop migraine headache later in life and the two may co-exist during adolescence.

Bening paroxysmal Vertigo Of Childhood

Are recurrent brief episodic attacks of vertigo. In order to diagnose benign paroxysmal vertigo of childhood there must have been at least 5 attacks of multiple episodes with severe vertigo, starting without warning and resolving spontaneously. The patient must have a normal neurological, audiometric and vestibular functions between attacks and a normal electroencephalogram.