Migraine – Diagnosis, Symptoms, and Treatment

What is a Migraine?

A Migraine is a headache characterized by its unilateral onset, pounding character, association with nausea and vomiting, and sensitivity to light and sound. Some migraines are preceded by an aura, a visual abnormality described as a “flashing” or “shimmering” of the vision. The pain from migraine headaches can last several hours to days and may be severe enough to cause temporary disability.  

What Causes a Migraine?

Experts believe that migraine headaches are related to changes in the blood vessels within the brain.  Some medications that lead to blood vessel dilation (e.g. nitrates and calcium channel blockers) can provoke migraine headaches in some patients. Genetics and gender also seem to be related to the development of migraines. Relatives of patients with a history of migraines are more likely to experience migraines and women are more commonly affected than men. 

There are multiple triggers that are known to lead to the onset of a migraine headache in those susceptible to them. The most common of these are: 

• Tobacco use
• Alcohol use or withdrawal
• Lack of sleep
• Elevated blood pressure
• Flu or sinus infections
• Depression or anxiety
• Certain medications (e.g. nitrates, albuterol inhalers, SSRIs)
• Head trauma

How Common are Migraines?

Migraine headaches are thought to be relatively common, exact figures for the number of individuals who regularly experience migraine headaches in the U.S. is difficult as there are many different presentations, time courses, and symptoms that a migraine may present with. 

The percentage of the population that has experienced a migraine in the U.S. is thought to be around 4% to 9% in men and 11% to 25% in women. Regular migraines are thought to occur in a relative small number of these individuals. Around 21% of individuals that experience a migraine will have recurrent migraines severe enough to seek medical care and 12% of those who seek care will have severe disability related to migraines. 

Overall, this means that around 2% of the population experiences recurrent and severe migraines and about .02% of the population has severe disability related to migraines. 

Signs and Symptoms

A headache, discomfort and a sensation of tension, throbbing, or pressure in the head, is the key symptom of a migraine. There are several other symptoms that are more specific to migraine headaches, the most common of these specific symptoms are: 

• Unilateral headache
• Nausea & vomiting
• Photophobia (sensitivity to light)
• Phonophobia (sensitivity to sound)
• Aura – may precede or occur during migraine – unilateral flashing lights in the peripheral field
• Temporary sensory loss or weakness – this can also occur with stroke or seizure

The frequency and duration of these symptoms is important. If the headache and associated symptoms lasts for hours to days it is more likely to be the result of a migraine. Symptoms that only last for very short periods of time (less than an hour) are less likely to be due to a migraine. 

Diagnosis

Diagnosing a migraine headache depends upon if you are currently experienceing a headache, the time course of your previous headaches, and the presence of the symptoms above. Testing is generally used to ensure that a life-threatening cause of headache is not present as opposed to diagnosing the migraine itself. 

If it is your first migraine or you have a change in the presentation of your typical migraine symptoms, your doctor may order blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), thyroid function (TSH, free T4), inflammatory markers (ESR/CRP), and coagulation studies (PT/INR, PTT).  They may also obtain a pregnancy test if you are a woman of childbearing age.

Your doctor may consider evaluating for other important causes of headache besides a simple migraine, including:

• Brain tumor
• Brain infection (e.g. meningitis, encephalitis)
• Temporal arteritis
• Trigeminal neuralgia
• Pseudotumor cerebri
• Intracranial hemorrhage – subdural hematoma, epidural hematoma, and parenchymal hemorrhage.
• Pregnancy

Your doctor may obtain a CT scan of the head or MRI of the brain to rule out several of the conditions above. Generally these imaging based tests are used to check for the presence of bleeding, brain tumors, or physical changes to the brain that could be leading to pain. 

If an infection is suspected (e.g. meningitis, encephalitis), your doctor may recommend a spinal tap.  During this procedure, they inject a needle into the fluid-filled pouch surrounding the spine – they then drain this fluid and analyze it for protein, blood, glucose, cell counts, and bacteria.  They will often send the fluid for bacterial culture.

If you have worrisome symptoms such as the worse headache in your life, or headache associated neurologic deficits such as weakness, numbness, confusion, or visual loss/double vision, this can suggest an intracranial hemorrhage or stroke, which warrants a visit to the hospital.  Also, if you have persistent nausea and vomiting severe enough to prevent the consumption of food and water you may have to go to emergency department or call 911.

Other concerning features that indicate a headache requires urgent evaluation includes recent head trauma, headache worsening at nighttime/early morning, and increasing headache during episodes of bearing down (e.g. coughing, straining). 

Migraine Medication and Treatment

The treatment of migraine headache begins with the avoidance of triggers. These triggers vary based on the individual but alcohol, tobacco, and lack of sleep are the most common triggers. 

Once a migraine begins patients often benefit from going into a quiet and dark room.  Proper hydration is important as dehydration can provoke migraine or increase its severity especially in the setting of nausea and vomiting.  Patients with a mild migraine headache often see improvement in symptoms with the following medications:

• Tylenol (acetaminophen)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Advil (ibuprofen)
• Naprosyn (naproxen) 

There are some oral preparations such as Excedrin that contain the combination of acetaminophen, aspirin, and caffeine.  

Migraine headaches often respond to a class of medications called Triptans - these are very effective in decreasing the severity of an acute migraine:

• Imitrex (sumatriptan)
• Zomig (zolmitriptan)
• Maxalt (rizatriptan)
• Amerge (naratriptan)

Most Triptans are administered orally or sublingually, but some come in nasal spray preparations.  The sublingual and nasal spray formulations are particularly useful in patients who are nauseated or vomiting.  These medications are generally taken prior to the onset of headache.  Taking them after the migraine starts can be less effective in improving symptoms.

If your headache is very severe and you decide to get evaluated in the emergency department, you may receive anti-nausea and antihistamine preparations to reduce your symptoms.  These often include Reglan (metoclopramide)and Benadryl (diphenhydramine) given intravenously at the same time.

Severe migraine headaches unresponsive to acetaminophen, NSAIDs, triptans, and IV medications may require the short term use of opiate analgesics.  This can include medications such as:

• Codeine
• Vicodin
• Tramadol
• Oxycodone

These are often found in formulations combined with acetaminophen such as Vicodin (hydrocodone-acetaminophen) and Percocet (oxycodone-acetaminophen).

Opiates are generally avoided due to their abuse potential and ability to cause dependence.  If used, they should be taken at the lowest dose possible and for the shortest duration of time. They are generally less effective for migraine than the other medications listed above, making their use in patients with migraine rare.