Migraine

What it is

Migraine is one of the primary headaches, together with cluster and tension; migraine and tension headaches are more common in females. The pain is unilateral and lasts 4-72 hr. Set side by side with the other two, migraine is the second most common primary headache, after tension-type headache and ahead of cluster headache.

Causes and risk

Common migraine triggers given are additives, alcohol, artificial sweeteners such as aspartame, caffeine (overconsumption or acute withdrawal from regular use), delayed or missed meals, exercise, foods such as chocolate and soft cheese, light, menses, odors such as perfumes, oral contraceptives, psychiatric comorbidities, red wine, sleep disturbances such as obstructive sleep apnea and insomnia, smoke, stress and weather changes.

How it presents

Migraine is pulsating pain with nausea, photophobia, and/or phonophobia, and may have an aura. It is due to irritation of CN V, meninges, or blood vessels, with release of vasoactive neuropeptides such as substance P and calcitonin gene-related peptide. The mnemonic POUND stands for Pulsatile, One-day duration, Unilateral, Nausea, Disabling. The subtypes named are hemiplegic migraine, migraine with brainstem aura and migrainous infarction. One table sets the three primary headaches beside each other, and adds the shape of the attack. The pain is unilateral, throbbing and pulsatile, often around the eye or temples; it is episodic, 4-72 hours, and may occur 1-4 times a month; and the associated symptoms are nausea, vomiting, photophobia, phonophobia and aura. The pathophysiology given on that table is cortical spreading depression and trigeminal nerve activation, and the diagnosis is clinical, with imaging to rule out other causes.