What are the clinical manifestations and treatment options for migraines?

Clinical Manifestations and Treatment of Migraine

Migraine is characterized by recurrent episodes of moderate to severe headache lasting 4 to 72 hours, typically with pulsating quality, often accompanied by nausea, vomiting, photophobia, and phonophobia, which can significantly impact quality of life and daily functioning. 1, 2

Clinical Manifestations

Headache Characteristics

• Location: Often unilateral, though population-based data indicate ~40% report bilateral pain 1
• Quality: Typically pulsating or throbbing 1
• Intensity: Moderate to severe, worsening with routine physical activity 1
• Duration: 4-72 hours if untreated 1, 2

Associated Symptoms

• Sensory sensitivities: Photophobia (light sensitivity), phonophobia (sound sensitivity) 1
• Gastrointestinal: Nausea, vomiting 1
• Prodromal symptoms: May include depressed mood, yawning, fatigue, food cravings 1
• Postdromal symptoms: Can last up to 48 hours and include tiredness, concentration difficulties, neck stiffness 1

Migraine with Aura

• Approximately one-third of individuals experience aura 1
• Visual aura occurs in >90% of affected individuals, classically as fortification spectra 1
• Sensory symptoms occur in ~31%, usually as unilateral paresthesia that spreads gradually 1
• Less common: aphasic speech disturbance, brainstem symptoms, motor weakness 1

Treatment Approaches

Acute Treatment

1. First-line medications for mild to moderate attacks:

   • NSAIDs (ibuprofen 400-800mg, naproxen 500-550mg) 2
   • Acetaminophen 2

2. For moderate to severe attacks:

   • Add a triptan to an NSAID for patients who don't respond adequately to NSAIDs alone 1
   • Add a triptan to acetaminophen for patients who don't respond adequately to acetaminophen alone 1

3. Triptan options:

   • Sumatriptan (shown effective in reducing headache severity from moderate/severe to mild/no pain within 2-4 hours) 3
   • Other triptans: zolmitriptan, rizatriptan, almotriptan 2

4. For migraine with significant nausea/vomiting:

   • Add anti-emetics 2
   • Consider non-oral routes of administration 2

5. Alternative options:

   • Dihydroergotamine (DHE) - particularly for severe migraines (contraindicated in pregnancy) 2
   • Butorphanol nasal spray for specific cases 2
   • Greater occipital nerve block with local anesthetic for migraines with occipital component 2

Preventive Treatment

Consider preventive therapy when:

• Attacks occur ≥4 times per month 2
• Attacks cause significant disability 2
• Acute treatments are ineffective or contraindicated 2
• Patient has frequent or disabling headaches 2
• Medication overuse is present 2

First-line preventive medications:

• Beta-blockers: Propranolol (80-240 mg/day), Timolol (20-30 mg/day) 2
• Antidepressants: Amitriptyline (30-150 mg/day) 2
• Anticonvulsants: Topiramate, Divalproex sodium (500-1500 mg/day), Sodium valproate (800-1500 mg/day) 2

Second/third-line options:

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 2
• Angiotensin-converting enzyme inhibitors and angiotensin II–receptor blockers (used off-label) 1

Lifestyle Modifications and Supplemental Therapies

• Regular habits: Maintain consistent sleep patterns, meal times, and hydration 2

• Physical activity: Regular exercise can help reduce frequency and intensity of headaches 2

• Caffeine management: Limit caffeine intake 2

• Stress management: Implement cognitive-behavioral therapy, biofeedback, relaxation training 2

• Supplements with modest efficacy:

  • Magnesium
  • Riboflavin (Vitamin B2)
  • Feverfew 2

Monitoring and Avoiding Complications

• Assess response to preventive treatment after 2-3 months 2
• Limit acute medications to ≤10 days per month to prevent medication overuse headache 2
• Consider referral to a neurologist if headaches remain refractory to multiple treatment options 2
• Consider neuroimaging (CT or MRI) for patients with abnormal neurological examination, atypical headache features, or other red flags 2

Common Pitfalls to Avoid

1. Underdiagnosis and undertreatment: Migraine is often underdiagnosed and undertreated, with only a small percentage of eligible patients receiving appropriate preventive treatments 1, 4

2. Medication overuse: Excessive use of acute medications (>10 days/month) can lead to medication overuse headache, which can transform episodic migraine into chronic daily headache 2, 4

3. Inappropriate acute treatment: Using inadequate doses or inappropriate medications for severe attacks can lead to poor outcomes 2

4. Delayed treatment: Taking medications early in an attack is more effective than waiting until pain is severe 5

5. Failure to address comorbidities: Managing comorbid conditions is essential for optimal migraine control 2

By understanding the clinical manifestations and implementing appropriate treatment strategies based on headache severity and frequency, clinicians can significantly improve outcomes for patients with migraine.