What are the diagnostic and treatment approaches for different types of migraines?

Diagnostic and Treatment Approaches for Different Types of Migraines

The diagnosis and management of migraine requires a systematic approach based on specific clinical criteria for each migraine type, with treatment tailored to the specific migraine classification and severity. 1

Migraine Types and Diagnostic Criteria

Migraine Without Aura

• Characterized by recurrent headache attacks lasting 4-72 hours with:
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity
  • At least one of: nausea/vomiting, photophobia and phonophobia 1
• Most common type, affecting approximately 40% of migraine patients with bilateral pain 1
• Often includes prodromal symptoms (depressed mood, yawning, fatigue, food cravings) and postdromal symptoms (tiredness, concentration difficulties, neck stiffness) 1

Migraine With Aura

• Affects approximately one-third of migraine patients 1
• Characterized by transient focal neurological symptoms that usually precede headache:
  • Visual aura (>90% of cases) - typically fortification spectra
  • Sensory symptoms (~31%) - unilateral paresthesia spreading gradually in face/arm
  • Less common: aphasic speech disturbance, brainstem symptoms, motor weakness (hemiplegic migraine), retinal symptoms 1
• Can be differentiated from TIA by gradual spread of symptoms (≥5 min) occurring in succession 1

Chronic Migraine

• Defined as ≥15 headache days per month for >3 months
• Must fulfill ICHD-3 criteria for migraine on ≥8 days per month 1
• May revert to episodic migraine; not a static condition 1

Diagnostic Approach

1. Medical History Assessment:

   • Document headache characteristics (duration, location, quality, intensity)
   • Record associated symptoms (nausea, photophobia, phonophobia)
   • Identify trigger factors and family history 1

2. Apply Diagnostic Criteria based on ICHD-3 classification 1

3. Consider Red Flags for secondary headaches:

   • Sudden onset or "thunderclap" headache
   • Onset after age 50
   • Abnormal neurological examination
   • Headache awakening patient from sleep
   • Worsening with Valsalva maneuvers
   • Fever or neck stiffness
   • History of cancer or immunosuppression 2

4. Neuroimaging:

   • Not routinely indicated for patients with typical migraine features and normal neurological examination (yield of significant findings only 0.2-0.5%) 2
   • Indicated when red flags are present
   • MRI preferred for most secondary headache evaluation
   • CT without contrast for suspected acute subarachnoid hemorrhage 2

Treatment Approaches

Acute Treatment

1. First-line medications:

   • NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium)
   • Should be used early in the headache phase 1

2. Second-line medications:

   • Triptans (sumatriptan, etc.)
   • Contraindicated in patients with:
     • Heart problems or history of heart problems
     • Peripheral vascular disease
     • Uncontrolled hypertension
     • History of stroke or TIA 3, 4
   • Can be combined with fast-acting NSAIDs for better relief 1

3. Third-line medications:

   • Ditans and gepants
   • Consider for patients who cannot take triptans 1
   • Gepants eliminate headache symptoms in 20% of patients by 2 hours 5

4. Adjunct medications:

   • Prokinetic antiemetics (domperidone, metoclopramide) for nausea/vomiting 1

5. Medications to avoid:

   • Oral ergot alkaloids (poorly effective, potentially toxic)
   • Opioids and barbiturates (questionable efficacy, risk of dependency) 1

Preventive Treatment

Indications for preventive therapy:

• Headaches significantly impacting quality of life despite optimized acute therapy
• Typically considered for patients affected on ≥2 days per month 1
• Medication overuse (risk of medication overuse headache)

Medication options:

• Beta-blockers (propranolol)
• Antiepileptics (topiramate)
• Tricyclic antidepressants (amitriptyline)
• CGRP monoclonal antibodies
• OnabotulinumtoxinA (for chronic migraine) 1

Special considerations:

• Efficacy assessment: 2-3 months for oral preventives; 3-6 months for CGRP antibodies; 6-9 months for onabotulinumtoxinA 1
• Consider pausing successful preventive treatment after 6-12 months 1

Management in Special Populations

Children and Adolescents

• Presentation may differ from adults
• Bed rest alone can be sufficient
• Ibuprofen for acute treatment
• Propranolol, amitriptyline, or topiramate for prevention 1

Pregnant or Breastfeeding Women

• Paracetamol (acetaminophen) for acute treatment
• Avoid preventive treatment if possible 1

Older Adults

• Higher risk of secondary headache and adverse events
• Limited evidence base for medications in this population 1

Common Pitfalls to Avoid

1. Medication overuse: Limit acute medications to prevent medication overuse headache (MOH)

   • Withdraw overused medication, preferably abruptly, if MOH develops 1

2. Misdiagnosis: Migraine with aura can be confused with TIA; careful history is essential 1

3. Inadequate follow-up: Use headache calendars to track frequency, severity, and treatment response 1

4. Overlooking comorbidities: Address comorbid conditions that may impact migraine management 1

5. Cardiovascular risk with triptans: Avoid in patients with coronary artery disease, uncontrolled hypertension, or history of stroke 3, 4

By following this structured approach to diagnosis and treatment, clinicians can effectively manage the various types of migraine and improve patient outcomes.