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 should follow a structured ten-step approach that includes proper identification of migraine type, application of diagnostic criteria, and implementation of appropriate treatment strategies based on migraine classification. 1

Migraine Types and Diagnostic Criteria

1. Migraine Without Aura

• Characterized by recurrent headache attacks lasting 4-72 hours
• Diagnostic criteria:
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity
  • At least one of: nausea/vomiting, photophobia and phonophobia
  • At least five attacks fulfilling these criteria 1
• Common prodromal symptoms: depressed mood, yawning, fatigue, food cravings
• Postdromal symptoms may last up to 48 hours: tiredness, concentration difficulties, neck stiffness

2. Migraine With Aura

• Affects approximately one-third of migraine patients
• Characterized by transient focal neurological symptoms preceding or accompanying headache
• Visual aura most common (>90%): fortification spectra
• Sensory symptoms in ~31%: unilateral paresthesia spreading gradually in face/arm
• Less common aura symptoms: aphasic speech disturbance, brainstem symptoms, motor weakness (hemiplegic migraine), retinal symptoms 1
• Differentiate from TIA: aura symptoms spread gradually (≥5 min) and occur in succession

3. Chronic Migraine

• Defined as ≥15 headache days per month for >3 months
• Must fulfill ICHD-3 criteria for migraine on ≥8 days per month
• May revert to episodic migraine 1

Diagnostic Approach

Initial Assessment

• Record detailed medical history
• Apply ICHD-3 diagnostic criteria
• Consider differential diagnoses
• Perform physical and neurological examination 1

Red Flags Requiring Neuroimaging

• Sudden onset or abrupt headache
• Onset after age 50
• Progressive worsening pattern
• Headache awakening patient from sleep
• Worsening with Valsalva maneuvers
• Fever or neck stiffness
• Focal neurological deficits
• Papilledema
• Recent head/neck trauma
• History of cancer or immunocompromised state 2

Neuroimaging Guidelines

• MRI is preferred for most secondary headache evaluation
• CT without contrast for suspected acute subarachnoid hemorrhage
• Neuroimaging not routinely indicated for patients with headaches meeting criteria for migraine, tension-type, or cluster headache without red flags (yield of clinically significant findings only 0.2-0.5%) 2

Treatment Approaches

Acute Treatment

1. First-line medications:

   • NSAIDs: acetylsalicylic acid, ibuprofen, diclofenac potassium 1
   • Use early in the headache phase for maximum effectiveness

2. Second-line medications:

   • Triptans (sumatriptan, etc.) 1
   • Contraindicated in patients with:
     • Heart problems or history of heart problems
     • Peripheral vascular disease
     • Uncontrolled hypertension
     • Severe liver problems
     • Hemiplegic or basilar migraines
     • History of stroke or TIAs 3, 4
   • May cause vasospastic reactions, including coronary artery vasospasm 3
   • Consider combining with fast-acting NSAIDs when triptans provide insufficient pain relief

3. Third-line medications:

   • Ditans and gepants 1
   • Gepants eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1-4% of patients 5
   • Lasmiditan (ditan) appears safe in patients with cardiovascular risk factors 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, adverse effects, dependency risk) 1

Preventive Treatment

• Consider when migraine continues to impair quality of life despite optimized acute therapy
• Generally indicated for patients adversely affected on at least 2 days per month 1
• Options include:
  • Antihypertensives (beta-blockers)
  • Antiepileptics (topiramate)
  • Antidepressants (tricyclics)
  • CGRP monoclonal antibodies
  • OnabotulinumtoxinA for chronic migraine 5
• Efficacy assessment timeline:
  • Oral preventives: 2-3 months
  • CGRP monoclonal antibodies: 3-6 months
  • OnabotulinumtoxinA: 6-9 months 1

Special Populations

Children and Adolescents

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

Pregnant/Breastfeeding Women

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

Older Adults

• Higher risk of secondary headache, comorbidities, and adverse events
• Limited evidence base for all drugs in this age group 1

Common Pitfalls to Avoid

1. Medication overuse headache (MOH):

   • Discourage medication overuse
   • Risk with NSAIDs ≥15 days/month or triptans ≥10 days/month
   • For established MOH, withdraw overused medication, preferably abruptly 1, 2

2. Misdiagnosis:

   • Recurrent "sinus headaches" are often migraines 2
   • Aura symptoms can be confused with TIA 1

3. Serotonin syndrome:

   • Risk when triptans are combined with SSRIs or SNRIs
   • Monitor for mental status changes, autonomic instability, neuromuscular aberrations, and gastrointestinal symptoms 3

4. Cardiovascular risks with triptans:

   • Avoid in patients with coronary artery disease, uncontrolled hypertension, or history of stroke 3, 4
   • May cause significant elevation in blood pressure 3

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