What are the different types of migraines?

Types of Migraines

According to the International Classification of Headache Disorders (ICHD-3), migraines are classified into several distinct types, with the three main categories being migraine without aura, migraine with aura, and chronic migraine. 1, 2

Migraine Without Aura

Migraine without aura (previously called common migraine or hemicrania simplex) is characterized by:

• Recurrent headache attacks lasting 4-72 hours (2-72 hours in children and adolescents)
• At least 5 attacks fulfilling diagnostic criteria
• Headache features must include at least 2 of:
  • Unilateral location (though ~40% report bilateral pain)
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity
• During headache, at least 1 of:
  • Nausea and/or vomiting
  • Photophobia and phonophobia

Common prodromal symptoms include depressed mood, yawning, fatigue, and food cravings. Postdromal symptoms can last up to 48 hours and often include tiredness, concentration difficulties, and neck stiffness. 1

Migraine With Aura

Migraine with aura (previously called classic or classical migraine) affects approximately one-third of migraine sufferers and is characterized by:

• At least 2 attacks fulfilling diagnostic criteria
• One or more fully reversible aura symptoms:
  • Visual (>90% of cases, often presenting as fortification spectra)
  • Sensory (~31% of cases, typically unilateral paresthesia)
  • Speech and/or language
  • Motor
  • Brainstem
  • Retinal
• At least 3 of the following characteristics:
  • At least 1 aura symptom spreads gradually over 5 minutes
  • Two or more aura symptoms occur in succession
  • Each individual aura symptom lasts 5-60 minutes
  • At least 1 aura symptom is unilateral
  • At least 1 aura symptom is positive (e.g., scintillations, pins and needles)
  • The aura is accompanied, or followed within 60 minutes, by headache

A rare subtype is typical aura without headache (also known as acephalgic migraine), which occurs exclusively in 4% of migraine patients and may develop at some point in 38% of patients with migraine with aura. 1, 3

Chronic Migraine

Chronic migraine is defined as:

• Headache occurring on ≥15 days per month for >3 months
• On ≥8 days per month, headaches fulfill criteria for migraine
• Not better accounted for by another ICHD-3 diagnosis
• Not attributable to medication overuse

Chronic migraine is severely disabling and difficult to manage. Patients experience substantially more frequent headaches, comorbid pain and affective disorders, and fewer pain-free intervals than those with episodic migraine. 2, 4

Vestibular Migraine

Vestibular migraine is characterized by:

• At least 5 episodes with vestibular symptoms of moderate or severe intensity
• Symptoms lasting 5 minutes to 72 hours
• Current or previous history of migraine with or without aura
• One or more migraine features with at least 50% of the vestibular episodes:
  • Headache with typical migraine characteristics
  • Photophobia and phonophobia
  • Visual aura

Vestibular symptoms can include spontaneous vertigo, positional vertigo, and head motion-induced vertigo. 1

Pathophysiological Differences Between Migraine Types

While all migraine types share some pathophysiological mechanisms, there are important differences:

• Migraine with aura involves cortical spreading depression, which is thought to be the neurobiological basis of the aura
• Genetic studies have identified different susceptibility gene variants between migraine with and without aura, many of which encode proteins involved in glutamate neurotransmission and synaptic plasticity 5, 6
• The trigeminovascular pathway activation is common to all migraine types and explains why the pain is restricted to the head 7

Clinical Implications

Understanding the different migraine types is crucial for proper diagnosis and treatment:

• Accurate classification helps determine appropriate treatment strategies
• Different migraine types may respond differently to preventive and acute treatments
• Recognition of rare subtypes (like acephalgic migraine) prevents misdiagnosis
• Identification of chronic migraine is essential as it requires more aggressive management approaches

Red Flags

When evaluating headaches, be alert for red flags that may indicate secondary causes:

• "Worst headache of life"
• New headache pattern after age 50
• Headache worsened by Valsalva maneuver
• Headache that awakens patient from sleep
• Headache with focal neurological deficits

These symptoms warrant urgent neuroimaging and further investigation. 2