What are the different types of migraines?

Types of Migraines

Migraines are classified into three main types: migraine without aura, migraine with aura, and chronic migraine, each with distinct diagnostic criteria and clinical presentations. 1

Migraine Without Aura

• Formerly called "common migraine" or "hemicrania simplex" 1
• Characterized by recurrent headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) 1
• Diagnostic criteria require at least 5 attacks fulfilling specific characteristics 1
• Headache features must include at least 2 of the following:
  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity 1
• Must be accompanied by at least one of:
  • Nausea and/or vomiting
  • Photophobia and phonophobia 1
• In children and adolescents, attacks may last 2-72 hours 1
• Most common type of migraine, affecting approximately 40% of migraine sufferers with bilateral pain 1

Migraine With Aura

• Formerly called "classic migraine," "ophthalmic migraine," or "complicated migraine" 1
• Characterized by recurrent attacks with fully reversible neurological symptoms that usually develop gradually and are followed by headache 1
• Diagnostic criteria require at least 2 attacks with specific aura characteristics 1
• Aura symptoms may include:
  • Visual (most common, occurring in >90% of cases, often as fortification spectra) 1
  • Sensory (occurs in ~31% of cases as unilateral paresthesia) 1
  • Speech/language disturbances
  • Motor symptoms
  • Brainstem symptoms
  • Retinal symptoms 1
• Aura characteristics must include at least 3 of:
  • At least one symptom spreads gradually over ≥5 minutes
  • Two or more symptoms occur in succession
  • Each symptom lasts 5-60 minutes
  • At least one symptom is unilateral
  • At least one symptom is positive (e.g., scintillations, pins and needles)
  • Aura is accompanied by or followed within 60 minutes by headache 1
• Motor symptoms may last up to 72 hours 1
• Approximately one-third of migraine sufferers experience aura 1

Chronic Migraine

• Defined as headache (migraine-like or tension-type-like) occurring on ≥15 days per month for >3 months 1
• Must fulfill criteria for migraine on ≥8 days per month 1
• Not a static condition - can revert to episodic migraine or transform back to chronic form 1
• Requires at least 5 prior attacks fulfilling criteria for migraine without aura and/or migraine with aura 1
• One-year prevalence is approximately 2-4% of the general population 2
• Progression from episodic to chronic form occurs over months or years with gradual increase in attack frequency 2

Special Migraine Types

Vestibular Migraine

• Characterized by vestibular symptoms of moderate to severe intensity 1
• Diagnostic criteria include:
  • At least 5 episodes with vestibular symptoms lasting 5 minutes to 72 hours
  • Current or previous history of migraine with or without aura
  • One or more migraine features during at least 50% of vestibular episodes
  • Not better accounted for by another diagnosis 1
• Previously known as "benign recurrent vertigo" or "vestibular Ménière's disease" 1

Migraine Aura Without Headache (Acephalgic Migraine)

• Characterized by typical migraine aura without subsequent headache 3
• Occurs exclusively in 4% of migraine patients 3
• May occur at some point in 38% of patients with migraine with aura 3
• Can present with visual aura, brainstem aura, or develop later in life (late-onset migraine accompaniment) 3
• Pathophysiology is similar to classic migraine with cortical spreading depression leading to aura formation but without associated headache 3

Probable Migraine

• Defined as migraine-like attacks missing one feature required to fulfill all criteria for a specific migraine type 1
• Considered a diagnosis pending confirmation during early follow-up 1
• For probable migraine without aura, patients meet criteria but have had fewer than 5 attacks 1

Medication-Overuse Headache

• Often complicates chronic migraine 1
• Characterized by headache on ≥15 days/month in a patient with pre-existing headache disorder 1
• Requires regular overuse of acute headache medications for >3 months:
  • Non-opioid analgesics on ≥15 days/month, or
  • Other acute medications on ≥10 days/month 1
• Most severe complication of chronic migraine with gradual onset 2
• Both chronic migraine and medication overuse headache have particular genetic backgrounds that favor chronicity and abuse 2

Clinical Considerations

• Migraine with and without aura can coexist in the same patient 1
• Family history is an important diagnostic factor due to strong genetic component 1
• Migraine with aura and migraine without aura may be distinct entities with different:
  • Epidemiological features
  • Headache characteristics
  • Natural history
  • Age at onset and resolution
  • Trigger factors
  • Correlation to female reproductive events
  • Comorbidities
  • Response to preventive therapies 4
• Migraine diagnosis is primarily based on medical history and application of ICHD-3 criteria 1