Severe attacks can be incapacitating, disrupting family and work life. Attacks vary significantly in frequency and severity. Many patients have several types of headache, including milder attacks without nausea or photophobia; they may resemble tension-type headache Tension-Type Headache Tension-type headache causes mild generalized pain usually viselike without the incapacity, nausea, or photophobia associated with migraine.
See also Approach to the Patient With Headache Patients with episodic migraine can develop chronic migraine. This headache disorder used to be called combination or mixed headache because it had features of migraine and tension-type headache. These headaches often develop in patients who overuse drugs for acute treatment of headaches. Basilar artery migraine causes combinations of vertigo, ataxia, visual field loss, sensory disturbances, focal weakness, and altered level of consciousness.
Diagnosis of migraine is based on characteristic symptoms and a normal physical examination, which includes a thorough neurologic examination Introduction to the Neurologic Examination The neurologic examination begins with careful observation of the patient entering the examination area and continues during history taking. The patient should be assisted as little as possible Red flag findings that suggest an alternate diagnosis even in patients known to have migraine include the following:.
Papilledema Papilledema Papilledema is swelling of the optic disk due to increased intracranial pressure. Optic disk swelling resulting from causes that do not involve increased intracranial pressure eg, malignant Patients with characteristic symptoms and no red flag findings do not require testing. Patients with red flag findings often require testing Testing Headache is pain in any part of the head, including the scalp, face including the orbitotemporal area , and interior of the head.
Misdiagnosing migraine as sinus headache or eye strain because autonomic and visual symptoms of migraine are absent. Assuming that any headache in patients known to have migraine represents another migraine attack a thunderclap headache or a change in the previous headache pattern may indicate a new, potentially serious disorder. Mistaking migraine with aura for a transient ischemic attack, especially when the aura occurs without headache, in older people.
Diagnosing a thunderclap headache as migraine because a triptan relieves it a triptan can also relieve a headache due to subarachnoid hemorrhage. MELAS Mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes MELAS Impairment of oxidative phosphorylation often, but not always, causes lactic acidosis, particularly affecting the central nervous system, retina, and muscle.
See also Approach to the Patient For some patients, migraine is an infrequent, tolerable inconvenience. For others, it is a devastating disorder resulting in frequent periods of incapacity, loss of productivity, and severely impaired quality of life.
For acute attacks, triptans, lasmiditan , gepants, or dihydroergotamine plus a dopamine antagonist antiemetic. A thorough explanation of the disorder helps patients understand that although migraine cannot be cured, it can be controlled, enabling them to better participate in treatment. Patients are urged to keep a written headache diary to document the number and timing of attacks, possible triggers, and response to treatment.
Identified triggers are eliminated when possible. However, elimination of triggers can be overdone. It usually develops in people with migraine or Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms Clinicians sometimes recommend behavioral interventions biofeedback, stress management, psychotherapy to manage migraine, especially when stress is a major trigger or when analgesics are being overused.
Yoga can reduce headache frequency and intensity; it enhances vagal tone and decreases sympathetic drive, thus improving cardiac autonomic balance.
Relaxation techniques can reduce sympathetic nervous system activity, ease muscle tension, and alter brain wave activity. Treatment of acute migraine headache is based on frequency, duration, and severity of attacks. If patients wish to avoid drug treatment or if drug treatment has been ineffective, neuromodulatory treatments Neuromodulatory treatments Migraine is an episodic primary headache disorder.
NSAIDs or acetaminophen is used to treat mild to moderate migraine attacks. If these drugs are ineffective, clinicians should consider using triptans or dihydroergotamine.
A good response to dihydroergotamine or a triptan should not be interpreted as diagnostic for migraine because these drugs may relieve headache due to subarachnoid hemorrhage or other structural abnormalities. If mild attacks worsen or if attacks are severe from the onset, triptans or dihydroergotamine can be used. When nausea is prominent, combining a triptan with an antiemetic at the onset of attacks is effective. Triptans are selective serotonin 1B,1D receptor agonists.
They are not analgesic per se but specifically block the release of neuropeptides that trigger migraine pain. Triptans are most effective when taken at the onset of attacks. They are available in oral, intranasal, and subcutaneous forms see table Drugs for Migraine and Cluster Headaches Drugs for Cluster Headaches Cluster headaches cause excruciating, unilateral periorbital or temporal pain, with ipsilateral autonomic symptoms ptosis, lacrimation, rhinorrhea, nasal congestion.
Diagnosis is clinical Triptans and dihydroergotamine can cause coronary artery constriction and are thus contraindicated in patients with coronary artery disease or uncontrolled hypertension; these drugs must be used with caution in older patients and in patients with vascular risk factors. Ubrogepant and rimegepant, which are gepants small-molecule calcitonin gene—related peptide [CGRP] receptor antagonists , are alternatives. Lasmiditan a new selective serotonin [5-HT] 1F receptor agonist or a gepant, such as ubrogepant or rimegepant, can be used when triptans or dihydroergotamine are contraindicated because of cardiovascular disorders.
Lasmiditan , which has a much greater affinity for serotonin 1F receptors than for 1B receptors, has no cardiovascular contraindications. Triptans cause vasoconstriction by activating 5-HT1B receptors. As of this time, gepants have no cardiovascular precautions or contraindications and have no serious cardiovascular and gastrointestinal effects. An antiemetic eg, metoclopramide , prochlorperazine alone may be used to relieve mild or moderate attacks.
Prochlorperazine suppositories 25 mg or tablets 10 mg are an option for patients who cannot tolerate triptans and other vasoconstrictors.
Migraine rescue medications that have been used for years include a class of drugs called triptans, as well as nonsteroidal anti-inflammatory drugs NSAIDs. Two newer classes of medications approved to treat acute migraine are gepants and ditans. Gepants are unique in that they are not associated with medication-overuse headache, a kind of headache that can occur when people overuse acute migraine medications , according to the American Migraine Foundation.
For cluster headaches, standard treatments include injectable triptans and high-flow oxygen, says Lipton. Fast treatment is advisable for cluster headaches, Diamond says, because the pain is so severe. These in-office procedures, in which a numbing agent, or anesthetic, is injected into the scalp near particular nerves, can improve cluster headaches for a few weeks to a few months, he adds.
According to both Lipton and Diamond, if migraine attacks occur regularly, preventive medications should be taken daily to stave them off. These include beta blockers propranolol or timolol , anti-seizure drugs such as Topamax topiramate , and some types of antidepressants.
Some forms of birth control pills can help improve migraine in women, though for some women the pills can increase the risk of stroke or heart disease, according to the American Migraine Foundation.
Cluster headache prevention may include daily doses of verapamil a calcium channel blocker , with or without a short course of steroids. Additional reporting by Becky Upham. By subscribing you agree to the Terms of Use and Privacy Policy. Health Topics. Health Tools. Reviewed: December 10, Medically Reviewed.
Learn about each different type of migraine, with and without headache, below. About a quarter of people who experience migraine also experience aura , a series of sensory and visual changes that can range from seeing black dots and zig zags to tingling numbness on one side of the body, or an inability to speak clearly.
Aura sets in shortly before or during a migraine and can last anywhere from 10 to 30 minutes. Diagnosing migraine without aura can be difficult because the symptoms are similar to several other types of migraine.
Pulsing or throbbing pain on one side of the head, photophobia , phonophobia, pain that is made worse by physical activity, and nausea and vomiting are all classic symptoms of Migraine without Aura. The key differentiator is that Common Migraine lacks the warning phases prodrome and aura that other types of migraine have.
Also called a Silent or Acephalgic Migraine, this type of migraine can be very alarming as you experience dizzying aura and other visual disturbances, nausea, and other phases of migraine, but no head pain.
The International Headache Society classifies this type as typical aura without headache. If you have ever had a migraine that felt more like a stroke, it was probably a Hemiplegic Migraine. It can last for as little as a few hours to several days. When a headache causes you to temporarily lose vision in one eye, it is a Retinal Migraine. Most common in women during their childbearing years, the blindness can last anywhere from a minute to months, but is usually fully reversible.
What we do know is that Retinal Migraine may be a sign of a more serious issue, and those who experience it should make a point to see a specialist. Many of the days often feel like typical migraine, but there may be considerable variability in the severity of the symptoms and head pain on any given day.
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