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What is a migraine, and how is it different from a normal headache?

A migraine is an episodic disorder, the centerpiece of which is a severe headache generally associated with nausea and/or light and sound sensitivity. It is one of the most common complaints encountered by neurologists in day-to-day practice.

Migraine headaches typically last 4-72 hours. The headache has at least two of the following characteristics: Unilateral location, pulsating quality, moderate to severe intensity and aggravation by exercise. During the headache, at least one of the following must occur: Nausea and/or vomiting, photophobia and phonophobia.

There are many headache disorders. When examining the lifetime prevalence of all headache disorders, tension type headaches represent approximately 78%, while migraines represent approximately 16%.

Tension type headaches are characterized by the following: pressing/tightening quality, bilateral location, not aggravated by routine physical activity. In addition, there should be no associated nausea, vomiting, photophobia and photophobia. Tension type headaches typically occur fewer than 15 days per month.

How do you know when migraines might be symptomatic of some larger problem—like an autoimmune disorder or a neurological problem?

Migraine is classified as a primary headache disorder. There are numerous secondary disorders including headaches associated with head trauma, vascular disorders, nonvascular intracranial disorder, substance abuse or withdrawal, non-cephalic infection and metabolic disorders as well as headache or facial pain associated with disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, cranial neuralgias, nerve trunk pain and deafferentation pain.

Diagnostic alarms that warrant further investigation include:

• The headache begins after the age of 50 years;
• The headache is sudden onset;
• There’s an accelerating pattern of headaches;
• We see a new onset headache in a patient with cancer or HIV;
• Headaches occur with systemic illness, like meningitis, encephalitis, Lyme disease, systemic infection, or collagen vascular disease;
• We identify focal neurologic symptoms or signs of disease;
• There’s evidence of papilledema—swelling in the optic nerve due to pressure changes in the brain.

What therapies and treatments do you commonly prescribe?

Acute/Abortive Therapy. There is high-quality evidence from placebo-controlled randomized trials that the following drugs are effective for the treatment of acute migraine attacks:

• Nonsteroidal anti-inflammatory drugs (NSAIDs);
• Triptans;
• The combination of sumatriptan and naproxen;
• Antiemetic/dopamine receptor antagonists: Chlorpromazine, prochlorperazine, and metoclopramide. 

For adults with mild to moderate migraine attacks not associated with vomiting or severe nausea, we suggest initial treatment with simple analgesics, including NSAIDs or acetaminophen, rather than other migraine-specific agents.

For adult outpatients with moderate to severe migraine attacks, we suggest treatment with a triptan or the combination of sumatriptan-naproxen, rather than other migraine-specific agents.

There are no efficacy data that definitively support use of one triptan versus another; different pharmacologic properties and delivery routes may help guide the choice. Patients who do not respond well to one triptan may respond better to a different triptan.

Many oral agents are ineffective at treating migraine, because of poor absorption secondary to migraine-induced gastric stasis. Therefore, a non-oral route of administration should be selected for patients whose migraines present early with significant nausea or vomiting.

Prevention. While there are no strict definitions for the precise frequency or duration of migraine headaches that would prompt preventive therapy, more than four headaches per month or headaches that last longer than 12 hours are generally considered reasonable thresholds.

The main goals of preventive therapy are to:

• Reduce attack frequency, severity, and duration;
• Improve responsiveness to treatment of acute attacks;
• Improve function and reduce disability;
• Prevent progression or transformation of episodic migraine to chronic migraine.

A number of drug classes are used for the prevention of migraine. Medications that have been effective in controlled trials include:

• Metoprolol, propranolol, and timolol;
• Amitriptyline and venlafaxine;
• Valproate and topiramate;
• Other agents, such as butterbur, magnesium and riboflavin.

In general, what can patients do prophylactically to prevent migraines? 

Nonpharmacological treatments for migraine include the following:

• Regulate sleep
• Get regular exercise
• Eat regular meals such as, Aged or fermented foods
• Avoid chocolate
• Avoid foods containing tyramine such as aged or fermented foods. 
• Avoid monosodium glutamate
• Avoid alcoholic beverages
• Limit caffeine
• Limit medications
• Use biofeedback or stress management
• Aromatherapy: lavender

NewYork-Presbyterian Medical Group Hudson Valley
1978 Crompond Road, Suite 101
Cortlandt Manor, NY 10567
914-293-8600 
www.nyp.org/medicalgroups/hudsonvalley

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