19th June 2023

Migraine

Diagnosis

Migraine is a common primary headache disorder characterised by intermittent moderate to severe headaches and associated symptoms such as photophobia, phonophobia, visual disturbance, nausea, and vomiting.

There are several different types of migraine, the clinical features and diagnostic criteria of which are detailed below.

Migraine without aura

At least 5 attacks fulfilling the following:

• Headache lasting 4-72 hrs in adults
• Headache with at least 2 of the following characteristics:
  • Unilateral
  • Pulsating quality
  • Moderate to severe intensity
  • Aggravation by, or causing avoidance of, routine activities of daily life
• Headache with associated symptoms, including at least one of the following:
  • Nausea and /or vomiting
  • Photophobia and phonophobia

• Headache not accounted for by any other diagnosis

Migraine with aura

At least 2 attacks fulfilling the following:

• One or more typical fully reversible aura symptoms, including
  • Visual symptoms – e.g. zigzag lines, scotomas
  • Sensory symptoms – e.g. unilateral paraesthesia or numbness
  • Speech and/or language symptoms – e.g. dysphasia

• At least 3 of the following:
  • ≥ 1 aura symptom spreads gradually over at least 5 mins
  • 2 or more aura symptoms occur in succession
  • Each individual aura symptom last 5-60 mins
  • ≥ 1 aura symptom is unilateral
  • ≥ 1 aura symptom is positive (e.g. zigzag lines, scintillating scotoma, as opposed to negative symptoms such as temporary visual loss and dark spots.)
  • The aura is accompanied or is followed within 60 mins by headache.

• Headache not accounted for by any other diagnosis

It should be noted that occasionally, aura can occur without headache or can be atypical in nature, e.g. causing motor weakness, diplopia, or decreased consciousness. These presentations often prompt further urgent investigation to rule out a more serious cause, such as a cerebrovascular event.

Episodic and chronic migraines

Differentiation depends on the frequency of headaches:

• Episodic – migraine on < 15 days per month
• Chronic – headache ≥ 15 days per month (with migraine features ≥ 8 days per month)

Menstrual-related migraine

Suspected when migraine occurs in the days immediately before and after the start of menstruation for consecutive menstrual cycles.

Management

• Avoidance of triggers where identifiable. Common triggers include disturbed sleep, irregular meals, caffeine excess, and stress.

• Avoidance of medication overuse headaches by restricting acute analgesic medication to a maximum of 2 days a week.

• Use of combined hormonal contraception is contraindicated in women who experience migraine with aura due to the risk of vascular events; alternative contraceptive options should be explored with the patient if required.

• Options for acute pharmacological management include:
  • Simple analgesia, e.g. ibuprofen, high dose aspirin (900mg) or paracetamol.
  • Triptan, e.g. sumatriptan (first choice), available in intranasal or subcutaneous formulations if unable to tolerate orally.
  • Consider antiemetics, e.g. metoclopramide or prochlorperazine, even in the absence of nausea and vomiting.
  • Avoid opioids

• Preventative treatment can be considered if migraines are frequent or severe enough to significantly impact the person’s quality of life, or if acute treatments are ineffective. Options for pharmacological prevention of migraine include:
  • Propranolol
  • Topiramate (contraindicated in pregnancy)
  • Amitriptyline
  • Frovatriptan (unlicensed), Zolmitriptan (unlicensed) for Menstrual related Migraine

NICE recommends referral to neurology if trial of 3 or more drugs is unsuccessful or if there is a development of atypical or red flag features.

Management of migraine in pregnancy and breastfeeding

• 1st line acute treatment – paracetamol
• 2nd line treatment – Ibuprofen (1st and 2nd trimester only) or triptan if paracetamol is ineffective.

NSAIDs are contraindicated in the 3rd trimester of pregnancy due to the risk of premature closure of ductus arteriosus.

Recommendation is to avoid triptan unless the potential benefit outweighs the risk and to minimise exposure of the drug to the infant by avoiding breastfeeding for 12 hours post treatment.