Neuroscience Clerkship

RECOGNITION OF MIGRAINE AND TENSION-TYPE HEADACHES

Migraine is one of the most common types of headache, with an estimated prevalence of 20% in women and 6% in men. Migraine occurs at all ages, often beginning as teenager or young adult. Up to 90% have a family history of migraine.

Criteria for Migraine by the International Headache Society

• Episodic attacks of headache lasting 4-72 hours

• With two of the following symptoms:

Unilateral pain

Throbbing

Aggravation on movement

Pain of moderate or severe intensity

• And one of the following symptoms:

Nausea or vomiting

Photophobia or phonophobia

Migraine is divided into those without a neurologic prodrome (a.k.a., common migraine or migraine without aura) and those that are accompanied by transient focal neurological symptoms (aura) before the headache (a.k.a., classic migraine or migraine with aura). The headache phase is similar in the two groups. Migraines are severe headaches associated with nausea and vomiting that usually put the person to bed (in past generations known as “sick headaches”). Once the full-blown headache is reached, patients appear very similar clinically to patients with a subarachnoid hemorrhage (i.e., severe headache, nausea and vomiting, curled up in bed in a dark room). However, compared to the temporal course of subarachnoid hemorrhage which is explosive, the pain of a migraine tends to “build up” over 30 minutes to hours. Migraine often affects one side of the head (hemicranial pain), although it can be global, frontal or occipital in different patients. Likewise, the quality of migraine pain is most often throbbing; however, some patients describe a constant pain.

In classic migraine, patients experience a transient focal neurologic symptom before the headache. These auras are most often visual, followed by sensory, motor or language disturbances. The most common aura is a scintillating scotoma. These are typically zigzag, shimmering or colored lines in one visual field that enlarge over 10 - 20 minutes. This "build-up" of symptoms over 10- 20 minutes is characteristic of migraine (much longer than would occur in a seizure). Also, of importance, migraine visual symptoms tend to be “positive.” The lines are bright or shimmering, as opposed to dark or absent vision (i.e., negative symptoms). However, following the scintillating scotoma, the visual disturbance may change to a loss of vision. Visual auras are thought to originate from the calcarine cortex. Next common are transient sensory symptoms, usually paresthesias (again, positive in nature, as opposed to numbness or lack of sensation) that slowly spread from one body segment to another. Similar to a visual aura, sensory auras build up over 10 - 20 minutes and then slowly resolve (often as the headache is beginning). In some patients, transient language of motor dysfunction occurs as part of an aura. One of the defining characteristics of migraine with aura is the presence of a “march.” In a migraine march, the visual aura comes first, followed by a sensory aura, followed by a motor or language disturbance.

Everyone has experienced tension-type headaches. There are characterized as bilateral pain, most prominent in the occiput and frontal regions, and described as "band-like" or tight. These headaches tend to grow worse as the day progresses. Most are associated with stress, eyestrain, poor sleep, as well as neck and scalp muscle tightness.

Diagnostic criteria include:

• Headache lasting 30 min to a week

• Absence of any transient neurologic symptoms

• Absence of nausea or vomiting

• Absence of photophobia and phonophobia

• At least two of the following

Pressing or tightening quality (non-pulsating)

Mild or moderate intensity

Bilateral location

No aggravation by physical activity

Tension-type headaches have often been thought to originate from scalp muscles, although it is unproven if muscle tension actually plays a role.