Migraine and Other Headaches



Migraine and Other Headaches





Migraine

Benign recurring headache, neurologic dysfunction, or both, with pain-free interludes.

Provoked by stereotyped stimuli (specific foods, relief of stress, exercise). Far more common in women. Hereditary predisposition. Head pain lateralized in about 60% of cases.

Severe attacks likely to be throbbing, associated with vomiting and scalp tenderness. Milder headaches nondescript—tight, band-like discomfort involving entire head.


Clinical Subtypes


Migraine without Aura

Previously called “common” migraine. Benign periodic headache lasting several hours, without preceding focal neurologic symptoms; most frequent type of headache; includes “tension headache.”

Unilateral pain, nausea or vomiting, positive family history, response to ergotamine, scalp tenderness in 60% to 80%.


Migraine with Aura

Previously “classic” migraine. Headache associated with characteristic premonitory sensory, motor, or visual symptoms. Focal symptoms in small proportion of attacks, more common during headache than as prodromal symptoms.



  • Most common premonitory symptoms: visual—scotomas or hallucinations (usually in central visual field) in about 33%. “Fortification spectrum” in 10%; paracentral scotoma expands into “C” shape, with luminous angles at outer edge. Duration 20 to 25 minutes. Pathognomonic of migraine.


  • “Complicated” migraine: term previously used for migraine with dramatic focal neurologic features, such as hemiplegia. Overlaps with classic migraine. Also used for persistent focal signs after migraine attack.



Basilar Migraine

Brainstem signs, including vertigo, dysarthria, diplopia; occur as sole neurologic symptoms of migraine in 25%.

Severe form: episodes of total blindness and sensorial clouding, with or followed by vertigo, ataxia, dysarthria, tinnitus, distal and perioral paresthesias. Confusion follows in 25%. Duration about 30 minutes. Episode followed by throbbing occipital headache. Most common in adolescent women. Sensorial alterations, including confusion, may last as long as 5 days.


Carotidynia (Facial Migraine)

Older patients. Continuous deep, dull, aching pain in jaw or neck, episodically throbbing. Sharp, ice pick–like jabs superimposed. Attacks one to several times a week, each lasting minutes to hours. Ipsilateral tenderness, prominent pulsations of cervical carotid artery, swelling of soft tissues. Commonly precipitated by dental trauma.



  • Differential diagnosis: carotid dissection.


Hemiplegic Migraine

Hemiparesis may occur during prodrome; lasts 20 to 30 minutes.

More severe form: hemiplegia for days to weeks after headache subsides. Accompanying findings: dysarthria, aphasia, hemisensory loss, CSF pleocytosis, CSF protein content increased.

Familial form autosomal dominant; CACNLIA4 gene, chromosome 19, encoding calcium channel.


Ophthalmoplegic Migraine

Attacks of periorbital pain and vomiting for 1 to 4 days. Complete third nerve palsy follows, often including pupillary dilation, loss of light response. May persist days to 2 months. Onset in childhood.


Migraine Equivalents

Episodic focal neurologic symptoms without headache or vomiting.


Pathogenesis

Cortical “spreading depression” of electrical activity suspected: wave of excitation followed by wave of complete inhibition of
activity across areas of cerebral cortex. Neurologic symptoms attributed to neuronal dysfunction from spreading inhibition. Vasoconstriction, vasodilation, secretion of vasoactive peptides likely to play role.



  • Three-phase sequence model: (a) brainstem generation; (b) “vasomotor activation” (arteries within and outside the brain may contract or dilate); (c) release of vasoactive neuropeptides at terminations of trigeminal nerve on blood vessels.

Role of serotonin receptors supported by efficacy of sumatriptan.

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Jul 27, 2016 | Posted by in NEUROLOGY | Comments Off on Migraine and Other Headaches

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