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Migraine

Headaches which are severe enough to interfere with normal daily activity are usually migraine. Migraine tends to be releived by sleep and associated with photo-phobia, phonophobia and osmophobia. In other words if the headaches are bad enough bto make you want to go and lie down in a dark room they are probably migraine.  

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Migraines can be episodic, lasting hours to days, or chronic, being present for more than 15 days in every month.

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People with migraine can also have superimposed 'tension type' headache (look for a chronic daily headache with superimposed exacerbations lasting a few hours to days) and medication induced headache.

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A quarter of people with migraine get an aura. Rarely, patients experience auras without accompanying headaches (sometimes termed acephalic migraines, migraine variant or migraine equivalent), which can lead to diagnostic confusion (including misdiagnoses of TIA). The history is therefore key to assessing migrainous auras. Unlike vascular events, auras usually evolve gradually over 2 to 20 minutes, last less than 60 minutes, and are reversible.

 

Typical auras include (i) visual symptoms (usually of a fortification spectrum – a spreading jagged crescentic pattern), most often in one eye; (ii) unilateral sensory disturbance (can involve the face including lips/mouth spreading to the arm and/or leg); (iii) unilateral weakness; (iv) dysphasia; (v) vertigo (more typically imbalance/rocking rather than rotatory movement. The balance between “positive” and “negative” symptoms is not always helpful in distinguishing aura from TIA.

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People with acute migraines often look extremely ill and vomit. They are photophobic but should not have a temperature. If the patient has a first ever severe headache with a fever then they should be investigated and treated for possible menigitis.

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The the treatment for migraine should be as follows:

  1. Lifestyle adjustment including a headache diary

  2. Physiotherapy

  3. Develop a good acute migraine rescue regime

  4. Prophylactic medication

  5. Scalp injections

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This page has been adapted from the Dudley Health Economy Guidelines on Headache written by Prof Douglas and colleagues

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