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Migraine

Definition
Migraine is a primary headache disorder characterized by recurrent moderate-to-severe headaches, often accompanied by nausea, vomiting, and/or sensitivity to light and sound.
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Pathophysiology
Migraine is due to complex brain network disorder involving the cortex, hypothalamus, thalamus, and brainstem in genetically predisposed individuals.
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Epidemiology
The overall prevalence of migraine over a 3-month period in the US adult population is 15.3%, affecting approximately 20.7% of females and 9.7% of males. The global lifetime prevalence of migraines is estimated at 14%.
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Disease course
The complex interplay between cortex, hypothalamus, thalamus, brainstem involved in modulation of nociceptive signaling results in trigeminovascular system activation, cortical-spreading depression-like event, a slowly propagating wave of neuronal and glial cell depolarization and hyperpolarization causing unilateral, pulsating, moderate to severe intensity headache with or without aura.
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Prognosis and risk of recurrence
Acute migraine therapies (triptans, ergotamines, NSAIDs) are ineffective and account for > 50% recurrence of migraine. Approximately 2.2-3.1% of people with episodic migraine progress to chronic migraine at 1-year follow up.
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Key sources
The following summarized guidelines for the management of migraine are prepared by our editorial team based on guidelines from the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the The Scottish Intercollegiate Guidelines Network (SIGN 2022; 2018), the American Academy of Neurology (AAN/AHS 2019), the American Academy of Neurology (AAN 2016; 2012), and the European Federation of Neurological Societies (EFNS 2009).
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Guidelines

1.Medical management

Management of acute attacks, analgesics, SIGN: offer aspirin 900 mg as first-line therapy in patients with acute migraine.
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do not use aspirin in doses for migraine during pregnancy.
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  • Management of acute attacks (triptans)

  • Management of acute attacks (cannabinoids)

  • Management of acute attacks (antiemetics)

  • Management of acute attacks (addressing medication overuse)

2.Specific circumstances

Pediatric and adolescent patients, diagnosis
Diagnose a specific headache type (primary, secondary, or other headache syndrome) when evaluating pediatric and adolescent patients with headache.
B
Elicit the following when evaluating pediatric and adolescent patients with headache in order to improve diagnostic accuracy for migraine and appropriately counsel the patient:
premonitory and aura symptoms
headache semiology (onset, location, quality, severity, frequency, duration, aggravating and alleviating factors)
associated symptoms (nausea, vomiting, phonophobia and photophobia)
pain-related disability
B

More topics in this section

  • Pediatric and adolescent patients (screening for comorbidities)

  • Pediatric and adolescent patients (counseling on prevention)

  • Pediatric and adolescent patients (pharmacologic prophylaxis)

  • Pediatric and adolescent patients (counseling on acute treatment)

  • Pediatric and adolescent patients (management of acute attacks)

  • Pediatric and adolescent patients (monitoring)

  • Patients with menstrual migraine

3.Preventative measures

Migraine prophylaxis, first-line agents, SIGN
Offer propranolol (80-160 mg daily) as first-line prophylactic therapy in patients with episodic or chronic migraine.
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Offer topiramate (50-100 mg daily) as prophylactic therapy in patients with episodic or chronic migraine. Counsel female patients who may become pregnant regarding the associated risks of topiramate during pregnancy, the need to use effective contraception, and the need to seek further advice on migraine prophylaxis if pregnant or planning a pregnancy.
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More topics in this section

  • Migraine prophylaxis (second-line agents)

  • Migraine prophylaxis (third-line agents)

  • Migraine prophylaxis (agents with no evidence for benefit)