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Migraine

1. Prodrome Aura Migraine attack Postdrome
Symptom severity
Few hours to days 4 to 72 hours5 to 60 minutes 24 to 48 hours
Diagnosis
Migraine episodes can be divided into
several phases: prodrome (also known
as premonitory), aura, migraine attack
and postdrome.
Prodromal and
postdromal phases can
be accompanied by
various symptoms such
as fatigue and reduced
concentration.
Migraine is typically
diagnosed by the
presence of suggestive
clinical manifestations
only, although ancillary
diagnostic tests may be
required in some
patients to rule out
other conditions.
Patients can be
subclassified as
those with migraine
with aura or those
with migraine
without aura.
For a diagnosis of migraine, patients must meet the diagnostic criteria in the International Classification of Headache Disorders, Third Edition.
Aura is associated with transient neurological symptoms. The most common aura symptom is scintillating scotoma, but other visual or sensory symptoms can also occur.
Management
Treatment of pain associated with migraine includes NSAIDs for mild to moderate pain and triptans for moderate to severe pain. Preventative therapies can be used to reduce the frequency of migraine attacks; however, most available therapies lack effectiveness. In general, adverse effects are common with migraine preventatives, evidence supporting their use is lacking, and few comparative trials have been carried out. CGRP receptor antagonists (gepants) and monoclonal antibodies targeting the CGRP pathway have recently been approved for acute therapy and the prevention of migraine attacks. These therapies have demonstrated good efficacy in clinical trials and are associated with few adverse effects. The precise mechanism of these therapies is unknown and requires further study.
zMany patients with migraine overuse
headache medication or caffeine, which
results in a cycle of withdrawal headaches
that are alleviated by use of headache
medication or caffeine.
Outlook
As many patients do not respond to, or have adverse effects with, treatments for migraine, new therapies are desperately required. These therapies should be able to consistently render patients pain free in a timely manner and without headache recurrence, with little risk of overuse and good tolerability.
Quality of life
Migraine can severely affect patients' lives owing to the unpredictable nature of attacks. The unpredictability can be associated with last-minute cancellations of various appointments, affecting both social and work life.
Mechanisms
Symptoms of migraine aura are thought to be caused by spreading depolarization, during which almost all cells in a brain region undergo depolarization and cause a depolarization wave spreading in all directions. Activation of trigeminal nociceptive pathways is also believed
to be involved in migraine. Indeed,
trigeminovascular thalamic neurons that
project to various cortical regions mediate
the sensory–discriminative components
of migraine, such as location, intensity
and quality of pain, in addition to other
symptoms, such as difficulty focusing,
amnesia and sensitivity to light and sound.
Subcortical brain regions, such as the
brainstem and diencephalon, are also
involved in migraine.
zFour rare monogenic migraine
syndromes have been identified:
CADASIL, RVCL-S, FASPS and familial
hemiplegic migraine. In the latter
condition, migraine is associated with
hemiparesis (motor weakness on one side
of the body).
Epidemiology
Ten to 15% of the general population are migraine patients and had at least one attack in the previous year. Migraine most commonly manifests in adolescence, although it can arise at any age. Fifty percent of patients have more than 1.5 attacks per month, 25% of patients have more than one attack weekly and up to 5% have chronic migraine (migraine that occurs for ≥15 days per month for >3 months). Disorders commonly comorbid with migraine include stroke, epilepsy, depression, anxiety and myocardial infarction.
zMigraine is classified as the third most
disabling disease worldwide in terms of
years lived with disability.
Migraine is characterized by episodes of disabling
headaches and associated symptoms that persist
for 4–72 hours. The characteristics of migraine vary
widely between patients and can vary within the
same individual.
Migraine
Written by Louise Adams; designed by Laura Marshall
doi: 10.1038/s41572-022-00335-z; Article citation ID: (2022) 8:1 For the Primer, visit doi: 10.1038/s41572-021-00328-4
© 2022 Springer Nature Limited. All rights reserved.
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