c. Headache with at least two of the following four characteristics:
menopausal women (Cavallaro Goodman et al., 2018). Currently, medications have the highest level of evidence for effectively managing migraine headaches (de Almeida Tolentino et al., 2021). However, physical therapy can be used in conjunction with pharmacological interventions. Specifically, evidence shows therapy can be used to address musculoskeletal and/or vestibular symptoms accompanying migraine (Carvahlo et al., 2020). Migraine manifests itself as recurrent attacks of headache with a range of accompanying symptoms. In approximately one- third of patients with migraines, headache is sometimes or always preceded or accompanied by transient neurological phenomena, referred to as migraine aura (Eigenbrodt et al., 2021). The pathogenesis of migraine is attributed to involvement of the peripheral and central activation of the trigeminovascular system (Eigenbrodt et al., 2021). The third edition of the International Classification of Headache Disorders classifies three main types of migraine: migraine without aura, migraine with aura, and chronic migraine: ● Migraine without aura. Migraine without aura is characterized by headaches that recur and last 4 to 72 hours (Eigenbrodt et al., 2021). Typical features of this headache type include unilateral location (although bilateral pain is reported by 40% of individuals), pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. Associated symptoms include photophobia, phonophobia, nausea, and vomiting. Prodromal symptoms include depressed mood, yawning, fatigue, and craving for certain foods (Eigenbrodt et al., 2021). ● Migraine with aura . Approximately one-thirds of individuals with migraine experience an aura (Eigenbrodt et al., 2021). Aura is defined as transient focal neurological symptoms that precede or accompany migraine headaches (Eigenbrodt et al., 2021). The majority of migraine patients have visual auras. About one-third of patients with migraines have sensory symptoms involving pins and needles and/or numbness that spreads gradually in the face or arm (Eigenbrodt et al., 2021). Less common aura symptoms include speech disturbance, motor weakness, and retinal disturbances such as repeated monocular visual disturbances (Eigenbrodt et al., 2021). ● Chronic migraine. Chronic migraine is defined as greater than or equal to 15 headache days per month with fulfillment of International Classification of Headache Disorders criteria for headaches more than 7 days per month (Eigenbrodt et al., 2021). Family history of migraine/age of onset There is a strong genetic component for migraine. First-degree relatives of people with migraine have a higher prevalence of migraine than the general population (Eigenbrodt et al., 2021). Onset of migraine headaches is typically at or around puberty Medical history is critical to migraine diagnosis. Medical history should include the following important elements: Age at onset of headache; duration of headache episodes; frequency of headaches; pain characteristics, including location, quality, severity, aggravating factors and relieving factors; accompanying symptoms such as photophobia, phonophobia, nausea and vomiting; and medication use. Diagnostic criteria Diagnosis of migraine headache is established via the diagnosis criteria established by application of the International Classification of Headache Disorders criteria. These criteria prioritize specificity over sensitivity (Eigenbrodt et al., 2021): 1. ICHD-3 criteria migraine without aura: a. At least five attacks that fulfil criteria b–e. b. Headache attacks that last at least 4–72 hours when untreated or unsuccessfully treated. (Eigenbrodt et al., 2021). Diagnosis of migraine
i. Unilateral location. ii. Pulsating quality. iii. Moderate or severe pain intensity.
iv. Aggravation by, or causing avoidance of, routine physical activity (e.g., walking or climbing stairs). d. At least one of the following during the headache: i. Nausea and/or vomiting. ii. Photophobia and phonophobia. e. Not better accounted for by another ICHD-3 diagnosis. 2. Migraine with aura: a. At least two attacks that fulfil criteria b and c. b. One or more of the following fully reversible aura symptoms: i. Visual. ii. Sensory. iii. Speech and/or language. iv. Motor. v. Brainstem. vi. Retinal. c. At least three of the following six characteristics: i. At least one aura symptom spreads gradually over ≥5 minutes. ii. Two or more aura symptoms occur in succession. iii. Each individual aura symptom lasts 5–60 minutes. iv. At least one aura symptom is unilateral. v. At least one aura symptom is positive. vi. The aura is accompanied with or followed by a headache within 60 minutes. d. Not better accounted for by another ICHD-3 diagnosis. 3. Chronic migraine: a. Headache (migraine-like or tension-type-like) on ≥15 days/month for >3 months that fulfil criteria b and c. b. Attacks occur in an individual who has had at least five attacks that fulfill the criteria for migraine without aura and/or migraine with aura. c. On ≥8 days/month for >3 months, any of the following criteria are met: i. Criteria c and d for migraine without aura. ii. Criteria b and c for migraine with aura. iii. Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative. d. Not better accounted for by another ICHD-3 diagnosis. Self-Assessment Quiz Question #16 All of the following are common symptoms associated with migraine headaches except: a. Muscle tenderness in the upper cervical spine. b. Nausea and vomiting. Differential diagnosis from other primary headaches is important. Tension- type headaches lack the symptoms that accompany migraine, are typically bilateral, are mild to moderate in intensity, and have a pressing or tightening quality that is not aggravated by routine physical activity (Eigenbrodt et al., 2021). Cluster headaches are much less prevalent and are characterized by recurrent but short-lasting attacks; strictly unilateral pain; severe or very severe intensity; and accompanying ipsilateral cranial autonomic symptoms such as conjunctival injection, lacrimation, and nasal congestion (Eigenbrodt et al., 2021). Medication overuse headaches commonly develop from overuse of acute medication to treat migraine attacks (Eigenbrodt et al., 2021). Migraine triggers Migraine headaches are often brought on by specific triggers. When interviewing the patient about their pain pattern, the onset of a headache associated with these triggers may help c. Photophobia. d. Phonophobia. Differential diagnosis and migraine headaches
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