● 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 (Eigenbrodt et al., 2021). Diagnosis of migraine 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. c. Headache with at least two of the following four characteristics: 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 i. Unilateral location. ii. Pulsating quality. iii. Moderate or severe pain intensity. 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. symptoms: i. Visual. ii. Sensory. iii. Speech and/or language. iv. Motor. v. Brainstem. vi. Retinal.
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 c. Photophobia. d. Phonophobia. Differential diagnosis and migraine headaches 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 you arrive at a diagnosis of migraine headache. These triggers include (Cavallaro Goodman et al., 2018): ● Alcohol. ● Food. ● Hormonal changes. ● Hunger. ● Lack of sleep. ● Perfume. ● Stress. ● Medications. ● Environmental factors such as pollutants, air pressure changes, and temperature changes. Self-Assessment Quiz Question #17 The onset of migraine headaches most commonly occurs: a. In puberty. b. In middle age. c. In older adulthood. d. There is no age correlation with onset of migraine headaches. Tension-type headaches According to Hainer et al. (2013), tension-type headache is the most common form of headache. Its main symptom is the feeling of pressure in the head bilaterally. The cause of this type of headache has not been defined, but muscular factors, especially from pericranial muscles; stress; and central sensitization all seem to play a role (Kroll et al., 2021). Women are affected more than men (Hainer et al., 2013).
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