SeminarMigraine
Section snippets
Migraine with or without aura (panel)
The International Headache Society2 has considerably improved the diagnosis of migraine and other headache syndromes. Different types of headache, rather than patients, are diagnosed. Patients may have concurrent types (eg, migraine and tension-type headache) which should be treated separately. The two main types of migraine are migraine without aura (common migraine), occurring in 75% of migraineurs, and migraine with aura (classic migraine), occurring in one-third of patients. Up to 33% of
Epidemiology
Migraine patients are defined as individuals who have had at least two attacks with aura or at least five attacks without aura.2 One-year prevalence figures—ie, migraine patients who have had at least one attack within the previous year (active migraineurs)—are remarkably similar across western countries and are primarily dependent on sex and age (figure 1).11, 12 Between age 10 and 19 there is sharp but transient rise in the one-year prevalence, with a peak around age 14–16;4, 12 for women
Migraine triggers
Anyone can have a migraine attack occasionally without necessarily being a migraine patient. It is not the attack but the repeated recurrence that is abnormal. Attacks seems to involve physiological mechanisms, initiated by migraine-specific triggers. Attacks recur only when the threshold is reduced or when the triggers are particularly strong and frequent. Genetic factors, possibly involving ion-channel function, appear to set the individual threshold; internal and environmental factors such
Pharmacology of antimigraine drugs
Specific acute antimigraine drugs include the ergot alkaloids (ergotamine and dihydroergotamine [DHE]), sumatriptan, and six “second-generation triptans”.
Migraine as cerebral calcium channelopathy
Complex genetic factors are involved in migraine, increasing its risk up to fourfold.15, 38, 39 The unravelling of a gene for the rare autosomal dominant subtype familial hemiplegic migraine (FHM) has revolutionised insight into the mechanisms involved in migraine.2, 5, 18, 38 Although often misdiagnosed as epilepsy, FHM is clearly part of the migraine spectrum: except for the hemiparesis, the aura and headache symptoms are identical to those of “non-hemiplegic” migraine and both types of
Treatment
There are remarkable differences across countries in treatment recommendations for migraine, many of which are not supported by scientific evidence.44, 45 This review will focus on evidence-based treatments. Non-pharmacological treatments, including avoidance of putative migraine triggers, lack demonstrated efficacy and are usually disappointing. Migraineurs have an inherited tendency to attacks, which may be triggered by a wide variety of factors. Complete avoidance seems impossible. There is
Attack treatment
Specific and non-specific symptomatic antimigraine drugs treat the headache and associated symptoms only, not the aura. Non-specific drugs include analgesics, rapidly absorbable NSAIDs, prokinetic and antiemetic compounds such as metoclopramide and domperidone, and narcotics such as codeine, pethidine, and morphine. The use of narcotics is highly controversial, not evidence-based, and associated with prominent side-effects and a high risk of dependency. Most patients who require narcotics are
Future directions
Over the next few years we may have answers to important questions such as: what are the “indirect” personal, social, and economic consequences of migraine; why is a subpopulation of migraine and other headache sufferers predisposed to misuse analgesic and antimigraine drugs and what are the pharmacological and clinical consequences of misuse; is it feasible to develop highly effective acute antimigraine drugs which are devoid of vasoconstrictor action; and are there better composite efficacy
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