Migraine Diagnosis and Clinical Symptomatology

Migraine is a very common phenomenon. Eighteen percent of women in this country and 6% of men have migraine. The old classification for headaches and diagnostic criteria were published in 1962, more than a quarter of a century ago. In 1988, the International Headache Society published a new classification and diagnostic criteria for all headache disorders, cranial neuralgias, and facial pain. The International Headache Society classification divides migraine, as it had been divided in the past, into two major categories: migraine without aura (formerly called common migraine) and migraine with aura (formerly called classical migraine). These criteria are rather complex and simpler criteria are proposed for clinical practice. The typical patient with migraine is a woman whose headaches began in adolescence or young adult life. There usually is a family history of migraine. Migraine is almost always more than just a headache. Virtually anything in the external environment and many things in the internal milieu may provoke migraine in a susceptible individual. There are many potential manifestations of the aura of migraine, but 90% are visual phenomena. Migraine in children is a little different than in adults. When the onset is below the age of puberty, the ratio of females to males is equal, but after puberty there is a striking predominance of women over men in a ratio of 3:1. Whenever the history of migraine is not typical or if something unexpected is found on examination, imaging studies are warranted.     

Prevalence of migraine and non-migrainous headache--head-HUNT, a large population-based study

The objective of this study was to estimate the 1-year prevalence of the following categories of headache; migraine, non-migrainous headache, frequent headache (>6 days/month), and chronic headache (>14 days/month). Between 1995 and 1997, all 92,566 inhabitants 20 years and older in Nord-Tr?ndelag county in Norway were invited to a comprehensive health study. Out of 64,560 participants, a total of 51,383 subjects (80%) completed a headache questionnaire. The overall age-adjusted 1-year prevalence of headache was 38% (46% in women and 30% in men). The prevalence of migraine was 12% (16% in women and 8% in men), and for non-migrainous headache 26% (30% in women and 22% in men). For frequent headache (> 6 days per month) and for chronic headache (>14 days per month), the prevalence was 8% and 2%, respectively. Women had a higher prevalence than men in all age groups and for all headache categories. Prevalence peaked in the fourth decade of life for both men and women, except for 'frequent non-migrainous headache', which was nearly constant across all age groups in both genders. In accordance with findings in other western countries, we found that headache suffering, including migraine, was highly prevalent, especially in younger women.     

IHS criteria and gender: a study on migraine and tension-type headache in children and adolescents

The aim of this study was to investigate whether the IHS criteria for migraine and tension-type headache depend on gender. Among 409 children and adolescents with recurrent idiopathic headache seen at a university outpatient clinic, girls had significantly more often migraine with aura. Also, there was a trend towards a higher frequency of tension-type headache in girls. In migraine, aggravation of headache by physical activity and occurrence of aura symptoms were more common in females, whereas vomiting and phonophobia occurred more often in males. In tension-type headache, females more often reported mild intensity of headache. All other criteria were similar in both sexes. Age influenced the expression of some of the accompanying symptoms in the various types of migraine, but had only minimal influence on other diagnostic criteria of migraine and tension-type headache in females as well as in males. Our study suggests that the frequency of migraine (except that of migraine with aura) is similar among girls and boys, that tension-type headache may occur more often in girls, and that gender has some influence on the IHS criteria for migraine, but almost no influence on those of tension-type headache.     

Time-series features of headache: individual distributions, patterns, and predictability of pain

OBJECTIVE: This preliminary study employed "within-patient" time-series methodology to examine headache symptom distributions (peak, sum) to assess predictability of day-to-day headache based on overall pattern, and to better characterize distributional properties of headache as they relate to study design and statistics in future research. BACKGROUND: Headache symptoms for a given patient may vary widely from one day to the next, ranging from days when the headache sufferer is asymptomatic to days when he or she is functionally disabled with severe headache. Although day-to-day variations are well recognized and appreciated clinically, headache is seldom studied using daily (eg, time-series) methodology that can elucidate potentially important individual and temporal variations. Instead, most headache research has relied upon cross-sectional designs aimed at examining group rather than individual effects which may serve to mask important individual differences. Additional within-patient time-series studies are needed to help identify symptom patterns, clinically meaningful patient subgroups, and relationships among precipitants, interventions, and outcomes. Such research would be aided by delineation of the distributional and temporal properties of key scales (eg, daily headache peak, sum). The present research provides such information derived from clinical samples of migraine and tension-type headache sufferers, laying a foundation for future time-series research. METHODS: Twenty-five migraine and 24 tension-type headache sufferers prospectively recorded daily headache activity for 1 month. Individual headache distributions were generated and examined individually and by diagnostic group. Predictability for headache was analyzed case by case and summarized by diagnostic group. RESULTS: The study determined the degree to which individual patients' headache activity distributions deviate from normality (skewness, kurtosis). For migraine and tension-type headache, individual patients' headache patterns were distinctly bimodal in nature. Notably, headache patterns with the lowest frequency were the most bimodal, and as frequency increased, the distributions tended to more closely approximate normal. Patterns were also detailed according to measures of predictability for headache (trends, autocorrelation). Generally, headache days tended to cluster together for both tension-type and migraine (positive autocorrelation) with headache on day 1 being a good predictor of headache on day 2. CONCLUSIONS: To the authors' knowledge, this is the first study to utilize time-series methodology to characterize individual patients' headache distributions and temporal patterns and to empirically address predictability in this manner. The bimodal distributions noted among less frequent headache patterns would suggest that basic assumptions underlying the use of inferential statistics may be violated when examining intra-individual relationships. Time-series research promises to yield unique insights into patterns, precipitants, and impact of headache disorders, but future research must address both the large degree of individual differences in headache and the account for the unique types of statistical distributions among individual headache sufferers.     

Epidemiology of migraine among students from randomly selected secondary schools in Lodz

The purpose of the present study was to determine the prevalence of migraine among 2351 secondary school students aged 15 to 19 years. Six hundred fifty-nine students (120 males and 539 females) complained of migraine, including 148 with additional tension-type headache (mixed headache). Migraine with aura was diagnosed in 213 students (49 with mixed headache). The remaining 446 students (99 with mixed headache) had migraine without aura. In 83 students (16 with mixed headache), headaches were developing into migrainous states. In 237 students (56 with mixed headache), headaches were accompanied by dizziness. In 128 females (25 with mixed headache), interrelation between migraine and menstruation was found. Familial factors affecting the occurrence of migraine were noted in 536 students (127 with mixed headache). It was found that 28% of secondary school students aged 15 to 19 years suffer from migraine. Nine percent of them have migraine with aura and 19%, migraine without aura. The prevalence of migraine among secondary school students is about three times higher in females than in males. Migraine with tension-type headache differs from pure migraine in respect of more numerous attacks within 1 year among females, and of more frequent occurrence of migraine with sensory aura among males.     

Nocturnal Plasma Melatonin Levels in Migraine: A Preliminary Report

We determined by radioimmunoassay plasma melatonin levels on blood samples drawn at 11 p.m. in migraine patients and control subjects. Ninety-three cephalalgic outpatients (75 females, 18 males) were compared to a control group (24 females, 22 males) matched according to age. Patients were divided into subgroups presenting common migraine (n = 38); ophthalmic migraine (n = 12); and tension headache associated with ophthalmic or common migraine (n = 24), and associated depressive status (n = 19). Statistical analysis revealed a decrease in plasma melatonin levels for the entire migraine population, compared to the control one, and a heterogeneity in both controls and patients; this heterogeneity was found mainly in the depressive and tension headache subgroups. When the migraine population--from which the depressive patients were excluded--was divided into male and female subgroups, a decrease in plasma melatonin levels was observed only for the female subgroups. Results are discussed with reference to the role of the pineal gland in the synchronization of the organism with the environmental conditions.     

Migraine Patients Show Increased Platelet Vasopressin Receptors

This study was designed to investigate vasopressin receptor status (B_max and K_d) on platelets, vasopressin plasma levels, and vasopressin-induced platelet aggregation in migraine patients (21 females and 6 males) during a headache-free interval and in a matched control group. In the migraine group, B max was significantly higher ( P = 0.02) at 53.9 ± 20.6 fmol/mg than in the control group (36.8 + 21.0 fmol/mg). A correlation between B_max and high or low sensitivity to vasopressin as an aggregator was evident in the control group, but not in the migraine group. No differences in K_d or in plasma levels of vasopressin between the migraine and control group were apparent. Men in both groups were much less sensitive to vasopressin as a platelet aggregator than were women ( P < 0.01). Whether the higher B_max in the migraine group is a reflection of temporarily higher vasopressin levels during headache or reflects a primary increase in sensitivity to vasopressin, remains to be clarified. The higher sensitivity of platelets (as a model for vessel wall receptors) from women may indicate why many more women than men suffer from migraine. Since the B_max of the vasopressin receptor on platelets from migraine patients is increased compared to controls, treating migraine headache with vasopressin may deserve more attention.     

A pivotal moment in 50 years of headache history: the first American Migraine Study

Objective.— To describe the magnitude and distribution of the public health problem posed by migraine in the United States by examining migraine prevalence, attack frequency, and attack‐related disability by gender, age, race, household income, geographic region, and urban vs rural residence. Design.— In 1989, a self‐administered questionnaire was sent to a sample of 15,000 households. A designated member of each household initially responded to the questionnaire. Each household member with severe headache was asked to respond to detailed questions about symptoms, frequency, and severity of headaches. Setting.— A sample of households selected from a panel to be representative of the US population in terms of age, gender, household size, and geographic area. Participants.— After a single mailing, 20,468 subjects (63.4% response rate) between 12 and 80 Years of age responded to the survey. Respondents and nonrespondents did not differ by gender, household income, region of the country, or urban vs rural status. Whites and the elderly were more likely to respond. Migraine headache cases were identified on the basis of reported symptoms using established diagnostic criteria. Results.— In total, 17.6% of females and 5.7% of males were found to have 1 or more migraine headaches per year. The prevalence of migraine varied considerably by age and was highest in both men and women between the ages of 35 to 45 years. Migraine prevalence was strongly associated with household income; prevalence in the lowest‐income group (less than $10,000) was more than 60% higher than in the 2 highest‐income groups (greater than or equal to $30,000). The proportion of migraine sufferers who experienced moderate to severe disability was not related to gender, age, income, urban vs rural residence, or region of the country. In contrast, the frequency of headaches was lower in higher‐income groups. Attack frequency was inversely related to disability. Conclusions.— A projection to the US population suggests that 8.7 million females and 2.6 million males suffer from migraine headache with moderate to severe disability. Of these, 3.4 million females and 1.1 million males experience 1 or more attacks per month. Females between ages 30 and 49 years from lower‐income households are at especially high risk of having migraines and are more likely than other groups to use emergency care services for their acute condition.     

Prophylaxis of Migraine and Mixed Headache. A Randomized Controlled Study

SYNOPSIS
The three most commonly used modalities in the prophylactic treatment of headache, namely propranolol, amitriptyline and biofeedback training, were compared individually and in combination. Three hundred forty patients with migraine end 375 patients with mixed headache were randomly allotted to 8 therapeutic categories. The total duration of the study was 312 years and the therapeutic groups were evaluated for a period of 7 months including I month of pretreatment observation. Improvement was assessed by percentage of change in the average headache index during the last three months of evaluation from the pretreatment headache index. In the migraine group 273 patients completed the study. Improvement was significantly higher in patients receiving prophylactic treatment compared to control patients who were on abortive Ergotamine treatment. Propranolol plus biofeedback yielded the best results in the migraine group and addition of amitriptyline did not significantly change the percentage of improvement. Propranolol alone (62%) was significantly superior to amitriptyline (42%) (p < 0.01). The differences between propranolol alone and propranolol plus amitriptyline was not statistically significant.
In the mixed headache group 281 patients completed the study. The most effective treatment was combination of amitriptyline, propranolol and biofeedback training. Amitriptyline alone was superior to propranolol alone in the treatment of mixed headache (p<0.01). A combination of propranolol and amitriptyline was superior to either of those alone. Biofeedback, though by itself, did not appear to be the treatment of choice, significantly contributed to better results as an adjunct when it is combined with pharmacological agents. Concomitant use of propranolol and amitriptyline did not result in any adverse reactions or clinical incompatibility.     

Disability, physician consultation, and use of prescription medications in a population-based study of headache

In a population-based telephone interview survey of 9,380 residents aged 12 to 29 yr in Washington County, Maryland, who reported having had a headache, 60% of females and 41% of males had had one or more headaches during the previous week; 14.4% of females and 6.0% of males in the study group had consulted a physician in the previous 12 months for a headache problem. The likelihood of consulting a physician differed according to the type of headache. Subjects with headache during the week before the interview meeting the criteria for certain migraine or certain mixed tension--migraine were twice as likely as subjects with all other types of headaches to consult a physician during the previous 12 months. Females with tension headache were considerably more likely than males with the tension headache to have consulted a physician during the previous 12 months. On the other hand, males with migraine headache during the previous week were more likely than females with migraine to consult a physician. Disability (defined as being absent from school or from work for all or part of the day) was relatively common among those subjects with a headache during the previous week (13.7% of females and 7.9% of males). However, even among those reporting disability as a result of their headache during the previous week, only 31% of females and 18% of males reported consulting a physician during the previous 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

Kinetics and thermolability of platelet monoamine oxidase in cluster headache and migraine

Platelet monoamine oxidase activity (MAO) from 33 cluster headache patients (17 males, 16 females) and 34 migraine patients (16 males, 18 females) was assayed. The kinetic constants (apparent V_max and apparent K_m) and the thermolability, measured as the ratio of the platelet MAO activity after and before heat treatment (+52°C, 30 min), were determined. The MAO activity and V_max values were significantly lower in cluster headache than in migraine and in both headache disorders compared to a control group (62 males, 66 females). When comparing all groups, K_m was not significantly different except for migraine females, who had lower K_m values compared to control females. Thermolability was significantly higher in cluster headache than in migraine and in both headache disorders compared to the control group. Smokers of five cigarettes or more per day had significantly lower V_max values but similar K_m and thermolability values compared to those smoking less or nothing. The findings of low maximal velocities and high thermolability of platelet MAO in cluster headache and migraine are suggested to represent constitutionally different enzyme properties.     

A community-based study of headache diagnosis and prevalence in Singapore

We present the results of a community survey based on the diagnostic criteria of the International Headache Society (IHS) describing headache prevalence and symptomatology in the Singapore population. A questionnaire administered by trained personnel was completed by 2096 individuals from a randomized sample of 1400 households. The overall lifetime prevalence of headache was 82.7%. The migraine prevalence was 2.4% in males and 3.6% in females; for episodic tension-type headache and chronic tension-type headache the corresponding figures were 11.1%/11.8% and 0.9%/1.8%, respectively. Inclusion of borderline cases (IHS codes 1.7 and 2.3) resulted in prevalences of 9.3% for migraine, 39.9% for episodic tension headache and 2.4% for chronic tension headache. Headaches described by 31.2% of the respondents were unclassifiable. The different premonitory symptoms, precipitants and aggravating factors in migraine and tension-type headache in our study population suggest that they represent two distinct syndromes rather than opposite ends of a clinical spectrum.     

Coping style and social support in men and women suffering from cluster headache or migraine

OBJECTIVE: To investigate similarities and differences between patients with cluster headache and patients with migraine. BACKGROUND: Patients with migraine and patients with cluster headache are considered, by many clinical neurologists, to be different psychologically and socially. METHODS: Twenty-five age-matched pairs of men and 24 age-matched pairs of women with either migraine or episodic cluster headache (men aged 31 to 62 years; mean, 47 years; women aged 23 to 72 years; mean, 44 years) were compared with regard to coping profiles as reflected in two "coping wheels," one for the present situation and one for the future. In addition, availability of attachment and social interaction was assessed by means of the ISSI (Interview Schedule for Social Interaction). RESULTS: Women with cluster headache anticipated fewer activities for themselves than women with migraine, and findings were similar in the male pairs. The men with cluster headache also anticipated significantly fewer activities for themselves in the present and with others in the present and in the future than the men with migraine. There was no significant difference as to emotional loading between the two groups. A tendency to more optimistic anticipation was found in the women with cluster headache. There were highly significant differences between the two groups in the "future" wheel. The group with migraine expected more concrete activities and more activities with their families in the future, and they also described their present situation to involve more activities with others. CONCLUSIONS: Results from the present study differ from those from studies utilizing more conventional questionnaires. In particular, we found that patients with cluster headache have fewer close social contacts than patients with migraine.     

A Population-Based Survey of Headache and Migraine in 22,809 Adults

SYNOPSIS
A population-based epidemiological study of the prevalence of headache in a sample of 24,682 adults was carried out in Finland. Enquiries were made concerning the frequency of headache, migraine and characteristics of headache attacks in a questionnaire survey in 1981. Headache was classified as migraine, and headache without migrainous features. Possible somatic causes of headache were excluded by record-linkage with three nation-wide medical registries.
The prevalence of both headache types depended on age and gender. Among women the overall prevalence of migraine was 10.1% with a maximum of 11.5% in the 40-49 age group. The prevalence rate among men was 2.5% and the female/male gender ratio was 4.0. Women with migraine had an average of 52.5 headache occasions during a year and men with migraine 61 headache occasions per year. At the individual level, headache without migrainous features was least invalidating. There were only 16.5 headache occasions a year among women and 11.5 among men. However, from a population perspective headache without migrainous features accounted for 46.5% of all headache occasions among women and for 60.8% among men. Thus, from the public health viewpoint, studies of "non-clinical" headache, e.g. headache without migrainous features should be emphasized.     

An Epidemiological Study of Headache in an Urban Population in Zimbabwe

SYNOPSIS
Information on the prevalence of headache and its characteristic features was collected from an urban population in Zimbabwe, using a combination of interview and questionnaire. Over five thousand people were questioned and the prevalence of headache was found to be 20.2% (17.6% in males and 27.0% in females). Severe headaches were experienced by approximately one third of the headache group and were more common in the younger age groups and in women. One third of the people with headaches had warning symptoms and more than half had precipitating factors. Several other features such as frequency, duration, site, age of onset and treatment sought were studied. The headaches described were classified, the most important finding being the infrequent occurrence of classical migraine.     

Quantifying headache symptoms and other headache features from chart notes

OBJECTIVES: To describe a method for quantifying headache symptoms/features in family practice charts for patients diagnosed with headache NOS (not otherwise specified, ICD-9: 784) and to determine the share of NOS headache diagnoses with clinical data strongly suggestive of migraine or probable migraine headache. BACKGROUND: Headache is one of the most common pain symptoms that brings patients to a family physician. However, the majority of headache sufferers do not receive a specific headache diagnosis when they visit physicians. METHODS: We examined the chart notes of 454 patients exclusively diagnosed with one or more ICD-9 coded headache NOS diagnoses from July 1, 1995 through December 31, 1999 at a large suburban, university-affiliated practice. We developed a template containing 20 headache items combining International Headache Society diagnostic criteria and additional headache symptoms/features, and decision rules for coding symptoms/features and collected data from patient charts. We then developed decision rules and reclassified NOS headaches into categories strongly suggestive of migraine, probable migraine headache, or other diagnosis. Our main outcome measure is the consistency in the application of decision rules and diagnostic criteria. RESULTS: With this method we estimate 3 in 10 (29%) headache NOS patients may have had migraine (8%) or probable migraine headache (21%). Reclassified migraine visits averaged 6.5 migraine symptoms and reclassified probable migraine headache visits 4.7 migraine symptoms. Logistic regression analysis supports the consistency of diagnostic criteria for classifying headache based on coded symptoms/features--our model correctly predicted 96% of visits. Evidence of physical examination was recorded at 75% of visits suggesting that physician attention is focused on elimination of secondary headache. CONCLUSIONS: We think the use of our rigorous procedures reveals that a substantial amount of migraine and probable migraine headache may be missed in everyday practice. We hope our findings will provide a basis for the development of diagnostic methods more closely suited to the needs of nonspecialists, and contribute to a better standard of care for headache patients seen in primary care practice. Finally, we are hopeful that other researchers will consider using our template and guideline procedures in their efforts to identify diagnostic patterns and study headache and other health problems.     

A prospective study of migraine with aura attacks in a headache clinic population

In order to investigate the prevalence of migraine with aura (MA) attacks according to the criteria set by the International Headache Society (IHS) for diagnosis down to the three-digit level of classification, and to determine the recurrence and possible variability of MA attacks over time, we conducted a 6-15-month-long prospective study on 64 MA patients (42 women and 22 men) consecutively referred for the first time to the University of Parma Headache Centre. At the end of the follow-up period, diagnosis was the same as at the first visit for 80.0% of patients, while it was changed for 20.0%. Throughout the duration of the study, the average number of attacks for each patient was 5.3 +/- 6.2 (range 0-30). Attacks of migraine with typical aura were the most frequent (69.1% of patients), but migraine aura without headache (29.1%) and migraine with prolonged aura (20.0%) were also common; by contrast, basilar migraine and migraine with acute onset aura were reported only by one patient in either case. Migraine aura without headache was statistically significantly more frequent in males than in females. Our study results suggest that in most cases the frequency of recurrent MA attacks is relatively low and provide interesting indications about the prevalence of the different MA subtypes listed in the IHS classification, albeit in a headache clinic population.     

A Comparison of MMPI Personality Data and Frontalis Electromyographic Readings in Migraine and Combination Headache Patients

SYNOPSIS
Three headache specialists independently evaluated one hundred and fifty patient headache histories and classified them into separate diagnostic categories. Personality data from selected scales of the MMPI and frontalis electromyographic readings during three stimulus conditions were compared between migraine patients and combination headache patients. Patients were also asked to rate the perceived level of stress elicited by the three conditions (sitting comfortably at rest, performing mental arithmetic, and imagining a severe headache).
Results indicated that raters could reliably classify patients into the migraine or combination headache group, as well as differentiate either of those groups from other headache diagnoses. Subjects in the combination group had higher MMPI scores on scale one (hypochondriasis), scale two (depression), scale three (hysteria), and scale seven (psychasthenia). There was no significant difference in frontalis muscle tension between the two groups although both showed a significant amount of muscular reactivity to the stress induction conditions. Subjects were accurate in their perception of this reactivity. Methodological suggestions were made regarding future phychophysiological research with headache patients.     

A cross-sectional population-based survey of migraine and headache in 21,177 Norwegians: the Akershus sleep apnea project

The objective was to investigate the prevalence and interrelation of migraine and headache in the general population. Forty thousand men and women aged 20-80 years from the Norwegian general population received a mailed questionnaire with questions about migraine and headache. The questionnaire response rate was 54.5%. The lifetime prevalence of migraine was 26.5% (95% CI 25.9-27.1%), i.e., 18.1% (95% CI 17.3-18.9%) in men and 34.1% (95% CI 33.2-35.0%) in women. The prevalence of migraine decreased slightly in both men and women after an age of 45. The 1 year prevalence of headache was 77.2%, i.e., 69.6% (95% CI 68.7-70.6%) in men and 84.0% (95% CI 83.3-84.7%) in women. The frequency of headache decreased with age, but some of the elders aged 70 or above experienced more frequent headache. The prevalence of being headache free increased from 19.1% (95% CI 14.2-25.6%) to 74.7% (95% CI 70.0-78.8%) in 20 and 80 years old men without co-occurrence of migraine, and from 5.1% (95% CI 2.9-8.8%) to 61.4% (95% CI 54.9-67.6%) in 20 and 80 years old women without co-occurrence of migraine. Co-occurrence of migraine significantly increased the frequency of headache and decreased the prevalence of being headache free.