Migraine classification
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Migraines can be divided in three different types: migraine without aura, typical migraine with aura and probable migraine without aura. Migraines are often underdiagnosed and misdiagnosed.[1][2] The diagnostic criteria for migraine include recurrent headache disorder manifesting in attacks that fulfill typical characteristics in a context of normal clinical examination that rules out other diagnoses. Migraine with aura is a recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes.
The International Classification of Headache Disorders (ICHD)
Migraine without Aura
The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria:[3]
- A - ≥ 5 attacks characterized by the symptoms presented in the criteria B through D
- B - Headaches can last form 4 to 72 hours.
- C - Headaches must contain at least one of the following:
- Unilateral location
- Pulsating quality
- Moderate to severe pain
- Aggravation or causing of the pain from normal physical activity
- D - Presence of one of the following:
- Nausea and/or vomit
- Photophobia and/or phonophobia
- E - The symptoms can not be better accounted for by any other diagnosis.
The mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likelihood ratio for diagnosing migraine is 24.[4]. The presence of either disability, nausea or sensitivity, can diagnose migraine with[5] sensitivity of 81% and specificity of 75%. Patients that meet the criterai for Migraine without aura, but have fewer than 5 attacks, are classified as Probable Migraine without aura.
Migraine with Aura
The diagnosis of migraine with aura, according to the International Headache Society, can be made according to the following criteria:[3]
- A - ≥ 2 attacks characterized by the symptoms presented in the criteria B through D
- B - At least 1 of the following reversible symptoms:
- C - At least two of the following:
- D - The symptoms can not be better accounted for by any other diagnosis.
Where these criteria are not fully met, a diagnosis of "probable migraine with aura" may be considered, although other neurological causes must also be excluded.
If the picture complies with the criteria but includes one-sided muscular weakness or paralysis, a diagnosis of "sporadic hemiplegic migraine" or "familial hemiplegic migraine" should be considered.
| Typical aura With migraine headache | Typical aura with migraine headache consists of a typical aura involving visual and/or sensory and/or speech symptoms, lasting no more than 60 minutes. The aura is characterized by complete reversibility of the symptoms and is associated with headache fulfilling the criteria for migraine without aura. It begins during the aura or follow the aura within 60 minutes and is not attributed to another disorder. |
| Typical aura with non-migraine headache | Is a typical aura involving visual and/or sensory and/or speech symptoms, lasting no more than 60 minutes. The aura is characterized by complete reversibility of the symptoms, which is associated with headache that does not fulfil the criteria for migraine without aura. |
| Typical aura without headache | Is a typical aura involving visual and/or sensory and/or speech symptoms, lasting no more than 60 minutes. The aura is characterized by complete reversibility of the symptoms, which is not associated with headache. |
| Familial hemiplegic migraine (FHM) | Familial hemiplegic migraine (FHM) is a type of migraine with a possible polygenetic component. These migraine attacks may last 4-72 hours[6] and are apparently caused by ion channel mutations, three types of which have been identified to date. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties. |
| Sporadic hemiplegic migraine | Sporadic hemiplegic migraine (SHM) have migraine attacks that may last 4-72 hours[6]. Patients who experience this syndrome have relatively typical migraine headaches preceded and/or accompanied by reversible limb weakness on one side as well as visual, sensory or speech difficulties without a first or second relative with hemiplegic migraine. |
| Basilar-type migraine | Basilar type migraine (BTM), formerly known as basilar artery migraine (BAM) or basilar migraine (BM), is an uncommon type of complicated migraine with aura. In the majority of migraineurs the aura progress gradually for 5 minutes or more, lasting 5 - 120 minutes and the headache starts after the onset of the aura.[7] The symptoms are originated from the brain stem and/or from both hemispheres simultaniously attacked, without weakness.[8] It always present 2 or more brain stem related aura symptoms (eg. Dysarthria, vertigo, hypoacusis, diplopia, ataxia, decreased level of consciousness) .[9] Serious episodes of BTM can lead to stroke, coma, or even death. The use of triptans and other vasoconstrictors as abortive treatments in BTM is contraindicated. Abortive treatments for BTM often focus on vasodilation and restoration of normal blood flow to the vertebrobasilar territory and subsequent return of normal brain stem function. |
Childhood Periodic Syndromes That Are Commonly Precursors Of Migraine
Cyclical Vomiting
Are recurrent episodic attacks that last from 1 hour to 5 days of nausea and vomiting at least 4 times per hour, free of symptoms between attacks and it is not attributed to another disorder.
Abdominal migraine
Is a recurrent disorder of unknown origin which occurs mainly in children. It is characterised by episodes of moderate to severe central abdominal pain lasting 1-72 hours. There is usually associated nausea and vomiting but the child is entirely well between attacks. In order to diagnose abdominal migraine, there must be at least five attacks, not attributable to another cause, fulfilling the following criteria
1. Attacks lasting 1-72 hours when untreated
2. Pain must have ALL of the following characteristics
- Location in the midline, around the umbilicus or poorly localised
- Dull or 'just sore' quality
- Moderate or severe intensity
3. During an attack there must be at least two of the following
Most children with abdominal migraine will develop migraine headache later in life and the two may co-exist during adolescence.
Bening paroxysmal Vertigo Of Childhood
Are recurrent brief episodic attacks of vertigo. In order to diagnose benign paroxysmal vertigo of childhood there must have been at least 5 attacks of multiple episodes with severe vertigo, starting without warning and resolving spontaneously. The patient must have a normal neurological, audiometric and vestibular functions between attacks and a normal electroencephalogram.
Retinal Migraine
Also called ocular migraine is a rare condition described as multiples attacks of monocular scotoma or blindness. In order to diagnose retinal migraine there must have been at least 2 attacks with reversible monocular (positive and/or negative) visual phenomena (eg, scotoma or blindness) and a headache fulfilling criteria for Migraine without aura begins during the visual symptoms or follows them within 60 minutes. The patient should have normal ophthalmological examination between attacks and is not attributed to another disorder.
References
- ↑ Lipton RB, Stewart WF, Celentano DD, Reed ML (1992). "Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis". Arch. Intern. Med. 152 (6): 1273–8. PMID 1599358.
- ↑ Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C (2004). "Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache". Arch. Intern. Med. 164 (16): 1769–72. doi:10.1001/archinte.164.16.1769. PMID 15364670.
- ↑ 3.0 3.1 Headache Classification Committee of the International Headache Society (IHS) (2013). "The International Classification of Headache Disorders, 3rd edition (beta version)". Cephalalgia. 33 (9): 629–808. doi:10.1177/0333102413485658. PMID 23771276.
- ↑ Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM (2006). "Does this patient with headache have a migraine or need neuroimaging?". JAMA. 296 (10): 1274–83. doi:10.1001/jama.296.10.1274. PMID 16968852.
- ↑ Lipton RB, Dodick D, Sadovsky R; et al. (2003). "A self-administered screener for migraine in primary care: The ID Migraine validation study". Neurology. 61 (3): 375–82. PMID 12913201.
- ↑ 6.0 6.1 "The International Classification of Headache Disorders: 2nd edition". Cephalalgia : an International Journal of Headache. 24 Suppl 1: 9–160. 2004. PMID 14979299. Retrieved 2012-08-30.
- ↑ name="pmid23771276">Headache Classification Committee of the International Headache Society (IHS) (2013). "The International Classification of Headache Disorders, 3rd edition (beta version)". Cephalalgia. 33 (9): 629–808. doi:10.1177/0333102413485658. PMID 23771276.
- ↑ name="pmid3537212">Pearce JM (1986). "Historical aspects of migraine". J Neurol Neurosurg Psychiatry. 49 (10): 1097–103. PMC 1029040. PMID 3537212.
- ↑ name="pmid23771276">Headache Classification Committee of the International Headache Society (IHS) (2013). "The International Classification of Headache Disorders, 3rd edition (beta version)". Cephalalgia. 33 (9): 629–808. doi:10.1177/0333102413485658. PMID 23771276.