Migraine classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Classification

Migraines have been classified by the International Headache Society which periodically revises their classification.

Defining Severity of Pain

In addition to classifying the type of headache, the International Headache Society defines intensity of pain on a verbal 4 point scale:

• 0 no pain
• 1 mild pain 'does not interfere with usual activities'
• 2 moderate pain 'inhibits, but does not wholly prevent usual activities'
• 3 severe pain 'prevents all activities'

Migraine Without Aura

This is the most commonly seen form of migraine; patients who primarily suffer from migraine without aura may also have attacks of migraine with aura. According to the International Classification of Headache Disorders, it is a recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia. In order to diagnose migraine without aura, there must have been at least five attacks not attributable to another cause that fulfill the following criteria

1. Headache attacks lasting 4-72 hours when untreated

2. At least two of the following characteristics

• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity

3. During the headache there must be at least one of the following associated symptom clusters

• Nausea and/or vomiting
• Photophobia and phonophobia

Where these criteria are not fully met, the problem may be classified as "probable migraine without aura" but other diagnoses such as "episodic tension type headache" must also be excluded.

Migraine With Aura

This is the second most commonly seen form of migraine: patients who primarily suffer from migraine with aura may also have attacks of migraine without aura. According to the International Classification of Headache Disorders, it 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. Headache with the features of "migraine without aura" usually follows the aura symptoms. Less commonly, the aura may occur without a subsequent headache or the headache may be non-migrainous in type.In order to diagnose migraine with aura, there must have been at least two attacks not attributable to another cause that fulfill the following criteria

1. Aura consisting of at least one of the following, but no muscle weakness or paralysis

• Fully reversible visual symptoms (e.g. flickering lights, spots, lines, loss of vision)
• Fully reversible sensory symptoms (e.g. pins and needles, numbness)
• Fully reversible dysphasia (speech disturbance)

2. Aura has at least two of the following characteristics

• Visual symptoms affecting just one side of the field of vision and/or sensory symptoms affecting just one side of the body
• At least one aura symptom develops gradually over more than 5 minutes and/or different aura symptoms occur one after the other over more than 5 minutes
• Each symptom lasts from 5-60 minutes

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.

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 symptoms that result from brainstem dysfunction. 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 brainstem function.

Familial Hemiplegic Migraine

See also the main article on Familial hemiplegic migraine

Familial hemiplegic migraine 'FHM' is a type of migraine with a possible polygenetic component. These migraine attacks may last 4-72 hours 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. A non-familial form exists as well, "sporadic hemiplegic migraine" (SHM). It is often difficult to make the diagnosis between basilar-type migraine and hemiplegic migraine. When making the differential diagnosis is difficult, the deciding symptom is often the motor weakness or unilateral paralysis which can occur in FHM or SHM. While basilar-type migraine can present with tingling or numbness, true motor weakness and/or paralysis occur only in hemiplegic migraine.

Abdominal Migraine

According to the International Classification of Headache Disorders 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

• Loss of appetite
• Nausea
• Vomiting
• Pallor - Most children with abdominal migraine will develop migraine headache later in life and the two may co-exist during adolescence.

Acephalgic Migraine

Acephalgic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience aura symptoms such as scintillating scotoma, nausea, photophobia, hemiparesis and other migraine symptoms but does not experience headache. Acephalgic migraine is also referred to as amigrainous migraine, ocular migraine, or optical migraine. Sufferers of acephalgic migraine are more likely than the general population to develop classical migraine with headache. The prevention and treatment of acephalgic migraine is broadly the same as for classical migraine. However, because of the absence of "headache", diagnosis of acephalgic migraine is apt to be significantly delayed and the risk of misdiagnosis significantly increased.Visual snow might be a form of acephalgic migraine.If symptoms are primarily visual, it may be necessary to consult an ophthalmologist to rule out potential eye disease before considering this diagnosis.