Wanda is a 27-year-old administrator who presents with a history of recurrent
headaches over the last few years. In the past she has self medicated her
headaches with ibuprofen but now has decided to see her physician for a
diagnosis and better treatment.
Tell me about your headaches Wanda
Well it typically starts at the back of my neck and then moves forward. It starts gradually and then
develops into such a severe throbbing pain that I am unable to work. I always feel nauseated with the
headaches and sometimes vomit. Usually I take some ibuprofen and go to bed and if I sleep for a few
hours I sometimes feel better when I wake up.
How long do the headaches last and how often do you get them?
The headaches can last up to 10 hours but as I said they often resolve if I go to sleep. I usually get
about 2 headaches a week but at times of stress it can be more. I first started getting these headaches
when I was in high school and I have noticed they are related to stress.
Have your headaches changed at all recently?
No I have had the same basic type of headache since they first started.
Have you any idea why you are getting more headaches than usual now?
I think it may be related to the increased stress I am having at work. Everything else at home is going
fine.
Does light or noise bother you when you have these headaches?
No.
Is your headache worsened by physical activity?
Oh yes I try and stay perfectly still when I get my headache otherwise it gets worse.
Do you have any warning signs that a headache is going to start?
I sometimes feel very hungry just before a headache starts and then I may eat something but it does
not prevent the headache.
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Does anyone else in your family have headaches?
Yes my mother and her sister both have headaches and their doctors have told them they have
migraines so I was wondering whether my headache was a migraine, although they both have problems
with their vision during their headaches and I do not.
Diagnosis
Wanda’s headache fulfils the criteria for migraine established by the international headache society
(IHS).1 Other common causes of headaches are tension type headache, cluster headache and sinus
headache.
IHS (International Headache Society) criteria for diagnosing migraines:
Over 5 attacks fulfilling 1-4
1. Attacks last 4-72 hours
2.
>2 of the following:
a. Unilateral
b. Pulsating
c. Moderate/severe intensity
d. Increases with physical activity
3.
>1 of the following during the headache
a. Nausea and/or vomiting
b. Photophobia and phonophobia
4.
Not attributable to any other disorder
A tension headache is usually bilateral and is described as a tight band like pain not as severe ( 3-6 out
of ten) as the pain of a migraine (usually >6 out of 10) and the pain does not worsen with physical
activity. In tension headache there is no associated nausea or vomiting although there may be one of
either phonophobia or photophobia.
Causes of primary headache:
1.
2.
3.
4.
Causes of secondary headache:
Tension type headache
Migraine
Cluster
Exertional
a. cough
b. exertion
1.
2.
3.
4.
5.
6.
Sinusitis
Meningitis
Fever
Brain tumor
Intracranial hemorrhage
Temporal arteritis
Cluster headaches are severe unilateral periorbital or temporal headaches associated with:
 conjunctival injection
 lacrimation
 miosis
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
ptosis nasal congestion
 rhinorrhea
 facial sweating
Sinus headache: To make this diagnosis there has to be the simultaneous onset of the headache with
the symptoms of sinus congestion. There is evidence that sinus headache is over diagnosed by
patients and physicians. In the summit study of 2,991 subjects with self-described or physician
diagnosed sinus headache, 80% actually had migraine by the IHS criteria. (Schrieber 2004).2
The diagnosis of migraine is made by a careful history to exclude secondary causes of headache. New
onset migraine in someone over 40 is unusual and raises the suspicion of a secondary headache with
an underlying cause.
Wanda has migraine without aura which is more common than migraine with aura (used to be called
classic migraine). She also has a prodrome with the migraine which she describes as a feeling of
hunger. Migraine often starts during the teenage years and then subsides by the age of 60 years.
Epidemiology
The American Migraine Studies conducted in 1989 and 1999 found that the
prevalence of migraine has remained unchanged in the last 10 years with a
prevalence in women of 18.2% and in men of 6.5%.3 This same study also found
that only 48% of people with migraine by the IHS criteria have had the diagnosis
of migraine made by a physician.4 Most patients with migraine manage their
headaches themselves with over the counter medications. 5 Migraine is more
common among lower socio-economic groups.
A migraine may have 4 phases
a.
b.
c.
d.
Prodrome: the patient may experience a specific sensation prior to the onset of their
headache for example hunger, a feeling of well-being, irritability or depression. 60% of
migraneurs experience a prodrome.
Aura: the headache may be preceded by an aura although some patients may just have the
aura with no headache. The aura may be fortification spectra, flashes of light, blind spots or
even hemianopsia. 10-15% of migraneurs experience an aura which should last less than 1
hour.
Headache
Postdrome: this comprises feelings of fatigue, weakness and poor concentration which
may last up to 24 hours.
Treatment of Migraine
Wanda has tried ibuprofen for her headache but it does not offer much relief. It would be appropriate to
try a migraine specific therapy such as a triptan and advise her to take it as soon as the headache
starts.
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Treatment Goals:
a.
Reduce severity and frequency of attacks.
b.
Improve quality of life
c.
Avoid acute headache medication escalation
d.
Educate patients in the management of migraine
I. NSAIDS, Tylenol or a combination containing caffeine are appropriate initial treatment choices for
mild to moderate migraine
II. Triptans or ergot alkaloids are appropriate initial treatment for a moderate to severe migraine
III. Patients who experience nausea or vomiting may also benefit from an anti-emetic such as
metoclopramide or prochlorperazine.
Use of Triptans
A meta-analysis of 53 clinical trials showed that all the oral triptans are effective and well tolerated.
10mg of rizatriptan, 80mg of eletriptan and 12.5mg of almotriptan provided the highest likelihood of
success.6
A systematic review of the triptans showed that the number needed to treat for pain relief at 2 hours
varies from 2 to 5.4.7
Studies show that the earlier on in the headache that triptans are given the better the pain free
response. (Headache 1198;38 173-183, Winner et al.8,9 Mayo clinic Proc. 2003;78:1214-1222.). For the
patient with a headache that has a rapid onset subcutaneous, nasal sprays or the newer rapidly
dissolving tablets may be more effective as they are absorbed more quickly.
Try the highest dose of the triptan before deciding it does not work. If one triptan does not work try
another.
There is some evidence that treating migraine during the prodrome may be more effective at
decreasing headache severity. (Lucianir et Al. Cephalgia 2000;20:122-26.10
The most common adverse event associated with triptans are fatigue, light headedness and nausea.
They are contraindicated in patients with coronary heart disease (CAD) or risk factors for CAD.
Drug
Treatment of Acute Migraine Attacks
Quality of Evidence
A
Triptans
Ergot Alkaloids
DHE nasal spray
DHE (IV/IM/SC)
Ergotamine caffeine
Non-opiate analgesics
Aspirin
Ibuprofen
Acetaminophen/aspirin/caffeine (Excedrin)
Naproxen
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A
B
B
A
A
A
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Tylenol
Ketoralac
Opiates
Butorphanol nasal spray
Barbituates
Butalbital/aspirin/caffeine (fiorinal)
Other
Isometheptene (Midrin)
*Adapted from Evidence based guidelines for migraine headache.11
B
B
A
C
B
Prevention Principles
Consider prevention when:
a. Headache interferes with patients daily routine
b. >2 attacks/week
c. Acute medications are ineffective, contraindicated or over used
d. Presence of complicated migraine, e.g., hemiplegic migraine
(Headache Consortium Guidelines.11)
Amitriptyline, propranolol and sodium valproate have the most evidence in the support of their use for
migraine prevention. The choice of prophylactic medication should take into account the patients comorbid conditions. For example beta-blockers or calcium channel blockers would be a good choice for
someone with hypertension. If one prophylactic agent does not work try two drugs together e.g. an
anticonvulsant and a calcium channel blocker. When the patient starts a prophylactic medication they
should keep a headache diary for approximately 3 months to document the progress of their
headaches.
Drugs
PREVENTIVE TREATMENT FOR MIGRAINE
Quality of Evidence
Antiepileptics
Sodium Valproate
Carbamazepine
Gabapentin
A
B
B
Antidepressants
Amitriptyline
Fluoxetine
Paroxetine
A
B
C
Beta-blockers
Propranolol
Atenolol
A
B
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Calcium Channel Blockers
Verapamil
Diltiazem
NSAIDS
Aspirin
Ibuprofen
Others
Feverfew
Vitamin B2
Magnesium
*Adapted from Evidence Based Guidelines To Improve Headache11
B
C
B
C
B
B
B
References
1. The International Classification of Headache Disorders. Second edition. Cephalgia. 2004; Vol 24. suppl 1.
2. Schrieber SP. Archives of Internal Medicine 2004. In publication.
3. Lipton RB, Stewart WF, Diamond S, Diamond ML. Reed M. Prevalence and burden of migraine in the United
States: data from the American Migraine Study II. Headache 2001; 41:646-57.
4. Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF. Migraine diagnosis and treatment: results from
the American Migraine Study II. Headache. 2001; 41(7): 638-45.
5. Lipton RB, Stewart WF, Scher AI. Epidemiology and economic impact of migraine. Current medical research
and opinion. 2001; 17 suppl 1:s4-12.
6. Ferrari MD, Roon KI, Lipton RB, Goadsby PJ. Oral triptans in acute migraine treatment: a meta-analysis of
53 trials. Lancet 2001; 358:1668-75.
7. Gawel MJ et al. A systematic review of the use of triptans in acute migraine. Canadian Journal of
Neurological Science 2001; 28:30-41.
8. Cady RK. The long-term tolerability and efficacy of oral zolmitriptan (ZOMIG, 31x90) in the acute treatment of
migraine. An international study. The Journal of Head and Face Pain. 1998; 38(3): 173-183,
9. Winner P et al. Painfree results with sumatriptan taken at the first sign of migraine: 2 randomized double
blind placebo controlled studies. Mayo clinic Proc. 2003; 78:1214-1222.).
10. Luciani R, Carter D, Mannix L, Hemphill M, Diamond M, Cady R. Prevention of migraine during prodrome
with naratriptan. Cephalgia 2000; 20:122-26.
11. Silberstein SD, Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based
review): Report of the Quality Standards subcommittee of the American Academy of Neurology. Neurology.
2000; 55(6): 754-762.
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