Migraine is an episodic headache lasting 4 to 72 hours if untreated or unsuccessfully treated. There must be 2 of the following 4 features present: a unilateral (one-sided) headache, pounding/throbbing/pulsating quality, moderate-to-severe pain intensity, and worsening by routine physical activity. There must also be 1 of the following 2 features present: nausea and/or vomiting, or both photophobia (sensitivity to light) and phonophobia (sensitivity to sound).
Approximately 20% of patients with migraine have neurological symptoms (aura) associated with their migraine. Those migraines are called migraine with aura (classic migraine), in contrast to migraine without aura occurring in 80% of patients (common migraine). The aura should last between 5-60 minutes and the headache commonly follows the aura within 1 hour. The most common type is visual aura and includes flashing lights, shimmering lines with areas of lost vision (scintillating scotoma), curved “c” shapes, squiggly lines, zig-zag lines, kaleidoscope colors, prisms, shapes, or other visual phenomena. The second most common type is sensory aura and consists of pins and needles or numbness in one area of the body on only one side, especially the face and arm/hand. The third most common type is speech and/or language aura and consists of trouble getting words out, or slurred speech.
There are less common types of aura as well. One of the less common types of aura is motor aura. This consists of a migraine with at least 1 of the common auras discussed above, as well as fully reversible motor weakness on 1 side of the body that lasts less than 72 hours. This type of migraine is called hemiplegic migraine. Brainstem aura is another less common type of aura. It consists of a migraine with at least 1 of the common auras discussed above, and at least 2 features including slurred speech, vertigo, tinnitus (ringing in the ear), hypacusis (hearing difficulty), diplopia (double vision), ataxia (unsteady, imbalanced walking such as an intoxicated appearance), and decreased level of consciousness. This type of migraine is called migraine with brainstem aura. Retinal aura is another less common type and consists of any of the visual disturbances mentioned above occurring clearly in only one eye. However, this is often difficult to differentiate between typical migraine with aura, which usually affects both eyes to some extent.
Chronic migraine is defined by headaches on 15 or more days per month for 3 or more months, with 8 of those days having more migrainous features. Patients that have a prior or current history of headaches such as migraine or tension-type headaches tend to be much more susceptible to developing medication overuse headache (rebound headache). Medication overuse headache is one of the most common causes of chronic daily headache (more than 15 days of headache per month) in the form of chronic migraine or chronic tension-type headache. This factor must be eliminated if present, and the headaches will never improve until a weaning detoxification from the overused medications happens. It can take 2-3 months for significant improvement to occur following detoxification, depending on medicine used, duration of use, frequency of use, and quantity of use. Preventive (daily medicines used to lessen the frequency and/or severity of headaches) and abortive (“as-needed” at headache onset) pain medications are also generally less effective in the setting of medication overuse headache. The overused medications are often taken for the headaches. However, these medicines are also commonly being used for some other type of body pain such as back pain, but inadvertently convert an infrequent headache to a frequent or daily headache. This is almost a guarantee to happen if there is a history of migraine headaches.
As discussed above, overuse of certain medications will typically convert underlying episodic migraine to chronic migraine over time. Research has shown that medication overuse can transform episodic migraine (less than 15 days of headache per month) to chronic migraine (greater than 15 days of headache per month) if the following medications are used at the following frequencies:
- 10 or more days per month for at least 2-3 consecutive months of over the counter (OTC) pain medications (Tylenol, Excedrin, Acetaminophen, Aleve, Naproxen, Motrin, Advil, Ibuprofen, or other non-steroidal anti-inflammatories (NSAIDs))
- 10 or more days per month for at least 2-3 consecutive months of triptans (Sumatriptan, Rizatriptan, Zolmitriptan, Almotriptan, Frovatriptan, Naratriptan, Eletriptan)
- 8 or more days per month for at least 2-3 months of any narcotic, opioid, or opiate medication (Vicodin, Norco, Hydrocodone, Oxycodone, Oxycontin, Percocet, Tramadol, Ultram, Ultracet, Morphine, Codeine)
- 5 or more days per month for at least 2-3 months of any butalbital containing medication (Fioricet, Fiorinal, Esgic)
Migraine occurs in about 18% of all women and 6% of all men. There are about 38 million migraineurs in the US, which accounts for about 12% of the population. Migraine is the 6th leading cause of all global disability and accounts for 50% of all neurologic disability. Migraine costs more than $20 billion/year and is associated with 113 million lost workdays per year. So clearly, migraine has significant negative impacts on the lives of patients and on society.