DR. LIPTON: My name is Richard Lipton. I’m a neurologist and epidemiologist at the Albert Einstein College of Medicine. I also direct the Montefiore Headache Center. This is a medical roundtable on the epidemiology, assessment, and diagnosis of migraine.
Joining me is an outstanding faculty. Dr. Stephen Silberstein is a neurologist who directs the Jefferson Headache Center and is a Professor of Neurology at Thomas Jefferson University.
DR. KURTH: I am Tobias Kurth, Director of Research at INSERM, the French National Institute of Health and Medical Research. I am also affiliated with the University of Bordeaux, and I am Adjunct Associate Professor of Epidemiology at the Harvard School of Public Health.
DR. BUSE: I am Dawn Buse, an Associate Professor of Neurology at the Albert Einstein College of Medicine, Assistant Professor in the Clinical Health Psychology Doctoral Program at the Ferkauf Graduate School of Psychology of Yeshiva University, and Director of Behavioral Medicine at the Montefiore Headache Center in Bronx, NY.
DR. LIPTON: Today, we will be discussing issues in epidemiology, assessment, and diagnosis of migraine. Migraine and headache disorders, in general, are one of the most common reasons that people seek help for, in primary care settings; therefore, this is a topic of great importance for primary care doctors. The first section of this talk will focus on the diagnosis of migraine. Dr. Silberstein, how do you approach diagnosing a patient with headaches?
DR. SILBERSTEIN: If a patient comes to a physician’s office complaining of recurrent moderate-to-severe headaches, his/her condition should be considered as migraine until proven otherwise. Clearly, there are certain features, but the criteria are that if the patient has a moderate headache associated with features such as one-sided, throbbing, headache aggravated by movement, nausea, vomiting, or sensitivity to light and sound, then it is clearly a migraine. The number of attacks can be used to differentiate migraine from a migraine mimic. In general, I consider it a migraine unless there’s a reason to think otherwise or unless you see so-called warning signs.
DR. LIPTON: Can you tell us about the situations where secondary headaches may be a problem?
DR. SILBERSTEIN: We, as a group, have developed something called the SNOOP. This is our mnemonic for worrisome headaches. First, the “S” refers to systemic symptoms such as fever or weight loss. The secondary risk factor is a new headache in a person with HIV or systemic cancer. The “N” stands for neurological symptoms or signs that cannot be explained by the aura of migraine such as confusion or alteration of consciousness. The “O” stands for a sudden onset. A sudden onset of headache should be taken as a serious neurological event until proven otherwise.
The second “O” stands for older. If there is a progressive onset of headache in an older patient, particularly a middle-aged one, one should always be concerned about a secondary headache. The “P” stands for previous headaches. Change in the attack frequency is a clinical feature that we worry about. These conditions indicate that an underlying condition may possibly be serious.
DR. LIPTON: Can you tell us about some signs that might reassure you that there is no serious cause of headache?
DR. SILBERSTEIN: The more the current headache is similar to a prior headache, the more likely that it is not serious. If a headache predictably occurs around menstruation or ovulation, it’s a sign that it is not serious. Other additional features of migraine that make us think it’s a benign headache disorder and not something else, include hunger or anger; alcohol consumption; insufficient sleep; family history of headaches; or so-called childhood precursors of migraine, particularly motion sickness or vertigo.
DR. LIPTON: Dr. Kurth, do you believe that everyone who presents with headache needs a neuroimaging procedure to exclude brain tumors or other secondary disorders?
DR. KURTH: The quick answer is no, but of course, it’s more complex as you go into the details—there are several aspects that need to be considered. Most importantly, not everybody in the population with a migraine needs neuroimaging, but that depends on detailed clinical symptoms, i.e., whether there’s any indication that the migraine is caused by another illness or there’s a clear change in the aura symptoms or recurrence of migraine with atypical features. We often see migraine reoccurring in the elderly and are suspicious of an underlying disease such as a vascular condition or maybe a tumor, in very rare cases, that can trigger migraine reoccurrence. In such cases, we should perform neuroimaging to rule out underlying diseases. However, if we’re talking about a patient with a typical migraine, typical aura, or typical age for a patient with migraine, neuroimaging studies are certainly not indicated.
There is an increasing number of studies showing that certain lesions in the brain, such as hyperintensities in the white matter, are more common in patients with migraine, but it remains unclear what these lesions mean for patients and what their consequences are. Therefore, there’s no need to perform an imaging study to potentially identify these brain lesions in patients with migraine.
DR. LIPTON: Dr. Silberstein, do you agree?
DR. SILBERSTEIN: I do.
DR. LIPTON: Dr. Silberstein, how do you diagnose migraine and its most important subsets?
DR. SILBERSTEIN: Migraine is more than a headache. When talking about migraine, we need to consider other aspects like the premonitory features, the aura, and the headache itself. These aspects really help us with subtypes. For migraine headache, there are criteria for making a diagnosis.
To make the diagnosis of migraine without aura, 5 attacks have to have occurred and need to be associated with 2 of the following 4 features: one-sidedness, pulsating or throbbing, aggravation of the headache due to movement, or moderate-to-severe intensity.
To summarize, if you have a one-sided pulsating headache with nausea, that’s a migraine. Since the ICHD-II criteria1 require that the headache is not attributed to another disorder, we look at the absence of red flags to diagnose migraine. If a red flag is present, we need to investigate the patient’s headache further. That is the headache of migraine without aura.
There is another variety of migraine called migraine with aura. The aura refers to focal neurological symptoms that precede or accompany the headache of migraine. The most common aura is visual (flashing lights or loss of vision). Some people can have problems with pins and needles or mild weakness. To make the diagnosis, a patient has to have unilateral symptoms that are often both positive and negative. What I mean by that is that there are both flashing lights and loss of vision. They usually develop over 5 min, and they usually continue for 5 to 60 min. That helps differentiate the aura of migraine from a focal seizure or a transient ischemic attack. If the aura is followed by a headache, then it is classified as a migraine aura with headache. The migraine aura can occur alone, particularly in the elderly.
The second type of distinction is between episodic and chronic migraine. When a person with migraine has multiple attacks with headaches for 14 or fewer total days per month, we call it episodic migraine. When a person with migraine has a headache for 15 or more days a month, we call it chronic migraine.1
The difference between episodic and chronic migraine is the frequency of the attack. Migraine with or without aura is based on the presence of the aura of migraine.
DR. LIPTON: Dr. Silberstein, what tools do you use in practice to support your diagnosis?
DR. SILBERSTEIN: When you see a patient for the first time, the more information you have, the better it is for diagnosis. If a patient, for example, brought in a diary or calendar delineating their attacks or information from another physician where they filled out a questionnaire or even a specific migraine information questionnaire, you are more equipped to, first, support the diagnosis, and second, identify the triggers and find out what medications they may or may not have tried in the past. We can figure out what will work and what won’t work with them.
DR. LIPTON: Let’s move on to a discussion of assessment. Dr. Buse, having diagnosed migraine, what are the most important features to assess before formulating a treatment plan?
DR. BUSE: It is vital to consider the impact of headache on all aspects of a patient’s life, including occupational or academic functioning and family, social, and personal arenas. These areas can be assessed by simply asking the patient, “How are your headaches affecting your life?” In addition, clinically validated instruments are available to assess headache-related disability, headache impact, and quality of life. It’s also useful to assess medical and psychiatric comorbidities. Migraine is comorbid with many medical and psychiatric conditions, including depression and anxiety. In some cases, migraine may be more severe, chronic, and treatment-refractory when associated with certain conditions. Inquire specifically about both pharmacologic treatments, which may be acute or preventive, and nonpharmacologic treatments, including behavioral/psychological; physical; lifestyle, such as asking about sleep habits and problems, exercise, and activity; and other nonpharmacologic therapies. In addition, asking the patient specifically about nutraceuticals, vitamins, and herbs is vital because if healthcare providers (HCPs) do not ask these questions, patients may not voluntarily offer this information.
DR. LIPTON: Dr. Buse, why is it important for primary care clinicians to assess disability and life impact? Are there tools that you might recommend for this?