Diagnosing the Migraine Headache: Types, Symptoms, Signs, Typical Migraine, Atypical Migraine
About Migraine Headache
International Headache Society (IHS) broadly classified headache in 1988 into two groups, primary and secondary headache. Migraine headache is a primary type of headache. Migraine is severe intense throbbing pain with pulsating character mostly localized on one side of head. Patient may suffer with nausea and vomiting during the episode of headache. Patients are sensitive to light and sound. Pain may last for hours or days. Migraine headache may precede or accompany aura. Auras are sensory symptoms such as light flashing, blind spot or feeling of tingling and numbness. Aura may precede migraine and is considered as warning symptoms.
Migraine headache is second most common headache after tension headache. Twelve to twenty six percent of all people suffer with migraine headache at least once in their life. Most of the patients suffer with migraine headache for short period of time. Some continue with migraine headache on and often over several years. Several studies have indicated 6 to 15% of adult male suffer with migraine headache for one year or more and 15 to 30% of adult female similarly suffer with migraine headache for one year if not more. Twenty-five percentage of the female population suffer with migraine headache between age 35 and 45 years and ten percentage of male suffer with similar migraine headache between ages of 35 to 45 years. Migraine as a disease begins after puberty in most of the adult females. After menopause, only 10% of female suffer with migraine headache and similarly after 55 years of age only 10% male suffer with migraine.
Diagnosing Migraine Headache
Two or more of the following symptom combinations is required to diagnose a migraine headache. Migraine headache is chronic neurological disorder and patients suffer with episodic attack of headache. Majority of migraine patient experience symptoms of aura, but few do not suffer with any aura. Migraine headache predominantly affects young and middle aged adults. It is a heterogeneous disease. Patient may suffer with symptoms of aura with mild or no headache. Symptoms of aura with mild headache or absence of headache is classified as Atypical Migraine.
Symptoms and Signs of Migraine Headache are Divided in Following Three Types-
- Typical Migraine (unilateral headache) With Aura.
- Typical Migraine (unilateral headache) Without Aura.
- Atypical Migraine (absence or mild unilateral headache) With Aura.
A. Typical Migraine Headache With Aura
Migraine headache resulting in unilateral headache with aura is diagnosed when two or more attacks with following symptoms are observed.
Characteristics of Typical Migraine Headache Is As Follows-
- Unilateral Headache - Moderate to severe in intensity
- Reversible Aura – Abnormal visual, sensory and speech symptoms are observed before headache.
- Abnormal Visual Symptoms: Homonymous visual symptoms includes both or either eyes, each symptom lasts for 5 min to 30 mins.
- Flickering Lights- Spots and lines in front of eyes before migraine headache.
- Loss of Vision- Loss of vision before and during aura.
- Somatic Sensory Symptoms:
- Positive Features: Pins and needles sensation on and often.
- Negative Features: Numbness feeling lasting until migraine attack continues.
- Somatic Motor Symptoms- No muscle or motor weakness are observed. Muscle spasm is absent. Power, tone and co-ordination is normal.
B. Typical Migraine Headache Without Aura
Migraine headache without aura is diagnosed when two or more attacks with following symptoms are observed.
- Unilateral headache
- Throbbing or pulsating headache
- Intensity of headache is moderate or severe.
- Physical Activities- Physical activities like walking, exercise involving weights, walking up the stairs, jogging or working for long hours aggravates the headache.
- Associated Symptoms (Not Aura)-
- Nausea and vomiting
C. Atypical Migraine Headache with Aura
Unilateral headache may not be the predominent symptoms. Headache may be mild and patient may not complaint of headache. Atypical migraine headache with aura has six sub types. All these subtypes suffer with symptoms of aura but may or may not have typical migraine headache. Aura is predominant symptom and headache is of mild intensity. Headache follows aura, headache is not unilateral or pulsatile. Headache is not increased following exercise. Headache may be mild and discrete.
i) Classic Aura in the Absence of Headaches
- Often occurs in middle-aged men.
- Aura lasts for short period of time and disappears without headache.
- In few cases aura may be prolonged and need further investigations to rule out life threatening disease.
- Patient older than 40 years must be investigated further if aura is prolonged.
ii) Hereditary Atypical Familial Hemiplegic Migraines
- A rare form of migraine with aura.
- Familial hemiplegic migraine is an autosomal dominant disease. This is the first migraine syndrome to be linked to a specific genetic set of polymorphisms.
- Mild to moderate headache
- Mild to severe hemiparesis of short or long duration.
- Familial: At least one first-degree relative has identical attacks.
- History of Cerebellar ataxia in family members. 20% of familial hemiplegic migraine sufferers have another member of family with history of cerebellar ataxia.
- Patients with sporadic hemiplegic migraine have migraine with aura including motor weakness but do not have an affected first- or second-degree relative
iii) Basilar Atypical Migraine- is seen mostly in young adults.
- Two or more fully reversible aura.
- Basilar Symptoms: Dysarthria, Vertigo, Tinnitus, Decreased hearing, Double vision, Ataxia, Decreased Level of Consciousness.
- Bilateral visual symptoms in both the temporal and the nasal field of both eyes
- Simultaneous bilateral paresthesias.
- No motor weakness is present.
- Symptoms are bilateral.
- Posterior fossa involvement seen.
iv) Atypical Migraine in Children- Periodic, following symptoms are common signs of migraine in childhood.
- School Children: Affect 2–2.5% of school going children.
- Recurrent episodes of unexplained nausea and vomiting, 4 times per hour. No evidence of any gastrointestinal disease.
- Period : lasts a few hours
- Symptom free between attacks, abdominal migraine, BPPV in childhood
v) Probable Atypical Cluster Type of Migraines
- Cluster type of headache with aura
- Patient falls asleep during migraine
- Wakes up without headache
- Duration of the attack is until time of awakening.
- Activities and Behavior: Sensitive to light and noise.
- Both type cluster and migraine headache are sensitive to light and noise and thus in some cases cluster headache is misdiagnosed as migraine headache.