Migraine treatment update guides clinicians through diagnosis

October 4, 2007

A migraine headache, while one of the more common conditions that physicians encounter in patients, remains one that they usually miss. One in four U.S. households in America has an individual who has migraines, said David Bazzo, MD, clinician at the University of California, San Diego, who is also part of a faculty headache practice. Migraines are as common as diabetes and asthma combined, yet physicians miss the opportunity to diagnose nearly one-half of the migraine patients they see.

A migraine headache, while one of the more common conditions that physicians encounter inpatients, remains one that they usually miss. One in four U.S. households in America has anindividual who has migraines, said David Bazzo, MD, clinician at the University of California, SanDiego, who is also part of a faculty headache practice. Migraines are as common as diabetes andasthma combined, yet physicians miss the opportunity to diagnose nearly one-half of the migrainepatients they see.

"Fully 52% of patients who meet the diagnostic criteria for migraine are never diagnosed," hesaid during the American Academy of Family Practitioners 2007 Scientific Assembly on Thursday. "It isvery important to make that diagnosis because without (it), we are just trying things atrandom."

Headaches fall into one of two categories: primary and secondary, according to Dr Bazzoexplained. Secondary headaches are secondary to some underlying condition, such as a brain tumor ormeningitis. Only approximately 2% of headaches reportedly have serious underlying pathology; allother headaches are primary.

Primary headaches generally fall in one of three categories: migraines, tension headaches andcluster headaches. If migraines remain untreated, they frequently transform into tension or clusterheadaches. In the worst case, untreated migraines can become chronic daily headaches.

"If we can properly treat migraine, we can prevent some of these people from falling intoworse forms of headache," Dr Bazzo said.

The International Headache Society has established four major and two minor criteria for migraines.Major criteria include:

  • unilateral headache
  • moderate to severe on a four-point scale
  • a throbbing or pulsitile quality, and
  • routine activity limited by headache pain.

Minor criteria include:

  • nausea or vomiting and
  • phonophobia or photophobia.

In migraine without aura, which comprises approximately 70% of all migraines, diagnosis needs onlytwo major criteria and a single minor criterion.

Migraines with aura can be trickier, Dr Bazzo cautioned. Aura is a neurologic phenomenon that usuallyincludes visual distortions such as wavy lines or auras around objects. It can also includehyperacute sensitivity to smells and neurologic symptoms that mimic stroke or transient ischemicattack (TIA).

Stroke or TIA do not include headache pain, Dr Bazzo noted. In migraine with aura, the aura occursfirst and headache pain follows.

Physicians must also consider red flags, such as brain tumors or bleeds. A mnemonic, SNOOP, has beendeveloped to guide practitioners through evaluation for secondary headaches. It is asfollows:

  • Systemic signs or symptoms
  • Neurologic signs or symptoms
  • Onset sudden
  • Onset under five years old or over age 50 for an initial migraine
  • Pattern change in headache frequency or quality

"If someone meets the criteria for a primary headache, you do not need to image that person," DrBazzo said. "If you have one of those red flags that could indicate a secondary headache, you have toimage that person. To not image is malpractice."

If imaging is indicated, he added, MRI is the preferred technique.

Triptans are the treatment of choice for migraines, Dr Bazzo noted. All seven agents in the classhave similar 60% to 70% efficacy. Chief differences are in their duration of action.

Patients with rebound headaches may do better with a long-acting agent, he continued. Longer actingtriptans remain active long enough to counteract any rebound migraines that occur within 24 hours ofthe primary migraine. Patients who do not suffer from rebound headaches may do better with shorteracting agents.