Dr neil jaddou m. D board certified and professor of family medicine


Triggered factor: Specific Lifestyle Factors



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Triggered factor: Specific Lifestyle Factors

Lifestyle triggers can vary from person to person. Some reported triggers include


  • Caffeine withdrawal

  • Changes in hormone levels during a woman's menstrual cycle or with the use of birth control pills

  • Changes in sleep patterns

  • Drinking alcohol

  • Exercise or other physical stress

  • Loud noises or bright lights

  • Missed meals

  • Odors or perfumes

  • Smoking or exposure to smoke

  • Stress and anxiety

Migraines can also be triggered by certain foods. Most common are:

  • Baked goods

  • Chocolate

  • Dairy foods

  • Foods with monosodium glutamate (MSG)

  • Foods with tyramine, which includes red wine, aged cheese, smoked fish, chicken livers, figs, and certain beans

  • Fruits (avocado, banana, citrus fruit)

  • Meats containing nitrates (bacon, hot dogs, salami, cured meats)

  • Onions

  • Processed, fermented, pickled, or marinated foods

Phases of Migraine. Migraine is divided into four phases, all of which may be present during the attack:

  • Premonitory symptoms occur up to 24 hours prior to developing a migraine. These include food cravings, unexplained mood changes (depression or euphoria), uncontrollable yawning, fluid retention, or increased urination.

  • Aura. Some people will see flashing or bright lights or what looks like heat waves immediately prior to or during the migraine, while others may experience muscle weakness or the sensation of being touched or grabbed.

  • Headache. A migraine usually starts gradually and builds in intensity. It is possible to have migraine without a headache.

  • Postdrome (following the headache). Individuals are often exhausted or confused following a migraine. The postdrome period may last up to a day before people feel healthy.



Migraine Headaches Are Classified?

Classification Of Migraine Headache According to The International Headache Society (IHS).

International Headache Society

International Classification Headache Disorders –II

Code Types of Migraine Headache

1.1 Migraine without Aura

1.2 Migraine with Aura

1.2.1 Typical Aura with Migraine Headache

1.2.2 Typical Aura with non-migraine headache

1.2.3 Typical aura without headache

1.2.4. Familial Hemiplegic Migraine

1.2.5 Sporadic Hemiplegic Migraine

1.2.6. Basilar-type Migraine

1.3 Childhood periodic Syndromes that are commonly precursors of migraine

1.3.1 Cyclical Vomiting

1.3.2 Abdominal Migraine

1.3.3 Benign Paroxysmal Vertigo of Childhood

1.4 Retinal Migraine

1.5 Complications of Migraine

1.5.1 Chronic Migraine

1.5.2 Status Migrainosus

1.5.3 Persistent aura without infarction

1.5.4 Migrainous infarction

1.5.5 Migraine-triggered seizure

1.6 Probable Migraine

1.6.1 Probable Migraine without Aura

1.6.2 Probable Migraine with Aura

1.6.3 Probable Chronic Migraine



Diagnoses

  • It is based on the headache’s characteristics and associated symptoms. The International Headache Society (IHS) diagnostic criteria for headache disorders provide definitions for six subtypes of migraine


Table 1.1. Diagnostic Criteria For Migraine Without Aura (Common Migraine)



A. At least 5 attacks fulfilling criteria B-D

B. Headache attack last 4 to 72 hours (untreated or unsuccessfully treated)

C. Headache has at least two of the following Characteristics:

1. Unilateral location

2. Pulsating Quality

3. Moderate or severity intensity

4. Aggravation by routine physical activity (i.e. walking or climbing stairs)


D. During headache at least one of the following:

1. Nausea &/or Vomiting

2. Photophobia or phonophobia


E. Not attributed to another disorder.


Table 1.2. Diagnostic Criteria for Migraine With Aura (Classic Migraine)



A. At least 2 attacks fulfilling criteria B-D

B. Aura consisting of at least 1 of the following but no motor weakness:

1. Fully reversible visual symptoms including positive features (eg. Flickering lights or

Spots or lines) &/or negative features (ie vision loss)

2. Fully reversible sensory symptoms including positive features(ie pins and needles)

&/or negative features( ie numbness)

3. Fully reversible dyphasic speech disturbances



C. At least 2 of the following:

1. Homonymous visual symptoms &/or unilateral sensory symptoms

2. At least one aura symptom develops gradually over ≥ 5 minutes

3. Each symptoms lasts ≥ 5 minutes or ≤ 60 minutes



D. Headache fulfilling criteria B-D for migraine without aura begins during the aura or

follows aura within 60 minutes



E. Not attributed to another disorder




Table 1.2.1 & 1.2.2. of Migraine has same Diagnostic Criteria as in Table 1.2 (Migraine with Aura)

Table 1.2.3. Diagnostic Criteria for Typical Aura Without Headache



A. At least 2 attacks fulfilling criteria B-D

B. Aura consisting of at least 1 of the following, with or without speech but no motor weakness:

1. Fully reversible visual symptoms including positive features (eg. Flickering lights or

Spots or lines) &/or negative features (ie vision loss)

2. Fully reversible sensory symptoms including positive features(ie pins and needles)

&/or negative features( ie numbness)

3. Fully reversible dyphasic speech disturbances



C. At least 2 of the following:

1. Homonymous visual symptoms &/or unilateral sensory symptoms

2. At least one aura symptom develops gradually over ≥ 5 minutes

3. Each symptoms lasts ≥ 5 minutes or ≤ 60 minutes



D. Headache does not occur during aura nor follow aura within 60 minutes

E. Not attributed to another disorder

NOTE: Additional loss or blurring of central vision may occur.


Table 1.2.4. Diagnostic Criteria for Familial Hemiplegic Migraine (FHM)



A. Migraine with aura including motor weakness and at least first- or Second-degree

Relative has migraine aura including motor weakness



B. At least 2 attacks fulfilling criteria C and D

C. Aura consisting of fully reversible motor weakness and at least one of the following:

1. Fully reversible visual symptoms including positive features(eg flickering lights,

Spots or lines) &/or negative features(ie loss of vision)

2. Fully reversible sensory symptoms including positive features( eg pins & needles)

&/or negative symptoms( ie numbness)

3. Fully reversible dysphasic speech disturbances



D. At least two of the following :

1. At least one aura symptom develops gradually over ≥ 5 minutes and/or different

Aura symptoms occur in succession over ≥ 5 minutes

2. Each aura symptoms last ≥5 minutes and <24 hours

3. Headache fulfilling criteria B-D for Migraine without aura begins during aura or

Follows onset of aura within 60 minutes.



E. At least one first-or second-degree relative has had attacks fulfilling these criteria B-F.

F. Not attributed to another disorder


Table 1.2.5. Diagnostic Criteria For Sporadic Hemiplegic Migraine



A. Migraine with aura including motor weakness but NO first-or second-degree Relative

Has aura including motor weakness.



B-F. Same as in Table 1.2.4 Familial Hemiplegic Migraine (FHM).


Table 1.2.6. Diagnostic Criteria For Basilar Migraine



A. Migraine with aura symptoms clearly originating from the brainstem and/or from both

Hemispheres simultaneously affected, but no motor weakness



B. At least 2 attacks fulfilling criteria C-E

C. Aura consisting of at least two of the following fully reversible symptoms but no

Motor weakness



  • Dysarthria

  • Vertigo

  • Tinnitus

  • Hypacusia

  • Diplopia

  • Visual Symptoms simultaneously in both temporal & nasal fields of both eyes

  • Ataxia

  • Decrease level of consciousness

  • Simultaneously bilateral paresthesiasis

D. At least one of the following:

1. At least one aura symptom develops gradually over ≥ 5 minutes and/or different

Aura symptoms occur in succession over ≥ 5 minutes

2. Each aura symptoms lasts ≥ 5 minutes and ≥ 60 minutes



E. Headache fulfilling criteria B-E for Migraine without aura begins during the aura or

Follows aura within 60 minutes



F. Not attributes to another disorder


Table 1.3-1.3.1. Childhood periodic Syndromes that are commonly precursors of Migraine: Diagnostic Criteria for Cyclic Vomiting

A. Recurrent Episodic attacks, usually stereotypical in the individual patient, of intense

Vomiting and intense Nausea. Attacks associated w/ Pallor & lethargy. There is

Complete resolution of symptoms between attacks.


B. At least 5 attacks fulfilling criteria C and D

C. Episodic attacks, stereotypical in the individual patient, of intense Nausea and

Vomiting last from 1 hours to 5 days



D. Vomiting during attacks occurs at least 4 times/ hr for at least 1 hr.

E. Symptoms-free between attacks

F. Not attributes to another disorder.

NOTE: In particular, H/P examination do not show signs of Gastrointestinal Disease


Table 1.3.2. Diagnostic Criteria for Abdominal Migraine

A. An Idiopathic Recurrent disorder seen mainly in children and characterized by

Episodic midline abd pain manifesting in attacks lasting 1-72 hours with

Normality between episodes. The pain is of moderate to severe intensity and

asso. w/ Vasomotor symptoms, N & V.



B. At least 5 attacks fulfilling criteria C-E

C. Attacks of Abd pain lasting 1-72 hrs (untreated or unsuccessfully treated)

D. Abd Pain has all of the following characteristic:

  • Midline location, periumbilical or poorly localized

  • Dull or “just sore” quality

  • Moderate or severe intensity

E. During Abd pain at least 2 of the following:

  • Anorexia

  • Nausea

  • Vomiting

  • Pallor

F. Not attributed to another disorder

NOTE: In H&P, do not show any signs of GI or renal disease. Pain is severe enough to interfere with daily activities. The pallor is often accompanied by dark shadow under eyes. In few patients flushing is predominant vasomotor phenomenon. MOST children with Abd migraine will develop migraine headache later in life.


Table 1.3.3. Diagnostic Criteria for Benign Positional Vertigo of Childhood



A. Heterogeneous Disorder is characterized by recurrent brief episodic attack of vertigo

Occurring without warning and resolving spontaneously in otherwise healthy children



B. At least 5 attacks fulfilling criteria C

C. Multiple episodes of severe vertigo, occurring without warning & resolving

Spontaneously after minutes to hour



D. Normal Neurological examination, audiometric &vestibular functions between attacks

E. Normal Electroencephlogram

NOTE: Often asso w/ Nystagmus or vomiting, unilateral throbbing headache may occur in some attacks.



Table 1.4 Diagnostic Criteria For Retinal Migraine

A. Repeated attacks of monocular visual disturbance, including scintillations, scotomata,

Or blindness, associated with Migraine headache



B. At least 2 attacks fulfilling criteria C & D

C. Fully reversible monocular positive and/or negative visual phenomenon

(eg scintillations, scotomata or blindness) confirmed by examination during an attack

Or ( after proper instruction) by the patient’s drawing of a monocular field defect

during attack



D. Headache fulfilling criteria B-D for Migraine without aura begins during visual

Symptoms or follow them within 60 minutes



E. Normal Ophthalmological examination between attacks

F. Not attributed to another disorder


Table 1.5-1.5.1. Complications of Migraine: Diag Crit for Chronic Migraine

A. Migraine headache occurring on 15 or more days per month for more than 3 months

In the absence of medication overuse



B. Headache Fulfilling criteria C & D for Migraine without aura on ≥15 days /month for

>3 months



C. Not attributed to another disorder


Table 1.5.2. Diagnostic Criteria for Status Migrainosus

A. A debilitating migraine attack last for more than 72 hours

B. The present attack in a patient with Migraine without aura is typical of previous

Attacks except for its duration

C. Headache has both of the following features:

1. Unremitting for >72 hours

2. Severe intensity


D. Not attributed to another disorder


Table 1.5.3. Diagnostic Criteria for Persistent aura without infarction

A. Aura symptoms persist for more than 1 week without radiographic evidence of

infarction



B. The present attack in a patient with Migraine with aura is typical of previous attacks

Except that one or more aura symptoms persists for > 1 week



C. Not attribute to another disorder


Table 1.5.4. Diagnostic Criteria for Migrainous Infarction

A. One or more Migrainous aura symptoms associated with an Ischemic brain lesion in

Appropriate territory demonstrated by neuroimaging



B. The present attack in a patient with Migraine with aura is typical of previous attacks

Except that one or more aura symptoms persists for >60 minutes



C. Neuroimaging demonstrates ischemic infarction in a relevant area

D. Not attributed to another disorder


Table 1.5.5. Diagnostic Criteria for Migraine-triggered Seizure

A. A seizure triggered by a migraine aura

B. Migraine fulfilling criteria for Migraine with aura

C. A seizure fulfilling diagnostic criteria for one type of epileptic attack occurs during or

Within 1 hour after a migraine aura




Table 1.6-1.6.1-1.6.2 Probable Migraine: Diag Crit for Prob Mig Without Aura & With Aura

A. Definition: Attacks and/or headaches missing one of the features needed to fulfill all

Criteria for a disorder.



B. Attacks fulfilling all but one of criteria A-D for Migraine without aura

C. Not attributed to another disorder


Table 1.6.3 Diagnostic Criteria for Probable Chronic Migriane

A. Same as Table 1.5.1 Chronic Migraine








Treatments


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