Migraine Case study Example Paper.
Patient Characteristics

Demographic Information: Patient is a 31 year old pregnant female. 
Medical diagnosis if applicable: Migraine with Aura
Co-morbidities: Allergies
Previous care or treatment: Patient has received physical therapy in the past for an injury sustained while running however, she has never received treatment for her present symptoms.  Migraine Case study Example Paper.

Examination
Subjective : Patient History and Systems Review (chief complaints, other relevant medical history, prior or current services related to the current episode, patient/family goals)
Self Report Outcome Measures
Physical Performance Measures
Objective : Physical Examination Tests and Measures
The examination should also include ICF Findings:
Body Functions and Structures
Impairments
Activity Limitations
Participation Restrictions
Environmental Factors
Subjective:
Patient is a 31 year old pregnant woman. Patient presents to physical therapy complaining of generalized mid-thoracic and upper cervical pain. Patient reports no recent falls or trauma. However, she is petite and four months pregnant and believes that the additional pregnancy weight is pulling her upper thoracic spine and shoulders are being into a rounded position. When questioned about her pain, the patient reports that by the third month of her pregnancy, she started to notice the achy, sore pain when she would be sitting at her desk at work. Migraine Case study Example Paper.The patient does not believe any activities make the pain worse, but sitting upright in her desk chair at home provides some relief. In addition, she is fearful of using ibuprofen because of the effects it may have on her unborn child, so she uses a heating pack at night to decrease her symptoms.
The patient was questioned further about the nature of her work and workspace. Currently, the patient is the marketing director of a large business. She works long, stressful hours at her desk. The patient describes how her chair does not accommodate her height well, so often she finds herself leaning forward a lot throughout the day in order to get close enough to the monitor and rest her feet on the ground. Recently, the patient has been increasingly stressed at work because she is behind schedule with multiple upcoming project deadlines. The therapist asks the patient if she has noticed any other changes lately that could be increasing the stress.
The patient reports that in the past few weeks, the patient reports that she has also started to experience severe throbbing headaches on the right side of her forehead and above the ear. Soon after the headache begins, she finds that she becomes very nauseous and occasionally gets dizzy. Migraine Case study Example Paper.When asked about the nature of the dizziness, the patient reports that it lasts only as long as the headache, and does not increase with changes in position. The patient believes that her pregnancy has been causing the nausea, but she is concerned with the headaches because they are often so strong and painful that she cannot get any work done. When questioned further, the patient goes on to describe how the sunlight from her large window and staring at her screen makes the headache much worse, and sometimes even causes some ringing in her ears. In addition, the patient believes the glare on her computer may be the cause of her headache because she starts to see bright spots on the screen prior to the onset of the headache. Migraine Case study Example Paper.Often, the pain is so extreme that she must leave work early to go home and rest. Normally, after sleeping an hour or two, the pain subsides. The patient is distressed because the prolonged back and neck pain, with the addition of the severe headaches have prevented her from fully participating in work and social activities.

Objective Measurements:
Vital Signs:
• Heart Rate: 84
• Blood Pressure: 124/ 82
• Respiratory Rate: 13
Migraine Case study Example Paper.
Outcomes:
• Neck Disability Index Score: 8 (moderate disability)
• Dizziness Handicap Index: 74
• Migraine Disability Assessment Questionaire: 11 (moderate disability)
Migraine Case study Example Paper.
Sensation: Intact
Reflexes: Intact

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AROM:
• Cervical Flexion: WNL
• Cervical Extension: WNL
• Cervical R/ L Rotation: WNL
• Cervical R/ L Sidebend: WNL
• Shoulder Flex/ ABD/ ER/ IR: WNL
• Thoracic/ Lumbar Forward Flexion: WFL (limited by stomach)
• Thoracic/ Lumbar Extension: 18 degrees, some discomfort reported.
• Thoracic/ Lumbar Rotation: Right : 75 Left: 70
MMT:
• Cervical Flexion/ Extension: 5/5
• Cervical ROT: 5/5
• Shoulder Flexion: 5/5
• Shoulder IR/ER: 4+/5
• Shoulder ABD: 4+/5
• Scapular Retractors: 4/5
• Elbow Flexion/ Extension: 5/5
Palpation:
Reproduction of reported tenderness with palpation along spinous processes of T1-T6 and superior medial border of bilateral scapulae.
Tenderness of pectoralis minor reported noticeable bilateral shoulder protraction secondary to tight musculature. Migraine Case study Example Paper.
Balance and Vestibular Assessments:
Single Limb Stance Eyes Open: 44 seconds
Single Limb Stance Eyes Closed: 12 seconds, trunk deviation to the left.
VOR x 1: Negative
VOR x 2: Negative. Migraine Case study Example Paper.
Dicks Hallpike: R/L Negative
Saccades: Negative
Smooth Pursuit: Negative
Nystagmus: Minimal nystagmus present at end range.
Visual Field Cut: Negative
Clinical Hypothesis
Based on the patient’s report of symptoms, I would want to determine several things. I would want to determine which symptoms and pains were of musculoskeletal origin and whether they were related in cause. Especially since she is pregnant, I would want to be very aware of potential yellow and red flags. Since her thoracic/scapular pain can be relieved by position, I would begin leaning towards a musculoskeletal origin. A potential cause of this pain area may be connected with her posturing at work combined with the physical stress of pregnancy.Migraine Case study Example Paper. I would also want to further investigate her complaints of dizziness. Due to the lack of positional changes causing changes in the patient’s symptoms, I am leaning towards headache related vertigo rather than BPPV. A Dix Hallpike test could hep further confirm this inclination. Migraine Case study Example Paper.
Regarding her headaches, I would use pain type, relieving factors, triggers, type of onset, duration of symptoms, associated symptoms, and effect of sleep to help with differentiating between cerviogenic, tension, migraine, and cluster headaches. My primary clinical impression would be a migraine due to the accompanying symptoms of nausea and photophobia. A migraine is characterized by a unilateral pulsatile pain accompanied by nausea and sensitivity to light and sound.[1] The pain can last between 4-72 hours and is lessened after sleeping. Sometimes, an aura accompanies a migraine which involves fully reversible visual, sensory, or dysphasic speech disturbances.[1] The spots described by the patient preceding the headaches could be attributed to an aura associated with a migraine.
A cervicogenic headache is typically non-throbbing and accompanies limitations in cervical ROM which were not experienced by the patient.[2] Migraine Case study Example Paper.
To assist in ruling out cervicogenic headache, the therapist can apply pressure to the upper cervical or occipital region and cause symptom exacerbation. It is difficult to distinguish between a cervicogenic headache and a migraine and the two can occur simultaneously. Women are more likely to experience this type of headache, especially with concurrent findings of poor posture.[2]The average age of onset is 42 years[2] which is older than our patient but used alone would not be enough to rule out this diagnosis. Both cervicogenic and migraine headaches are typically unilateral.[2]
Cluster headaches would be a much less likely diagnosis consideration based on the lack of typical associated autonomic symptoms, and the report of sleep lessening the pain. Cluster headaches are also typically males between the ages of 20-40.[3] The pain is typically sharp, pulsating, or pressure.[1] Pain is commonly unilateral temporal or periorbital pain that lasts from 15 minutes to 3 hours and typically occurs with other autonomic symptoms. Repeated occurrences of cluster headaches can occur in the same day.[1]Common associated symptoms include ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinnorrhea, eyelid edema, forehead and facial swelling, miosis, and ptosis. It occurs suddenly and often reappears at similar times each day.[3] A cluster headache will improve with activity while a migraine can worsen. A cluster headache could occur during sleep while a migraine typically is relieved or lessened with sleep. Cluster headaches are often associated with comorbitities such as depression, sleep apnea, restless leg syndrome, and asthma.[1]
Although muscle tension is most likely present in this patient due to her posturing at work and otherwise, a tension headache is less likely to be the correct classification for this patient because a tension headache is typically described as bilateral mild to moderate pressure and does not have associated symtoms.[1] Migraine Case study Example Paper.
Factors to be aware of that may warrant immediate referral in patients complaining of headaches include:[1]
– a thunderclap headache with pain occurring suddenly and peaking within a few minutes
– history of HIV
– coexisting infection
– reports of experiencing the worst headache of their life in a patient >50 years old
– associated neurological findings
– an aura lasting greater than 60 minutes
– SBP >180 or DBP >120

Due to the patient being pregnant, referral for CT or MRI of the head without contrast is recommended by the American College of Radiology[1]

[4]
Intervention

Multidisciplinary approach

Neurologist
ENT
PT: May need to rule out more serious complications before initiating PT

Vestibular Exercises

VORx1 [5]
VORx2 [5]
Proprioception target exercises
(habituation exercises) [5]

[6]
Balance Exercises (Somatosensory System)

Stand on wobble board – frontal and sagittal planes
Head turns on wobble board – both planes
Head turns while walking
Head turns on bosu ball
SLS
Balance on foam EO, EC

Postural exercises [5],[7]

Y’s and T’s
Deep neck flexors

Manual Therapy

Mobilizations to cervical spine [8] Migraine Case study Example Paper.

Other

General stretching to postural muscles (i.e. Upper trap) [5]
Heat [9]
US [9]
TENS [9]
Soft tissue/trigger point massage [7],[9]
Balance and gait training with use of varying sensory inputs [5]
Posture education [5],[7]
Education on ergonomics at home and in the workplace [7]

[10]
Out of our scope

Relaxation therapy [5],[7],[8]
Biofeedback [7]
Cognitive-behavioral therapy (stress-management) [9]
Acupuncture [9]
Medications [7],[8] Migraine Case study Example Paper.

Outcomes
Since our patient presents 4 months pregnant our primary goal is to help her deal with the migraines without medical interventions. Current research support the use of physical therapy programs targeting vestibular rehab to improve migraine symptoms such as vertigo and dizziness[11][5][12].
Although research supports the use of vestibular physical therapy programs, there are discrepancies when it comes to conducting vestibular rehabilitation with or without the use of medication. Many studies have reported these improvements in symptoms come with the use of a combination of vestibular rehab and pharmacological therapy[12][5][11]. For instance, Johnson et al found subjective improvements in symptoms in 92% of patients who received this treatment combination. He also found 85% of patients reported a decrease in aural fullness symptoms, 63% reported a decrease in ear pain and 89% reported a decrease in phonophobia. Other studies have found that the use of prophylactic medication to treat the migraine did not affect the outcomes of vestibular physical therapy[13]. More research is needed to determine the role of these medications as well as the scheduling of medication use around physical therapy. Migraine Case study Example Paper.
In most cases, the exact prognosis of patients with migraines and dizziness will depend on the exact cause of the migraine, use of medication and other comorbidities that may impact treatment results.
Discussion
One-half of the adult population worldwide is affected by a headache disorder.[1] Migraines and Cluster headaches fall under this umbrella, with migraines having a much higher prevalence. As physical therapists, we will experience patients who are affected by multiple comorbidities that will influence their plan of care. We may not focus our treatment solely on the headache, but we must consider the impact it can have on their treatment. We will want to address all impairments to the extent that we are qualified due to the overall affect they can have on our patient’s quality of life. A knowledge of the various headache disorder presentations will help determine which patient’s symptoms fall within our scope of practice. Migraine Case study Example Paper.We need to have an understanding of the various factors that can contribute to a patient’s head pain and to what extent we can impact these. As we treat other impairments, a patient’s headache and related symptoms could be impacted. Headaches can impact posture, balance, gait, and overall quality of life. A multidisciplinary approach is needed to ensure optimal patient care. Any medical professional involved in the patient’s care should be included in the treatment plan. We can do our part by addressing the musculoskeletal and neurological deficits that fall within our scope. Spinal manipulation, modalities, exercise therapy, thermal biofeedback, neuro feedback, lifestyle modifications, relaxation techniques, acupuncture, massage are all treatment options discussed in current literature.[14] As the profession evolves and research expands, newer techniques such as dry needling may provide promising opportunities to increase our impact for headaches and related disorders. Migraine Case study Example Paper.
References

↑ Jump up to:1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Hainer BL, Matheson EM. Approach to Acute Headache in Adults. Am Fam Physcian. 2013 May; 87(10): 682-687.
↑ Jump up to:2.0 2.1 2.2 2.3 Biondi DM. Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. J Am Osteopath Assoc. 2005 April; 105(4):S16-S22.
↑ Jump up to:3.0 3.1 Weaver-Agostoni J. Cluster Headache. Am Fam Physician. 2013 July; 88(2): 122-128. Migraine Case study Example Paper.
Jump up↑ Migraine stages Picture (My Brain Test website){internet image}.2014. Available from: http://www.mybraintest.org/chronic-migraine-headache-symptoms-causes/
↑ Jump up to:5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Whitney S, Wrisley D, Brown K, Furman J. Physical Therapy for Migraine-Related Vestibulopathy and Vestibular Dysfunction with History of Migraine. Laryngoscope. 2000 Sept; 110 (9): 1528-34
Jump up↑ VOR Exercises (Dizziness-and-balance.com) {internet image}. 2011. Available from: http://www.dizziness-and-balance.com/treatment/rehab.html
↑ Jump up to:7.0 7.1 7.2 7.3 7.4 7.5 7.6 Biondi D. Physical Treatments for Headache: A Structured Review. Headache.2005 Jun;45(6):738-46.
↑ Jump up to:8.0 8.1 8.2 Chaibi A, Tuchin PJ, Russell MB. Manual Therapies for Migraine: A Systematic Review. J Headache Pain. 2011 Apr;12(2):127-33.
↑ Jump up to:9.0 9.1 9.2 9.3 9.4 9.5 Vernon H, McDermaid C S, Hagino C. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. PubMed [10581824]. 2002 Feb [cited 2015 Mar]. Available from: http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?AccessionNumber=12000003174#.VQyOvEtgNuY.
Jump up↑ Types of Headaches Picture (House Call MD blog) {internet image}. 2011. Available from: http://www.myhousecallmd.com/headaches-why-wont-my-head-stop-pounding/
↑ Jump up to:11.0 11.1 Johnson GD. Medical Management of Migraine-Related Dizziness & Vertigo. Laryngoscope. 1998 Jan; 108 (1): 1-28
↑ Jump up to:12.0 12.1 Gottshall K, Moore R, Hoffer M. Vestibular Rehabilitation for Migraine-Associated Dizziness. International Tinnitus Journal. 2005; 11(1): 81-84
Jump up↑ Vitkovic J, Winoto A, Rance G et al. Vestibular Rehabilitation Outcomes in Patient with & without Vestibular Migraine. J Neurol. 2013: 260: 3039-3048
Jump up↑ Smitherman TA, Burch R, Sheikh H et al. The prevalence, impact, and treatment of migraine and severe headache in the United States: A review of statistics from National Surveillance Studies. Headache. 2013 Mar; 53(3): 427-36. Migraine Case study Example Paper.

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Dr. Michael Teixido, MD – Jefferson Medical College
Dr. John Carey, MD – Johns Hopkins Otolaryngology-Head & Neck Surgery
Updated May 14, 2014
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The following website compiles many of the references related to migraine
associated vertigo and has an active forum on the subject:
www.mvertigo.org
Vitamins and Dietary Supplements
Certain vitamins and food supplements may provide a benefit in terms of
headache prevention. Many unsubstantiated claims can be found on the internet
and at health food stores. The best evidence exists for the agents below
(published peer reviewed, randomized controlled trials, albeit small ones in some
cases). Side effects are typically mild. Migraine Case study Example Paper.
• B2/Riboflavin – up to 400mg / day
• Magnesium – up to 400mg 2x / day (diarrhea possible)
• Coenzyme Q10 – up to 100mg 3x / day (expensive)
Note: There are a few companies that package more than one of the above
vitamins / supplements into a single pill for convenience. One such product is
“Migravent”, info. available at http://www.migravent.com.; another is “MigreLief”,
info. available at http://www.migrelief.com.
• Melatonin – There is some weaker evidence that melatonin, a hormone
that helps regulate sleep, may help headaches if 3–6 mg is taken an hour
or so before bedtime. Significant side effects are rare. Probably most
useful in treating cluster headaches.
The following are used in Europe more commonly, but are less regulated or
reliable in the US:
• Butterburr (Petasites hybridus) extract, Petadolex brand (pyrrolizidine
alkaloid free), 50–75mg twice a day with food (expensive)
• Feverfew (Parthenium integrifolium) 50mg+ per day (inexpensive)
We do not specifically endorse any brand name item, nor do we have any
financial interest in any of these products.
Migraine Diet
(Thanks to Dr. Jason Rosenberg and the Johns Hopkins Headache Center for this compilation, which we have modified from our
experience.)
Food may play a significant role in the frequency of migraine. Although some migraine patients find that eating certain foods will
provoke symptoms every single time, the effect of diet may be less obvious. In general, the more “trigger” foods you consume, the
more symptoms you may have. The hope is that by avoiding these possible triggers, the better off you will be. Eating regularly timed
meals, avoiding hunger, avoiding dehydration, and avoiding skipping meals is probably more important than the specific foods you do
or do not eat. Try following this list as strictly as possible for at least two months. If it helps, you may gradually add back your
favorite foods one at a time, keeping track of your headaches as you do so. Migraine Case study Example Paper.
Category Foods to Avoid, Reduce, or Limit Foods that are OK
Caffeine No more than 2 servings / day. Do not vary the amount
or timing from day to day. Coffee, tea, colas, Mountain
Dew, Sunkist, certain medications (Anacin, Excedrin)
Decaffeinated coffee, herbal or green tea, caffeinefree sodas, fruit juice (see below)
Snacks /
Desserts
Chocolate, nuts (peanuts, especially), peanut butter,
seeds
Fruits listed below, sherbet, ice cream, cakes,
pudding, Jello, sugar, jam, jelly, honey, hard candy,
cookies made w/o chocolate or nuts
Alcohol Avoid all, especially: ales, Burgundy, chianti, malted
beers, red wine, sherry, vermouth. Note: some
medications contain alcohol (Nyquil)
Non-alcoholic beverages
Dairy Aged cheeses: Brie, blue, boursault, brick, Camembert,
cheddar, Emmenlalaer, gouda, mozzarella, Parmesan,
Provolone, Romano, Roquefort, stilton, Swiss, etc.
Buttermilk, chocolate milk, sour cream
Eggs and yogurt should be limited to 2-3 times per
week
Other cheeses: American, cottage, cream cheese,
farmer, ricotta, Velveeta.
Milk,
Egg substitute
Cereals &
Grains
Fresh breads and yeast products, fresh bagels, fresh
doughnuts, yeast extracts, brewer’s yeast, sourdough
(*freezing bread may inactivate yeast) Migraine Case study Example Paper.
Commercial breads (white, wheat, rye, multi-grain,
Italian), English Muffins, crackers, rye, toast, bagels,
potatoes, rice, spaghetti, noodles, hot or dried cereals,
oatmeal
Meats Aged, canned, cured, or processed meats (bologna,
pepperoni, salami, other pre-packaged deli meats),
pickled meats or fish, salted or dried meats or poultry,
hot dogs, sausages, jerky
Fresh / unprocessed meats, poultry, fish, lamb, pork,
veal, lamb, tuna
MSG
(monosodium
glutamate)
Avoid glutamate in all its multiple forms: MSG,
“natural flavoring,” “flavor enhancer,” etc.
Soy sauce, foods containing “hydrolyzed protein
products” or “autolyzed yeast”, canned soups, bouillon
cubes, Accent, meat tenderizers, seasoned salts.
Pickled, preserved or marinated foods
Salt and other spices, butter, margarine, cooking oil,
white vinegar, salad dressing (small amounts)
Sweeteners Aspartame (Equal, Nutrasweet) (somewhat
controversial)
Sucrose (sugar), high fructose corn syrup, sucralose
(Splenda), saccharin (Sweet ‘n Low) Migraine Case study Example Paper.
Vegetables Pole or broad beans, lima beans, Italian beans, lentils,
snow peas, fava beans, Navy beans, pinto beans, pea
pods, sauerkraut, garbanzo beans, onions, olives,
pickles
Asparagus, beets, broccoli, carrots, corn, lettuce,
pumpkins, spinach, squash, string beans, tomatoes–
all those not listed
Fruit Avocados, figs, papaya, passion fruit, raisins, red
plums. Limit bananas and citrus fruit & juice (orange,
lemon, lime, grapefruit, tangerines) to ½ cup per day
Apples, berries, peaches, pears, prunes, fruit cocktail
Mixed Dishes Beef stroganoff, cheese blintzes, frozen meals / TV
diners, lasagna, macaroni and cheese, pizza

Migraine is a common intermittently debilitating neurovascular disorder that affects younger adults, especially women.
The diagnosis is generally made based on clinical criteria, with neuroimaging
used in some cases to exclude secondary causes of headache. This article
reviews current understanding of the mechanisms underlying migraine and approaches to treating it.
Migraine is an extraordinarily  common, chronic, intermittently disabling, and usually inherited neurovascular disorder. Migraine Case study Example Paper.
Patients with this condition typically suffer severe headache accompanied by autonomic symptoms, and a minority experience transient neurological symptoms known as an aura. The incidence of migraine peaks between 15 years and 24
years of age,1 and the prevalence is highest among persons between the ages of 35
and 45 years.2 In the United States, the one-year prevalence rate of migraine is estimated to be 17.6% in women and 5.7% in men,2 and the cumulative lifetime incidence of migraine is 43% in women and 18% in men.1 Evidence suggests that migraine is under diagnosed. One study reported that one-fourth of patients whose
headaches met the criteria for migraine
were not diagnosed as having this condition;3 another found that approximately
half of patients with migraine were undiagnosed.4 Even when diagnosed, migraine is often under treated.
The frequency, duration, and intensity of migraine attacks can vary from
person to person and from episode to episode. The majority of migraine patients
experience periods of temporary disability
that affect their work and leisure activities
and, thus, their productivity and quality of life. Migraine Case study Example Paper.This article reviews recent developments in the understanding and treatment
of migraine.
Diagnosing Migraine
Evolving diagnostic criteria have facilitated the diagnosis and study of headache
in general and migraine in particular.5,6
Migraine is the most common severe primary headache. It has six subtypes, several
of which have subforms (Table 1).6 The  forms of migraine most frequently experienced are migraine without aura, typical aura with migraine headache, and typical aura without headache. In one population study, 64% of patients with migraine
had migraine without aura, 18% had migraine with aura, 13% had both types of
migraine, and 5% could not be subtyped. Migraine Case study Example Paper.
The International Classification of Headache Disorders, Second Edition
(ICHD-II) diagnostic criteria for common forms of migraine and typical aura are provided in Table 2.6 The ICHD-II criteria for migraine and other primary head-
aches uniformly include “not attributed to another disorder” and recommend that secondary headache disorders suggested by the patient’s history and/or physical and/or neurological examinations be excluded by “appropriate investigations.”
The presence of red, more so than yellow, flags increases the likelihood of a secondary cause of headache and should prompt further evaluation (Table 3).8
The probability that a patient has migraine increases with each of the following: asymmetry of pain; throbbing pain;
pain that is moderate to severe in intensity; pain that is accompanied by nau-
sea; associated sensitivity to light, sound,
and often smell; the presence of typical migraine aura symptoms; and a family
history of migraine (found in about two thirds of patients). Allodynia (a painful response to a stimulus that does not nor-
Migraine Update
Diagnosis and Treatment
By J. D. Bartleson, M.D., and F. Michael Cutrer, M.D.
Table 1
Subtypes and Subforms
of Migraine. Migraine Case study Example Paper.
Migraine without aura
Migraine with aura
• Typical aura with migraine
headache
• Typical aura with nonmigraine
headache
• Typical aura without headache
• Familial hemiplegic migraine
• Sporadic hemiplegic migraine
• Basilar-type migraine
Childhood periodic syndromes that
are commonly precursors of migraine
• Cyclical vomiting
• Abdominal migraine
• Benign paroxysmal vertigo of
childhood. Migraine Case study Example Paper.
Retinal migraine
Complications of migraine
• Chronic migraine
• Status migrainosus
• Persistent aura without infarction
• Migrainous infarction
• Migraine-triggered seizure
Probable migraine
• Probable migraine without aura
• Probable migraine with aura
• Probable chronic migraine
Source: Headache Classification Sub-
committee of the International Headache
Society. The International Classification of
Headache Disorders: 2nd edition. Available
at: www.ihs-classification.org/en/. Accessed
April 15, 2010. Migraine Case study Example Paper.
36 | Minnesota Medicine • May 2010

clinical & health affairs
mally produce pain such as light touch or
pressure) is also typical during a migraine
attack, and its severity tends to correlate
with migraine duration, attack frequency,
and disability.Migraine Case study Example Paper.9 Migraine headaches with-
out aura tend to be more frequent, more
severe, longer-lasting, more disabling, and
more likely to become chronic than migraine headaches with aura.
The following three-question screening developed by Lipton et al. can help in
diagnosing migraine:10
In the last three months, did you have
the following with your headaches:
1.You felt nauseated or sick to your
stomach? Migraine Case study Example Paper.
2. Light bothered you a lot more than
when you do not have headaches?
3. Your headaches limited your ability to
work, study, or do what you needed to
do for at least one day?
If a patient responds positively to two
out of the three questions, there is a 93%
chance that their headaches are migraine;
if all three responses are positive, they have
a 98% chance of having migraine head-
aches. In most patients, migraine can be
diagnosed based on clinical criteria. When
it cannot or when the patient’s presentation suggests the possibility of a secondary
cause of headache, the patient should be
referred to a neurologist or other headache
specialist. Neuroimaging is the best diagnostic tool for excluding most secondary headache disorders. CT imaging is preferred for ruling out acute hemorrhage,
fracture, or paranasal sinus disease, while
MRI is better if other conditions are suspected. These include infarction, brain
Table 2
Criteria for Diagnosing Migraine
Migraine without aura
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting four 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 severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity (eg, walking
or climbing stairs)
D. During headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not attributed to another disorder
Typical aura with migraine headache
A. At least two attacks fulfilling criteria B-D
B. Aura consisting of at least one of the following, but no motor weakness:
1. Fully reversible visual symptoms including positive features (eg, flickering
lights, spots, or lines) and/or negative features (ie, loss of vision)
2. Fully reversible sensory symptoms including positive features (ie, pins and
needles) and/or negative features (ie, numbness) Migraine Case study Example Paper.
3. Fully reversible dysphasic speech disturbance
C. At least two of the following:
1. Homonymous visual symptoms and/or unilateral sensory symptoms
2. At least one aura symptom developing gradually over ≥5 minutes and/or
different aura symptoms occurring in succession over ≥5 minutes
3. Each symptom lasting ≥5 and ≤60 minutes
D. Headache fulfilling criteria B-D for migraine without aura begins during the aura
or within 60 minutes
E. Not attributed to another disorder
Typical aura without headache is the same as typical aura with migraine headache,
except that criterion D is replaced by “Headache does not occur during aura nor fol-
low aura within 60 minutes.”
Source: Headache Classification Subcommittee of the International Headache Society. The International
Classification of Headache Disorders: 2nd edition. Available at: www.ihs-classification.org/en/.
Accessed April 15, 2010. Migraine Case study Example Paper.
Table 3
Headache Warning Signs
Red Flags
• Head or neck injury
• New onset or new type or worsen-
ing pattern of existing headache
• New level of pain (eg, worst ever)
• Abrupt or split-second onset
• Triggered by Valsalva maneuver or
cough
• Triggered by exertion
• Triggered by sexual activity (preor-
gasmic, orgasmic)
• Headache during pregnancy or
puerperium
• Age >50 years
• Neurological signs or symptoms
(seizures, confusion, impaired alert-
ness, weakness, papilledema, etc.)
• Systemic illness
Fever
Nuchal rigidity
Weight loss
Scalp artery tenderness
• Secondary risk factors
Cancer
Immunocompromised host (HIV,
on immunosuppressants, etc.)
Recent travel (domestic, foreign)
Yellow Flags
• Wakes patient from sleep at night
• New onset side-locked headaches
• Postural headaches
Source: De Luca GC, Bartleson JD. When and
how to investigate the patient with headache.
Semin Neurol. 2010;30(2):131-44. Migraine Case study Example Paper.
May 2010 • Minnesota Medicine | 37

clinical & health affairs |
tumors, brain infections, posterior fossa
abnormalities including Chiari malforma-
tion, low CSF pressure syndrome, pitu-
itary lesions, and craniocervical junction
abnormalities.8 Unfortunately, MRI often
shows too much. In a population-based
study of 2,000 individuals, MRI detected
brain infarcts in 7.2%, cerebral aneurysms
in 1.8%, and benign tumors in 1.6%.11
These incidental findings cause worry
and frequently result in additional tests
and sometimes treatment, none of which
helps the headache for which the diagnos-
tic study was obtained. Migraine Case study Example Paper.
Pathophysiology
Migraine can be viewed as an inherited
disorder with episodic symptoms that
arise in the brain. Sensory input from the
trigeminal nerve and the ninth and 10th
cranial nerves, humoral factors (eg, blood
glucose, ingested food substances, gonado-
trophic hormones), environmental factors
(eg, too much or too little sleep, stress and release from stress, strong smells, bright lights, and change in barometric pressure), and other factors can trigger attacks.
The brain events that initiate a migraine attack are not well understood.
Given the emerging evidence that migraine is based on complex, heterogeneous genetics, migraine attacks may be
initiated in several ways. All humans have a trigeminocervical pain system that governs the head and upper neck, serving as a
type of early warning system to protect the
brain and upper cervical spinal cord from
real or threatened injury. Any alteration
in the stability of pathways either directly
involved in or modulating the trigemino cervical pain system is a potential cause of
migraine. Some people may inherit a low activation threshold for migraine; others, a very high activation threshold. The more often destabilizing triggering factors in the environment either separately or in combination meet this threshold, the more often the pain system is activated.
This would explain why some people are headache prone and others are headache resistant.
Aura is thought to be caused by a
spreading wave of depolarization (cortical spreading depression). Migraine Case study Example Paper.Aura is associated with a localized reduction in blood flow followed by an increase in blood flow and characteristically affects the parietooccipital cortex.12 Experimental evidence
suggests that the cortical events underlying aura symptoms may be one of the
ways that headaches are initiated in migraine patients. It is likely that the genes that make a person susceptible to aura are distinct from the ones that confer susceptibility to migraine headaches.
We are just beginning to identify the genes underlying migraine. Three different abnormal genes have been discovered in separate kindreds who suffer from familial hemiplegic migraine, a relatively
rare and severe subform of migraine accompanied by motor weakness. The mutations relate to ion channel function and neuronal hyperexcitability.
There also have been reports of an
increased occurrence of patent foramen ovale (PFO) in patients with migraine with aura and possibly migraine with- out aura. There also have been anecdotal
reports that PFO closure results in a reduced frequency of migraine attacks.14 It is
postulated that microemboli or humoral factors pass through the PFO, bypass the lungs, and trigger a migraine.
Treatment
There are three broad approaches for treating patients with migraine: avoidance of
recognized triggers; prompt treatment of acute attacks; and preventive antimigraine therapy. These three approaches can and should be combined, if needed. Migraine Case study Example Paper.
n Avoiding Migraine Triggers
Many factors have been associated with the provocation of migraine attacks
(Table 4). Patients should be advised to analyze their headaches to see if they can identify anything that triggers them.
Keeping a headache diary or calendar can help in this regard. It may take up to 24 hours for a trigger to provoke a migraine attack.
Patients should, of course, avoid headache triggers if they can. However, this may not always be possible for three reasons: the majority of migraine attacks are not triggered, many known migraine triggers are unavoidable (eg, menstruation, a change in the weather, stress), and migraine triggers are often variable in their ability to cause an attack.
n Acute Treatment
For most patients, the mainstay of migraine therapy is prompt treatment of the acute attack with a medication that is effective for them. A number of drugs are available for treating patients who experience migraine attacks.
Triptans. The development of triptans during the last 20 years has been a remarkable achievement. Triptans offer benefits to patients with migraine that are similar in magnitude to the benefit  levodopa provides to patients with Parkinson’s disease. There are seven different triptans (Table 5). Migraine Case study Example Paper.All are 5-HT1B/1D receptor agonists. The potential mechanisms of action include cranial vasoconstriction and inhibition of peripheral and central trigeminal nerve transmission.15 All trip- tans are available in pill form. Only one can be administered by injection (sumatriptan), two are available as a nasal spray (sumatriptan and zolmitriptan), and two are available in an oral-dissolving tablet (rizatriptan and zolmitriptan).

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Triptans reverse nausea and pain while leaving the patient clear-headed; they also are nonaddictive. Triptans provide substantial headache relief in up to three-fourths of patients. Many patients who have menstrually associated migraine attacks can be successfully treated with a triptan. In general, almotriptan, eletriptan, and rizatriptan are probably the most effective triptans. Almotriptan, frovatriptan, and naratriptan have fewer side effects. Rizatriptan and zolmitriptan are associated with more nausea.16-18
Side effects of triptans include tingling, flushing, and sensations of warmth,
heaviness, pressure, or tightness in different parts of the body including the chest and neck. Triptans can constrict the coronary arteries and in rare instances may cause myocardial ischemia. They are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, cerebrovascular disease, peripheral vascular disease, or hemiplegic or basilar migraine.15,18 They are compatible with most  other medications. Migraine Case study Example Paper.However, patients who are using selective serotonin reuptake inhibitors (SSRIs) and selective no repinephrine re uptake inhibitors (SNRIs) should be cautioned to watch for symptoms of serotonin syndrome. If a patient does not respond to one triptan, he or she may respond to another. An adequate trial of triptan therapy should include trying at least two different triptans for two migraine attacks each.

Dihydroergotamine. Dihydroer-
gotamine (DHE) is an old drug that is
still useful for some patients with severe
migraine. One-half to 1 mg can be in-
jected subcutaneously, intramuscularly, or
intravenously, and the dose can be admin-
istered a total of three times in 24 hours.
DHE is also available as a nasal spray and
may soon be released in an orally inhaled
form. DHE is also a 5-HT1B/1D receptor ag-
onist and cannot be used within 24 hours
of taking a triptan. Migraine Case study Example Paper.It has the same contraindications as triptans, and it should
not be used by women who are pregnant or nursing. Ergotamine tartrate is also an ergot, but it is rarely used because it is associated with more side effects and is not
widely available.
Other Drugs. In addition to migraine-specific drugs such as triptans and
DHE, there are multiple single-ingredient and multi-ingredient, over-the-counter
and prescription analgesics that are helpful to individuals who experience milder
attacks and for whom migraine-specific drugs are unhelpful or contraindicated.
These include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen,
weak and strong opioid analgesics, and combinations of these drugs. Triptans also can be combined with another analgesic such as a NSAID. In this regard, there is a new formulation of sumatriptan called
Treximet, which contains 85 mg of sumatriptan and 500 mg of naproxen in each
tablet. Alternatively, the patient could be directed to take any triptan with an over- the-counter NSAID.
Considerations for Acute Treatment. Migraine Case study Example Paper.When treating an acute attack, it is
critical that patients take their medication as soon as the headache begins. Patients
almost universally report that if they can catch the headache early, they are much more likely to reduce its intensity and duration. Many also find that rest, especially
in a dark room, can be helpful in stopping an acute migraine attack. Unfortunately,
many patients with migraine wait in an
effort to avoid taking their medication
and/or with the hope that this time will be different. Medications may fail to work if the patient takes them too late, takes too low a dose, has expectations that are too high, or experiences early vomiting that prevents absorption. Also, patients may experience relief from their headache but still have nausea or bothersome medication side effects; or they may experience
headache recurrence.
Because acute treatment can fail, it
can be helpful for the patient to have a res-cue treatment to use when their standard
Table 4
Common Migraine Triggers
• Fasting
• Alcoholic beveraes
• Hormonal therapy
• Caffeine withdrawal
• Stress or release from stress
• Too much or too little sleep
• Menstruation
• Fatigue
• Exposure to bright lights, loud
noises, smoke, and strong scents
• Change in the weather
• Acute head injury
• Foodstuffs including:
Chocolate
Aged cheeses
Processed meats
Fermented foods. Migraine Case study Example Paper.
Aspartame
Monosodium glutamate
Citrus fruits
Nuts
Table 5
Currently Available Triptans
Triptan
Medication form
and strength (mg) (usual
optimum dose is in bold)
Recommended
dosage interval
(≥ hours)
Maximal
daily dosage
(mg/24 hours)
Almotriptan (Axert) Tablet, 6.25, 12.5 2 25
Eletriptan (Relpax) Tablet, 20, 40 2 80
Frovatriptan (Frova) Tablet, 2.5 2 7.5
Naratriptan
(Amerge) Migraine Case study Example Paper.
Tablet, 1, 2.5 4 5
Rizatriptan (Maxalt) Tablet, 5, 10 2 30
Oral disintegrating tablet,
5, 10
2 30
Sumatriptan
(Imitrex)
Tablet, 25, 50, 100 2 200
Nasal spray, 5, 20 2 40
Subcutaneous, 61 12
Sumatriptan 85 mg
+ naproxen 500 mg
(Treximet)
One fixed-dose tablet 2 2 tablets
Zolmitriptan
(Zomig)
Tablet, 2.5, 5 2 10
Oral disintegrating tablet,
2.5, 5
2 10
Nasal spray, 52 10
May 2010 • Minnesota Medicine | 39

clinical & health affairs |
treatments do not work. This might include an outpatient injection of an opioid
or ketorolac with an adjuvant or antinauseant. One of three treatment options may
be used to break up a protracted migraine
attack: intravenous DHE, intravenous valproate sodium (Depacon), or a short course of corticosteroids.
Although many patients experience
only occasional migraine attacks that are mild or easily treated, some patients develop frequent or even daily headaches. Migraine Case study Example Paper.
The ICHD-II recognizes chronic migraine as a specific diagnosis when patients
experience headaches at least 15 days per
month for at least three months, and more
than half of their headaches meet criteria
for migraine without aura.6,19 In some patients, progression of their migraine from
episodic to chronic is associated with
the frequent use of simple and multi-
ingredient analgesics or acute antimigraine drugs. Caffeine consumption can
cause the same phenomenon. The risk of medication overuse is higher with opioid analgesics and butalbital.20 Because of the risk of progression as a result of medication overuse, it is recommended that any
acute treatment not be used more than two days per week and that butalbital and opioid-containing analgesics not be used more than once a week.
Nausea and vomiting are frequent
migraine accompaniments and also can
occur as a side effect of the medications used to treat it. It may be helpful to treat patients who have nausea and vomiting with an antiemetic such as prochlorperazine, chlorpromazine, or promethazine
administered by mouth or rectum, or metoclopramide by mouth. Antiemetics
can be used in combination with analgesic and acute antimigraine medications. If
the patient has early vomiting with their migraine attacks, consider using an acute medication that can be administered by injection, nasal spray, or oral-dissolving tablet in order to bypass the stomach or reduce the chance of vomiting. Migraine Case study Example Paper.
n Preventive Treatment
If the frequency, duration, and severity
of the patient’s migraine attacks are bad
enough, consideration should be given to
preventive therapy in which medications
are given on a regular basis whether or not
the patient has a headache. Guidelines
for the use of preventive therapy include:
when a patient has more than four to six headache days per month; when symptomatic medications are contraindicated or ineffective; when acute medication is required more than twice a week; and for rare types of migraine including hemiplegic migraine, basilar migraine, migraine
with prolonged aura, and migraine associated with cerebral infarction. Preventive therapy also should be considered for
individuals whose migraine attacks could
affect their safety or livelihood (eg, a pilot or professional athlete).
In the case of women who experience
migraine attacks exclusively before or during menses, cyclic preventive treatment
with an anti-inflammatory drug, transcutaneous estrogen, or twice-daily frovatriptan or naratriptan can be given during the perimenstrual period.21 If a woman’s  migraine headaches are severe enough, she can be treated continuously with a preventive medication.
Evidenced-based guidelines for the use of acute and preventive anti-migraine therapy are available.22,23 The commonly used preventive antimigraine medications
are listed in Table 6. In general, a preventive agent is started at a low dose and
gradually increased over time until the patient sees benefit, experiences side effects,
or reaches the maximal dose. These medications take a minimum of three to four
weeks and can take as long as eight to 12 weeks to become effective. They are rarely 100% effective in preventing migraine attacks; a 50% reduction in headache burden is considered a good result and can often be achieved. In general, one preventive medication is used at a time, but combinations of two or more drugs can have added benefit. A combination of a tricyclic agent and a beta blocker or verapamil
has been suggested for refractory patients.
A preventive agent is chosen or avoided because of its potential benefit or adverse effect on the patient’s other medi-
Table 6
Commonly Used Preventive Antimigraine Medications
Drug Initial daily dose (mg)
Target daily
dose (mg) Common side effects
Amitriptyline and
Nortriptyline
10 or 25 25 to 150 Weight gain, dry mouth,
sedation, constipation
Propranolol 60 to 80 120 to 240 Depression, fatigue, hypotension, bradycardia
Atenolol 25 50 to 100 Depression, fatigue, hypotension, bradycardia
Verapamil 80 to 160 240 to 480 Edema, constipation,
hypotension
Gabapentin 300 900 to 2,700 Edema, sedation,
fatigue, dizziness
Topiramate 15 to 25 100 to 200 Paresthesias, mental
slowing, weight loss,
kidney stones
Divalproex sodium 250 to 500 750 to 1500 Alopecia, weight gain,
nausea, tremor
Botulinum toxin A
(Circumferential
scalp muscle injections repeated at
≥3-month intervals)
Not applicable Not applicable Excessive weakness in
facial or upper cervical muscle, ptosis
40 | Minnesota Medicine • May 2010 Migraine Case study Example Paper.