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Moving on to our evaluation of headache Part 2:

Migraine can be divided into:

Migraine without aura

1. At least five attacks fulfilling criteria 2-4
2. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated)
3. Headache has at least two of the following four characteristics:
a. unilateral location
b. pulsating quality
c. moderate or severe pain intensity
d. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
4. During headache at least one of the following:
a. nausea and/or vomiting
b. photophobia and phonophobia
5. Not better accounted for by another ICHD-3 diagnosis.

Migraine with aura

Same as above plus:
1. fully reversible visual, sensory and/or speech/language symptoms
2. no motor, brainstem or retinal symptoms.

Migraine with brainstem aura

At least 2 of the following fully reversible brainstem symptoms:

dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia not attributable to sensory deficit, decreased level of consciousness (GCS ≤13), no motor or retinal symptoms.

Hemiplegic migraine

1. fully reversible motor weakness
2. fully reversible visual, sensory and/or speech/language symptoms.

Motor symptoms generally last less than 72 hours but, in some patients, motor weakness may persist for weeks.

Retinal migraine

1. fully reversible, monocular, positive and/or negative visual phenomena (eg, scintillations, scotomata or blindness) confirmed during an attack by either or both of the following:
a. clinical visual field examination
b. the patient’s drawing of a monocular field defect
2. at least two of the following:
a. spreading gradually over ≥5 minutes
b. symptoms last 5-60 minutes
c. accompanied, or followed within 60 minutes, by headache

A headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, although photophobia or phonophobia may be present. Can last from 30 minutes to 7 days

1. Infrequent: At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year)

2. Frequent: At least 10 episodes of headache occurring on 1-14 days/month on average for >3 months (≥12 and <180 days/year)

3. Chronic: Headache occurring on ≥15 days/month on average for >3 months (≥180 days/year)

TRIGEMINAL AUTONOMIC CEPHALALGIAS (TACs)

1. unilateral headache
2. usually, prominent cranial parasympathetic autonomic features, which are lateralized and ipsilateral to the headache.
a. conjunctival injection and/or lacrimation
b. nasal congestion and/or rhinorrhea
c. eyelid edema
d. forehead and facial sweating
e. miosis and/or ptosis

Cluster headache
1. attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination
2. lasting 15-180 minutes
3. occurring from once every other day to 8 times a day.
4. pain is associated with autonomic symptoms and/or with restlessness or agitation

Other lesser known TACs

Paroxysmal hemicrania and Hemicrania continua
1. unilateral headache 
2. autonomic features 
3. significant response to indomethacin
  
Short-lasting unilateral neuralgiform headache attacks
1. at least 20 attacks fulfilling criteria 2-4
2. moderate or severe unilateral head pain, with orbital, supraorbital, temporal and/or other trigeminal distribution, lasting for 1–600 seconds and occurring as single stabs, series of stabs or in a saw-tooth pattern
3. at least one of the following cranial autonomic symptoms or signs, ipsilateral to the pain:
a. conjunctival injection and/or lacrimation
b. nasal congestion and/or rhinorrhea
c. eyelid edema
d. forehead and facial sweating
e. forehead and facial flushing
f. sensation of fullness in the ear
g. miosis and/or ptosis
4. Occurring with a frequency of at least one a day
5. Not better accounted for by another ICHD-3 diagnosis.

Subtypes

SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing)

SUNA (short-lasting unilateral neuralgiform headache attacks with cranial Autonomic symptoms)

TREATMENT

Until next time, keep those synapses firing!