MIGRAINE CLASSIFICATION Nada Šternić WE CARE ¾At most, only 30% of migraineurs have classic aura ¾The same patient may have ¾ Introduction migraine headache without aura, ¾ Classification migraine headache with aura as ¾ Migraine well as migraine aura without ¾ Premonitory headache, If sufficient criteria but ¾ Aura one are present, the hedache is ¾ Headache called as probable migraine ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 1 ¾ General rule: To establish diagnosis of migraine under the IHS classification certain clinical ¾ Introduction features must be present and ¾ Classification organidiic disease must be exc lddluded ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾MIGRAINE CLASSIFICATION♦ ¾ Introduction ¾ Classification ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ♦ ¾ Cephalalgia. 2004;24:9-160. Variants The International Classification of Headache Disorders: 2nd edition ¾ Ddg Headache Classification Subcommittee of the International Headache Society WE CARE 2 ¾ I MIGRAINE 1. Migraine without aura 2. Migraine with aura ¾ Introduction • typical aura with migraine ¾ Classification headache ¾ Migraine • typical aura with nonmigraine headache ¾ Premonitory • typical aura without headache ¾ Aura • familial hemiplegic migraine ¾ Headache • sporadic hemiplegic migraine ¾ Postdrome • basilar‐type migraine ¾ Variants ¾ Ddg WE CARE ¾ I MIGRAINE 3. Childhood periodic syndromes that are commonly precursors of ¾ Introduction migraine ¾ Classification • cyclicvomiting ¾ • abdominal migraine Migraine • benign paroxysmal vertigo of ¾ Premonitory childhood ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 3 ¾ I MIGRAINE 4. Retinal migraine 5. Complications of migraine ¾ Introduction • chronic migraine ¾ Classification • status migrainosus ¾ Migraine • persistent aura without infarction ¾ Premonitory • migrainous infarction • migraine – triggered seizures ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ I MIGRAINE 6. Probable migraine • Probable migraine without aura ¾ Introduction • Probable migraine with aura ¾ Classification • Probable chronic migraine ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 4 ¾ A migraine attack usually lasts less than a day ¾ When it persists for more than 3 ¾ Introduction days the term status migrainosus is applied ¾ Classification ¾ Although migraine often begins in ¾ Migraine the morning, sometimes awakening ¾ Premonitory the patient from the sleep at dawn, it can begin at any time of the day ¾ Aura or night ¾ Headache ¾ The frequency of attacks is ¾ Postdrome extremely variable, but the median ¾ Variants frequency is 1.5 monthly ¾ Ddg WE CARE ¾ The diagnosis of migraine with aura (MA) requires at least two attacks with any two of three features: ¾ Introduction • one or more fully reversible aura ¾ Classification symptoms ¾ Migraine • the aura developing over more than 4 minutes, but lasting less ¾ Premonitory than 60 minutes ¾ Aura • the headache following the aura ¾ Headache wihith a fifree interva lflh60l of less than 60 ¾ Postdrome minutes ¾ Variants ¾ Migraine with aura is subdivided as according to the Table abowe ¾ Ddg WE CARE 5 ¾ Aura usually lasts 20 to 30 minutes and typically precedes the headache, but occasionally it occurs ¾ Introduction with headache or only during the ¾ Classification headache ¾ Migraine ¾ In contrast to a transient ischemic attack (TIA), the migraine aura ¾ Premonitory evolves gradually and typically is ¾ Aura consisted of both positive ¾ Headache (ll)d(scintillations…) and negative ¾ Postdrome (scotoma, numbness…) features ¾ Variants ¾ Ddg WE CARE ¾ Almost any symptom or sign of brain disfunction may be a feature of the migraine aura, but commonly ¾ Introduction the aura is visual ¾ Classification ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 6 ¾ If the aura lasts for more than one hour, but less than one week than that episode is called MA and an atypical feature ¾ Introduction ¾ If the signs persist for more than 2 ¾ Classification weeks, without the neuroimaging ¾ Migraine evidence of infarction, such an ¾ Premonitory episode is called persistent aura without infarction ¾ Aura ¾ But if neuroimaging procedure ¾ Headache demonstrates a stroke, it means ¾ Postdrome that a migrenous infarction has occurred ¾ Variants ¾ Ddg WE CARE 7 ¾ Particularly in mid or late life the migraine aura may not be followed by the headache ¾ Introduction ¾ Classification ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ Associated symptoms of migraine such as nausea, phonophobia or photophobia, may occur before ¾ Introduction headache, as part of premonitory ¾ Classification phase ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 8 ¾ CLINICAL FEATURES OF MIGRAINE ¾ The migraine attack can be divided into 4 phases: ¾ Introduction • premonitory (occurs hours or days ¾ Classification before the headache) ¾ Migraine • the aura which immediately precedes the headache ¾ Premonitory • the headache itself and ¾ Aura • the postdrome ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ Premonitory phenomena can consist of: • psychological symptoms ¾ Introduction • neurological symptoms ¾ Classification • general symptoms ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 9 ¾ Psychological • Depression or euphoria, irritability, restlessness, mental slowness, ¾ Introduction hyperactivity, fatigue, drowsiness ¾ Classification ¾ Neurolillogical ¾ Migraine • Phonophobia and photophobia, hyperosmia… ¾ Premonitory ¾ General symptoms ¾ Aura • Stiff neck,,g, cold feeling, increased ¾ Headache thirst, constipation, or diarrhea, ¾ Postdrome fluid retention, swelling… ¾ Variants ¾ Ddg WE CARE ¾ Two types of migraine premonitory are described: • nonevolutive (precedes the attack ¾ Introduction by up to 48 hours) ¾ Classification • evolutive (one which starts ¾ Migraine approximatdely 6 hours before the attack, gradually increases in ¾ Premonitory intensity and culmuinate in the ¾ Aura attack; a dopaminergic mechamism ¾ Headache has been suggested) ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 10 ¾ In migraine, the headache may begin before or simultaneously with the aura, or the aura may occur in ¾ Introduction isolation ¾ Classification ¾ Rarely auras may occur repeatedly ¾ Migraine ¾ This may be many times an hour for ¾ Premonitory as long as several months ¾ Aura ¾ These have been termed migraine aura status, but other organic ¾ Headache causes must be considered ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ Visual aura is the most common of the neurological events in migraine ¾ It occurs in up to 99% of patients ¾ Introduction who have an aura and often has a ¾ Classification hemianopic distribution ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 11 12 13 ¾ Visual (scotoma, geometric forms, fortifications…) ¾ Visual Hallucinations or Distorsions ¾ Introduction (metamorphopsia, macropsia, ¾ Classification mosaic vision…) ¾ Migraine ¾ Sensory (paresthesias often lasting ¾ Premonitory for minutes…) ¾ Aura ¾ Olfactory (hallucinations…) ¾ Headache ¾ Motor (weakness or ataxia) ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ Language (dysathria, aphasia…) ¾ Delusions and Disturbed Consciousness (déjà vu…) ¾ Introduction ¾ Periodic neurological phenomena ¾ Classification which may be the migraine aura ¾ Migraine can occur in isolation, without the ¾ Premonitory headache ¾ • Differential diagnosis: Aura ‐ TIA ¾ Headache ‐ focal seizures ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 14 ¾ Migraine headache is bilateral in 40% and unilateral in 60% of cases ¾ It consistently occurs on the same ¾ Introduction side in 20% of patients ¾ Classification ¾ The intensity of migraine pain ¾ Migraine varies greatly, ranging from ¾ Premonitory annoying to incapacitating, but majority of patients report at least ¾ Aura moderate pain ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ Associated phenomena: • nausea occurs in 90% of patients, and vomiting in one third of them ¾ Introduction (gastric emptying can be delayed ¾ and oral drug absorption impaired Classification during the attack) ¾ Migraine • neck pain is common in patients ¾ Premonitory with migraine, occurring in 60‐90% ¾ Aura of migraines studied ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 15 ¾ Following the headache the patient may have impaired concentration or feel tired, washed out or irritable ¾ Introduction ¾ Classification ¾ Migraine ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE ¾ Hemiplegic migraine • The HIS has divided hemiplegic migraine into sporadic and familial ¾ Introduction forms, both of which typically begin ¾ in childhood and cease with Classification adulthood ¾ Migraine • FHM I, FHM II, FHM III ¾ Premonitory ¾ Aura ¾ Headache ¾ Postdrome ¾ Variants ¾ Ddg WE CARE 16 ¾ Retinal (ocular) migraine ¾ Retinal migraine is a rare condition, most commonly in young adults, in ¾ Introduction which monocular scotoma or ¾ Classification blin dness accompanies migraine ¾ Migraine headache ¾ Premonitory ¾ Retinal migraine is most likely caused by spasm of the ophtalmic ¾ Aura artery ¾ Headache ¾ Spreading depression of retinal ¾ Postdrome neurons could explain some cases ¾ Variants ¾ Ddg WE CARE 17 ¾ Basilar migraine ¾ In this type of migraine variants the aura generally lasts less than one ¾ Introduction hour and headache may be ¾ Classification occipital ¾ Migraine ¾ A typical hemianopic field ¾ Premonitory disturbance can rapidly