Evaluate headache characteristics to classify as migraine

LAS VEGAS — Certain red flags can indicate that a patient’s headaches are the migraine type, Merle Diamond, MD, said at PAINWeek 2022.

A primary headache is idiopathic, “with no identifiable underlying pathology and no single diagnostic test,” Diamond, managing director and president of Diamond Headache Clinic in Chicago, said. “It is defined by clinical symptomatology and based on ruling out pathology.

“We actually have to talk to the patient,” she said. “Typically, most of our patients will have had some type of scan to rule out other pathology.”

Secondary headache is usually related to an increase in intracranial pressure, Diamond said. In this case the pathology must be defined with diagnostic tests.

Red flags include a headache that is the first or “worst;” an abrupt onset; new headache patterns after the age of 50 years or in those younger than 5 years; headache in conjunction with cancer, HIV, pregnancy or an abnormal physical exam; with neurological symptoms of more than an hour’s duration; and an onset with seizure, syncope, exertion, sex or Valsalva.

Migraines can also be triggered by hormonal cycle, specific foods, specific sensory input, light, odors and weather changes, Diamond added.

Migraine, tension-type, cluster and other trigeminal autonomic cephalgias are considered primary headaches. Traumatic, vascular, infectious, metabolic and oncologic are secondary, she said.

“If it doesn’t smell right or look right, go back and ask questions,” Diamond said. “Typically, if it’s a brain tumor, headache will not be the most common presentation — it will be a seizure.

“Progression of symptoms is a big deal,” she said. “Papilledema is a big deal. It’s important to look for this — also if position changes cause headache or it is precipitated by Valsalva.”

She noted that patients with headache typically first go to see an optometrist or ophthalmologist, thinking they are having trouble with their eyes.

Diamond said an MRI can indicate changes accompanied with migraine. In the ED, CTs with and without contrast and angiography and MRIs with and without contrast can pick up different things.

About 44 million Americans of all ages are impacted by migraine, Diamond said, and almost 37% of these patients have at least four migraine days a month. In at least 50% of migraine attacks patients will require bed rest, and at least 40% of patients have significant impairment.

“People with migraine have a hypersensitive nervous system,” Diamond said. “It doesn’t tolerate change well. It doesn’t like it if you skip meals, if your sleep is disrupted; it can easily be triggered into headache, and what that looks like is a lower threshold for sensitivation and episodes. ‘Migraine brain’ doesn’t like rain or other environmental changes.”

Good self-care is important, she said, as with any chronic disorder.

“Over the past 5 years or so, the evolution of our treatment and diagnosis has changed,” Diamond said. “We now have very specific medicines to address very specific receptors and treatments for most headache disorders.”

Calcitonin gene-related peptide (CGRP) is everywhere in your body, she said, and it vasodilates and transmits the pain message to higher neurons. Blocking the transmission of CGRP, the nociceptive signal, will help prevent migraine.

“CGRP is released in a bucket and activates the trigeminal neurovascular system, which sends pain signals up to transmit the pain message,” she continued. “CGRP is a big molecule, and our newer medications are very specific for CGRP.”

Diamond also said that 60% of patients have prodromes.

“This is important, because if you can recognize migraine prodrome, and the medication works well enough, you can stop it in its tracks,” she said, adding that 20% of patients have auras, which usually resolve before the headache.

Rick factors for transformation to chronic headache include longer, harder headaches (6-10 migraine days per month); comorbidity; obesity; sleep disorders; lower access to care; head and neck trauma; stress; and medication overuse, Diamond said.

Patients with new daily, persistent headaches are not rare.

“Typically, it has a migraine flavor, and you should treat it as such,” she said.