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DISCUSSION

Migraine Definition
According to International Headache Society (IHS) Migraine is a common disabling
primary headache disorder. Typical characteristics of the headache are unilateral location,
pulsating quality, moderate or severe intensity, aggravation by routine physical activity and
association with nausea and/or photophobia and phonophobia.
Migraine Classification
Migraine have two major subtype :
1. Migraine with aura
Migraine without aura is a clinical syndrome characterized by headache with
specific features and associated symptoms.
2. Migraine without aura
Migraine with aura is primarily characterized by the transient focal
neurological symptoms that usually precede or sometimes accompany the headache.
Some patients also experience a premonitory phase, occurring hours or days before
the headache, and a headache resolution phase. Premonitory and resolution symptoms
include hyperactivity, hypoactivity, depression, cravings for particular foods,
repetitive yawning, fatigue and neck stiffness and/or pain.
Etiology Migraine
Journal from Arulmozi DK, etc there is 3 theory about etiology migraine:
1. Vascular Theory
In the late 1930s, Harold Wolff became the first researcher to place migraine
on a scientific basis, Wolf measured the diameter of the extracranial (temporal)
arteries in patients suffering migraine attacks and found them to be dilated.
In line with the finding that carotid arteriovenous anastomoses dilatation play
a role in the pathogenesis of migraine, it is reasonable to believe that compounds
which produce a cranioselective vasoconstriction may have a potential therapeutic use
in the treatment of migraine.

There is relationship between migraine and circle of wills at vetebrobasiler

system. Vasodilation and incomplete circle of wills is one of the cause from migraine
headache. Patient with incomplete circle of wills is more common with patient with
migraine with aura then migraine without aura.
2. Neurological Theory
A second theory of migraine is the neurological theory of migraine. This
theory suggests that migraine arises as a result of abnormal neuronal firing and
neurotransmitter release in brain neurons. This theory focuses on an explanation for
certain symptoms, such as premonitory symptoms occurring prior to an attack
(prodrome), which are difficult to explain based on the vascular hypothesis. The fact
that migraine headaches begin and develop slowly coupled to the fact that external
factors, such as stress, and hunger can precipitate migraine attacks to pathologies
arising in the neuronal system, thus supporting a neurological basis of migraine.
Cortical spreading depression, an expanding depolarization of cortical neurons
which is well characterized in many species but not in man is often suggested to
underlie the aura or prodrome associated with initiation of migraine attack. During
spreading depression, cortical function is disrupted subsequent to neuronal
depolarization and increased extracellular potassium. These cortical changes are
thought to be the cause of the transient sensory or motor impairments that frequently
precede the painful period of a migraine attack.
3. Neurogenic Theory
In 1983 Lance et al demonstrated that blood flow changes similar to those
known to occur in migraine could be produced by electrically stimulating brain stem
structures. This finding led to the neurogenic theory. Stimulation studies investigated
the relationship between the trigeminal nerve and the cranial vasculature.
Mozkowitz in 1992 showed that trigeminovascular axons from blood vessels
of the pia mater and dura mater release vasoactive peptides producing a sterile
inflammatory reaction with pain. During this neurogenic inflammation, the trigeminal
ganglion is stimulated and this induces neurogenic protein extravasation. Vasodilatory
peptides then released, including calcitonin gene related peptide (CGRP), substance P
(SP) and neurokinin A.

Neurogenic theory is an attempt to reconcile the vascular changes in the

neuronal dysfunction that may occur in migraine headache and proposes that migraine
pain is associated with inflammation and dilation of the meninges, particularly the
dura, a membrane surrounding the brain. Neurogenic dural inflammation is thought to
result from the actions of inflammatory neuropeptides released from the primary
sensory nerve terminals innervating the dural blood vessels. In fact, the dural
membrane surrounding the brain is the source for the majority of intracranial pain
afferents and dural stimulation produces headache like pain in human.
Diagnose Migraine
Diagnose migraine we can use patient history of illness, physical examination and
support examination. With history of illness from patient usually enough for diagnose
migraine headache and type from migraine headache.
1. Migraine without aura
a. At least five attacks1 fulfilling criteria BD
b. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)2,3
c. Headache has at least two of the following four characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g.
walking or climbing stairs)
d. During headache at least one of the following: 1. nausea and/or vomiting 2.
photophobia and phonophobia .
e. Not better accounted for by another ICHD-3 diagnosis.
2. Migraine with aura
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
1. visual
2. sensory
3. speech and/or language
4. motor

5. brainstem
6. retinal
C. At least two of the following four characteristics:
1. at least one aura symptom spreads gradually over 5 minutes, and/or two or
more symptoms occur in succession
2. each individual aura symptom lasts 5-60 minutes1
3. at least one aura symptom is unilateral2
4. the aura is accompanied, or followed within 60 minutes, by headache
D. Not better accounted for by another ICHD-3 diagnosis, and transient ischaemic
attack has been excluded.
In primary health its very important to know how to diagnose migraine headache and
how to do first treatment to migraine acute. We should differentiate migraine headache with
other headache from primary headache and secondary headache.

The example for Aura at migraine is Some patients also experience a premonitory
phase, occurring hours or days before the headache, and a headache resolution phase.
Premonitory and resolution symptoms include hyperactivity, hypoactivity, depression,
cravings for particular foods, repetitive yawning, fatigue and neck stiffness and/or pain.
Physical examination for patient with migraine aura or without aura usually normal.
For find etiology migraine at patient Magnetic Resonance angiography (MRA) can detect
abnormal from circle of wills.
Therapy For Migraine
Acute Migraine Treatment
Type

Acute medication

First line

Ibuprofen 400 mg, ASA 1000 mg, naproxen sodium 500-550 mg,
acetaminophen 1000 mg

Second line

Triptans: oral sumatriptan 100 mg, rizatriptan 10 mg, almotriptan 12.5 mg,
zolmitriptan 2.5 mg, eletriptan 40 mg, frovatriptan 2.5 mg, naratriptan 2.5 mg
Subcutaneous sumatriptan 6 mg if the patient is vomiting early in the
attack. Consider for attacks resistant to oral triptans
Oral wafer: rizatriptan 10 mg or zolmitriptan 2.5 mg if fluid ingestion
worsens nausea
Nasal spray: zolmitriptan 5 mg or sumatriptan 20 mg if patient is nauseated
Antiemetics: domperidone 10 mg or metoclopramide 10 mg for nausea

Third line

Naproxen sodium 500-550 mg in combination with a triptan

Fourth line

Fixed-dose combination analgesics (with codeine if necessary; not

recommended for routine use)

For acute attack from migraine drugs of choice we can chose analgetik, NSAID and
Triptan. The drugs from that table use for reduce pain from migraine headache in patient.

Prophylactic Treatment for Migraine

Anti epileptic can use as prophyltactic for migraine headache attack. Many choice of
anti epileptic drugs can patient use to reduce migraine headache attack.
Complication from Migraine

There is many complication from migraine headache. The complication from

migraine maybe because wrong diagnose from type of headache and wrong treatment to
migraine headache.
The complication of migraine :
1. Status Migrainosus
A debilitating migraine attack lasting for more than 72 hours.
With diagnostic criteria :
A. A headache attack fulfilling criteria B and C
B. Occurring in a patient with 1.1 Migraine without aura and/or 1.2 Migraine
with aura, and typical of previous attacks except for its duration and severity
C. Both of the following characteristics:
1. unremitting for >72 hours1
2. pain and/or associated symptoms are debilitating2
D. Not better accounted for by another ICHD-3 diagnosis.
2.

Persistent aura without infarction

Aura symptoms persisting for 1 week or more without evidence of infarction
on neuroimaging.
Diagnostic criteria :
A. Aura fulfilling criterion B
B. Occurring in a patient with 1.2 Migraine with aura and typical of previous
auras except that one or more aura symptoms persists for 1 week
C. Neuroimaging shows no evidence of infarction
D. Not better accounted for by another ICHD-3 diagnosis.

3.

Migrainous infarction
One or more migraine aura symptoms associated with an ischaemic brain
lesion in the appropriate territory demonstrated by neuroimaging.
Diagnostic criteria :
A. A migraine attack fulfilling criteria B and C
B. Occurring in a patient with 1.2 Migraine with aura and typical of previous
attacks except that one or more aura symptoms persists for >60 minutes
C. Neuroimaging demonstrates ischaemic infarction in a relevant area D. Not
better accounted for by another diagnosis.

BASE OF DIAGNOSTIC
Clinical Diagnostic

Clinical diagnostic in patient is migraine because, headache with unilateral pain at left
head, intensity of pain is severe, during the headache attack following by vomiting, the
headache appear when patient doing activity, and from the physical examination doesnt
show an abnormal result.
Patient dont have aura sing like abnormal to visual, abnormal otonom system, no
abnormal sensory and patient motoric is normal. Patient also more sensitive for light and
sensitive for with the loud sound.
Topic Diagnostic
Topic diagnostic in patient is circle of willis. Because the common cause of the
migraine from many research and journal is abnormal from circle of willis. Incomplete circle
of willis and vasodilation of circle of willis is cause the migraine headache.
Etiology Diagnostic
Etiology Diagnostic from patient is migraine without aura because from the patient
dont have an aura sign like abnormal to visual, abnormal otonom system, no abnormal
sensory and patient motoric is normal. And the duration of attack is more that 5 times in a
week and the duration time headache attack is from 24 hours to 48 hours and never more than
hours. the patient also feel more sensitive to light and loud sound.