Migraine Migraine. By: ICD Code: Robert A. Davidoff Classical migraine (migraine with aura):34 .!

Common migraine (migraine without aura):34 ." #ariants of migraine:34 .$ %ther forms of migraine:34 .& "'(3!! )linding headache* Classical migraine* Common migraine* +ic, headache Migraine without aura aura* cheiro-oral .aresthesias* classical migraine* common migraine* cortical s.reading de.ression* headaches* hemicranial .ain* migraine with aura* migraine without aura

McKusick: Synonyms: Sub-topics: Keywords:

Historical note and nomenclature /he earliest recognition of a headache s0ndrome involving one side of the head1 fre2uentl0 correlated with gastrointestinal distress and visual disturbances1 is usuall0 attributed to Aretaeus of Ca..adocia (second centur0 AD). /homas 3illis (" $"4" (') wrote the first modern monogra.h on migraine and called attention to vascular factors in the genesis of the disorder. /issot ("($&4"(5() assembled information on the signs and s0m.toms as well as the clinical course of migraine from available sources. 6n "&(31 7iveing wrote the first s0stematic account of migraine and recogni8ed man0 of its variants. /he classic re.ort b0 9raham and 3olff contained the first com.rehensive set of assum.tions about the cause of migrainous s0m.toms (9raham and 3olff "53&). Clinical mani estation A bout of migraine ma0 commence at an0 time of the da0 or night. An intense .ounding headache ma0 awa,en some individuals from slee.* other individuals detect a headache on awa,ening. +till others develo. an e.isode graduall0 as the da0 .rogresses. /he fre2uenc0 of attac,s also differs among individuals. :or e;am.le1 over half of clinic .atients are estimated to endure one or more attac,s a month (+elb0 and 7ance "5 !). 6n contrast1 some individuals onl0 suffer two or three bouts during their lives. /he t0.ical attac, of migraine consists of a se2uence of events that include (") .rodrome1 ($) aura1 (3) headache1 (4) resolution1 and (') .ostdrome ()lau "5&(). 6n an individual migraineur1 however1 the attributes of a s.ecific bout can var0 from a limited number of s0m.toms to a severe siege in which the entire s.ectrum of the disorder is .resent. A..ro;imatel0 !< of migraineurs detect an assortment of .remonitor0 s0m.toms (.rodromes) that are the initial events in the attac,. /hese fre2uentl0 vague s0m.toms can .recede the aura or head .ain b0 several hours or even b0 da0s ()lau "5&!* Amer0 et al "5& ). =rodromal s0m.toms t0.icall0 include changes in mood or behavior (eg1 irritabilit01 de.ression1 sluggishness1 an;iet01 a.ath01 eu.horia1 e;citement)1 neurologic s0m.toms (eg1 e;cessive 0awning1 .hono.hobia and .hoto.hobia1 blurred vision1 di88iness)1 constitutional s0m.toms (eg1 e;cessive fatigue1 .allor1 aching muscles1 fluid retention)1 and alimentar0 s0m.toms (eg1 hunger1 craving for food1 bulimia1 nausea1 anore;ia). =rodromal s0m.toms var0 widel0 among individuals1 but the0 are often consistent in a .articular migraineur. /he absence or .resence of an aura>an e.isode of focal1 transitor0 neurologic d0sfunction>in the .reheadache .hase of a migraine attac, distinguishes common migraine (migraine without aura) from classic migraine (migraine with aura) (?eadache Classification Committee "5&&). @eurologic s0m.toms usuall0 develo. over ' to $! minutes and last less than ! minutes. A..ro;imatel0 &!< of migraine sufferers have common migraine (+elb0 and 7ance "5 !). About (!< of .atients with classic migraine also have attac,s without aura. @eurologic s0m.toms usuall0 develo. over ' to $! minutes and last less than ! minutes. /he most common auras are visual1 but an aura ma0 consist of essentiall0 an0 neurologic s0m.tom. #isual auras are of two t0.es: .ositive visual .henomena with hallucinations and negative visual .henomena (scotomas) with either incom.lete or com.lete loss of vision in a .ortion or the whole of the visual field. Most visual auras have a hemiano.ic distribution. =hoto.sias are the sim.lest t0.e of visual hallucination1 consisting of small s.ots1 dots1 stars1 unformed flashes or stea,s of light1 or sim.le geometric forms and .atterns that t0.icall0 flic,er or s.ar,le. +cintillating scotomas (also called teicho.sias or fortification s.ectra) are considered to be the most distinctive migrainous visual s0m.tom. +uch scotomas consist of an absent arc or band of vision with a shimmering or glittering1 bright1 8ig8ag border (Richards "5("). /he visual alteration usuall0 commences in the center of the visual field and slowl0 e;tends laterall0. /he scotoma fre2uentl0 is semicircular or horseshoe-sha.ed. %n occasion1 obAects ma0 a..ear to change in si8e and sha.e. =atients ma0 also have somatosensor0 auras consisting of circumscribed feelings of numbness or sensations of tingling or .ins and needles involving the i.silateral hand1 face1 and tongue (cheiro-oral or

digito-lingual .aresthesias) (Bensen et al "5& ). Minimal1 brief hemi.aresis is not uncommon1 but .rolonged1 severe .aresis is a rare aura. D0sarthria and a.hasia ma0 be associated with .aresthesias or hemi.aresis in some .atients1 or a.hasia ma0 occur as an isolated .henomenon. /rue rotational vertigo sometimes constitutes a migraine aura (+elb0 and 7ance "5 !). 6n some individuals1 one t0.e of aura ma0 follow another (eg1 somatosensor0 s0m.toms ma0 occur as visual s0m.toms disa..ear). /he headache .hase of the bout follows the aura and varies from mild discomfort to intense and disabling. /he .ain of migraine is t0.icall0 described as throbbing or .ulsating. )ut the .ain of fewer than half of adult migraineurs has a .ulsating 2ualit0 (%lesen "5(&). /he head .ain can last from a few hours to several da0s1 but it .ersists for less than a da0 in most .atients (+elb0 and 7ance "5 !). /he unilateral nature of the headache has been stressed (?eadache Classification Committee "5&&)1 but migrainous head .ain is unilateral in onl0 ' < to &< of .atients (7ance and Anthon0 "5 * %lesen "5(&* +Aaastad et al "5&5). /he .ain ma0 be bilateral at the onset of the attac, or begin on one side and become generali8ed as the bout continues. 6n .atients with unilateral .ain1 the side affected in different attac,s ma0 var0 or ma0 invariabl0 be the same in each attac,. /he .ain is usuall0 located in the frontotem.oral region of the head or in1 around1 or behind an e0e. )ut an0 region of the head or face ma0 be affected including the .arietal region1 the u..er or lower Aaw or teeth1 the malar eminence1 or the u..er anterior nec,. Migrainous .ain is t0.icall0 diminished b0 l0ing or sitting still and is increased b0 an0 activit0 or effort or b0 an0 active or .assive head movement. 6ntolerance of light (.hoto.hobia) and noise (.hono.hobia) are the most fre2uent s0m.toms accom.an0ing the head .ain. As a result of these s0m.toms1 most .atients see, a 2uiet1 dar, room. A..ro;imatel0 5!< of .atients e;.erience nausea1 and vomiting affects more than half of migraineurs (7ance and Anthon0 "5 * %lesen "5(&). %ther gastrointestinal s0m.toms are common and include anore;ia1 diarrhea1 consti.ation1 and abdominal distension and cram.s. %ther .atients com.lain of blurr0 vision1 facial .allor1 edema that is most .rominent in the tem.oral and .eriorbital lobes1 nasal congestion1 cold and clamm0 hands and feet1 and .ol0uria. =tosis and miosis (?ornerCs s0ndrome) have been observed during the height of an attac, in some individuals1 but in rare .atients the .u.il dilates on the side of the head .ain. Man0 migraineurs suffer from changes in their .s0chological and mental state during an attac,. Man0 feel de.ressed* others feel irritable and hostile. Man0 are lethargic1 drows01 or irresistibl0 slee.0. Minor cognitive changes are common during migraine attac,s and include reduced abilit0 to concentrate1 mildl0 decreased memor01 and difficult0 with abstract thought. 6n most migraineurs1 the .ain graduall0 diminishes over a .eriod of hours1 but man0 migraine attac,s are concluded b0 slee. ()lau "5&$). Man0 migraineurs have a .ostdromal .eriod after a headache lasting several hours to several da0s. =atients ma0 feel fatigued1 wea,1 listless1 or lethargic1 although some feel refreshed or even eu.horic. /he ?eadache Classification Committee of the 6nternational ?eadache +ociet0 has formulated criteria for migraine without aura and migraine without aura that have been acce.ted worldwide (?eadache Classification Committee "5&&). Diagnostic Criteria or Migraine !it"out #ura $Common Migraine% D At least five attac,s lasting 4 to ($ hours D ?eadache has at least two of the following characteristics: unilateral location .ulsating 2ualit0 moderate or severe intensit0 aggravation b0 routine .h0sical activit0 D At least one of the following during headache: nausea andEor vomiting .hoto.hobia and .hono.hobia D @ormal neurologic e;am and no evidence of organic disease that could cause headaches Diagnostic Criteria or Migraine wit" #ura $Classic Migraine% D At least two attac,s D Aura must e;hibit at least three of the following characteristics: full0 reversible and indicative of focal cerebral cortical or brainstem d0sfunction gradual onset lasts less than ! minutes followed b0 headache with a free interval of less than ! minutes or headache ma0 begin before or simultaneousl0 with the aura D @ormal neurologic e;am and no evidence of organic disease that could cause headaches

&tiology Most migraine sufferers ,now that migraine is .resent in several famil0 members. /he .rominent familial .revalence im.lies that genetic factors .la0 a role in migraine (Meri,angas "55!* Meri,angas "55 ). )ut the .atterns of inheritance are com.licated and as a result the mode of inheritance of migraine is unclear. An acce.table assum.tion is that several genes render an individual more li,el0 to develo. the disorder when e;.osed to a mi;ture of environmental and internal trigger factors. 9enes for familial hemi.legic migraine have been ma..ed to chromosome "5."3. :amilial hemi.legic migraine1 a s0ndrome of recurring e.isodes of hemi.aresis during the aura .hase of migraine headaches1 a..ears to be caused b0 a mutation in a CaFF channel gene (%.hoff et al "55 ). Biological basis /here are two fundamental1 and seemingl0 com.eting1 theories concerning the genesis of migraine> the vascular and neurogenic theories. 6t is now believed1 however1 that both neural and vascular mechanisms are involved>that the migrainous .rocess originates in the brain and then evolves to involve e;tracerebral blood vessels. /he mechanisms are1 however1 still the subAect of debate. Much wor, suggests that cortical s.reading de.ression (or a .rocess related to s.reading de.ression) originating in the .osterior .ole of the brain causes the aura in .atients with classic migraine (7aurit8en "554). /he idea is largel0 based on the results of measurements of regional cerebral blood flow during acute attac,s of migraine .rovo,ed b0 angiogra.h0 or occurring s.ontaneousl0. /hese results have been critici8ed as being largel0 artifactual (+,0hGA %lesen "55'). At the .resent time1 it is not clear whether the decreased cerebral blood flow recorded during migrainous auras is caused b0 a neurogenic .rocess such as s.reading de.ression or b0 a vascular .rocess such as vasoconstriction. A mechanism involving vasos.asm ma0 cause changes in cerebral blood flow1 changes that are the basis for the s.reading de.ression and aura s0m.toms. Aminergic brainstem nuclei (locus coeruleus1 ra.he nuclei) regulate cerebral blood flow1 influence cortical neuron e;citabilit01 and modulate endogenous .ain control mechanisms. A discharge from these nuclei has been h0.othesi8ed to initiate .arts of the migrainous .rocess (7ance "5&&)* what activates the brainstem structures is not 0et ,nown. Data now .oint to the trigeminovascular s0stem as the anatomical substrate res.onsible for migraine .ain (Mos,owit8 "55!* 7immroth et al "55 ). /he .ain is thought to result from neurogenic inflammation1 .roduced b0 the antidromic release of neuro.e.tides b0 trigeminal nerve endings and associated with the release of other algesic substances from .lasma1 .latelets1 and mast cells (eg1 histamine1 .rostaglandin1 serotonin). /his release of neuro.e.tides and algesic com.ounds induces the vasodilatation and e;travasation of .lasma .roteins and the sensiti8ation of trigeminal nocice.tive nerve endings. +erotonin has been im.licated as the catal0st res.onsible for the genesis of migraine attac,s (:errari et al "5&5). )ut the locus (blood vessels1 neurons1 .latelets) of the changes in serotonin activit0 that could initiate the .rocess is still un,nown. 6t is still not ,nown where serotonin acts1 if it is in fact res.onsible for migraine attac,s. &pidemiology :igures for the .revalence of migraine var0 dramaticall0 among different studies1 from "< to 3"< (7inet and +tewart "5&4* "5&(). Contem.orar0 data show that the fre2uenc0 of migraine is much higher than suggested b0 earlier studies>"&< to $5< in women and < to $!< in men (+tewart et al "55$). /he first bout evolves .rior to age 4! 0ears in about 5!< of .atients1 with a..ro;imatel0 half of the cases a..earing during childhood or adolescence (+elb0 and 7ance "5 !). )efore .ubert01 the .revalence of migraine is higher in bo0s than girls. =revalence increases until a..ro;imatel0 age 4!1 after which it declines. Adult women are at greater ris, for the develo.ment of migraine than adult men1 but estimates for the female-to-male ratio var0 from a..ro;imatel0 two to one to a..ro;imatel0 three to one. Marital situation1 intelligence1 educational level1 occu.ational categor01 and em.lo0ment situation are not correlated with migraine. Migraine ma0 be more fre2uent in individuals from lower income grou.s (+tewart et al "55$)* it a..ears to be a disease of high-income grou.s in the .h0sicianCs office but not in the communit0. Migraine has been lin,ed with a heterogeneous grou. of medical .roblems1 such as mitral valve .rola.se1 s0stemic lu.us er0thematosus1 multi.le sclerosis1 and h0.ertension. A number of studies have lin,ed stro,e and migraine (@arbone et al "55 )1 but the .ro.ortion of all stro,e attributable to migraine varies from "< to "(< in .atients under the age of '! (7i.ton and +tewart "55(). A bod0 of recent data suggests that migraine and e.ile.s0 are comrbid (%ttman and 7i.ton "554* %ttman and 7i.ton "55 ). Recent e.idemiologic studies have 0ielded evidence of strong associations between migraine and maAor de.ression1 an;iet0 s0m.toms1 and .anic disorders ()reslau et al "554* +tewart et al "554). 're(ention A..ro;imatel0 &'< of migraineurs recogni8e definite trigger factors>e;ogenous and endogenous factors that .reci.itate migraine attac,s (#an den )ergh et al "5&(). +uch factors include .s0chosocial conditions (acute .s0chological e;.eriences that elicit strong emotions)1 dietar0 constituents (.articular foodstuffs such as ri.ened cheese or chocolate1 food additives such as monosodium glutamate or as.artame1 alcohol)1 .h0sical stimuli (bright or flic,ering lights1 .erfumes1 cigarette smo,e1 diesel fumes1 alterations in barometric .ressure)1 changes in hormonal levels (menstruation1 .regnanc01 administration of

.ro.h0lactic .ills)1 lac, of slee. or overslee.ing1 s,i..ing meals1 or administration of medications (nitrogl0cerin1 reser.ine). :or man0 .atients the identification of trigger factors is essential for successful headache management because removal of individual .reci.itants ma0 substantial0 reduce the fre2uenc0 of their attac,s. Di erential Diagnosis /ension-t0.e headache and cluster headache must be differentiated from migraine. /he 6nternational ?eadache +ociet0 .romulgates clear-cut criteria for tension-t0.e headache that differentiate it from migraine (?eadache Classification Committee "5&&)1 but there is ongoing debate regarding the relationshi. between the two disorders. +everal researchers 2uestion whether migraine and tension-t0.e headache are discrete headache entities. +ome researchers consider migraine to be one e;treme in a s.ectrum of headache ranging from mild to severe and disabling. @onetheless1 according to the 6nternational ?eadache +ociet0 criteria tension-t0.e headache has at least two of the following characteristics: .ressingEtightening 2ualit01 mild to moderate intensit01 bilateral location1 no aggravation b0 routine .h0sical activit0* .ossible .hono.hobia and .hoto.hobia1 but no nausea or vomiting* and normal neurologic e;am. /he same grou. also has s.ecific criteria for cluster headache: severe1 unilateral orbital1 su.raorbital1 andEor tem.le .ain that lasts for "' to "&! minutes associated with i.silateral signs indicative of autonomic nervous s0stem involvement (conAunctival inAection1 lacrimation1 nasal congestion1 rhinorrhea1 miosis1 .tosis)* a fre2uenc0 of attac,s from one ever0 other da0 to eight .er da0* and a normal neurologic e;am and no evidence of another organic disease that could cause headaches (?eadache Classification Committee "5&&). Diagnostic !orkup @o obAective test is .resentl0 available that can be used to either ma,e or confirm the diagnosis of migraine. +imilarl01 laborator0 tests are su.erfluous for most migraineurs. Although nons.ecific abnormalities are seen with considerable fre2uenc0 in com.uted tomogra.hic scans1 magnetic resonance imaging1 electroence.halograms1 evo,ed .otentials1 and thermograms1 the abnormalities are seldom significant or diagnostic. :ar too man0 e;aminations are .erformed on migraineurs sim.l0 because the tests are available. /hus1 C/1 MR6 and HH9s do not a..ear to be cost-effective .rocedures for the routine screening of .atients with migraine headaches who have normal .h0sical e;ams (:rishberg et al "554*(9ronseth and 9reenberg "55'). 'rognosis and Complications Migraine is often a life-long disease. )ut with a..ro.riate management1 the condition of more than 5!< of .atients with migraine can be im.roved. /here is a subgrou. of migraineurs afflicted with a chronic dail0 headache s0ndrome that evolves from migraine. Attac,s increase in fre2uenc0 over a number of 0ears or decades until a .attern of dail0 headache develo.s. /he maAorit0 of these .atients are overusing analgesic medication. +tatus migrainosus is the term a..lied to ceaseless bouts of migraine lasting more than 3 da0s. /hese attac,s are resistant to the usual analgesics and are associated with .rotracted vomiting1 .rostration1 and deh0dration. /he0 ma0 re2uire hos.itali8ation for correction of deh0dration and .ain relief. H;tended attac,s of this nature ma0 be triggered b0 severe emotional stress* misuse of medications such as ergots1 analgesics1 and narcotics* dietar0 indiscretions* and alcohol abuse (Couch and Diamond "5&$). 7ong-lasting or .ermanent neurologic se2uelae with evidence of ischemic infarction of the cerebrum or brainstem (migrainous infarction) can occur during or following an attac, of migraine ()oisen "5('* Dorfman et al "5(5). /he ris, of such an infarction is low1 but it is increased in .atients who use oral contrace.tives1 who smo,e1 or who discontinue antimigraine thera.0. Management /he management of .atients with migraine headaches consists of several maAor com.onents: ". /he .revention of bouts b0 identification and removal of ,nown trigger factors. Determination of trigger factors is fundamental for effective migraine management because man0 headaches ma0 be .revented if a .articular migraineur abstains from alcohol1 eliminates chocolate1 sto.s contrace.tive .ills1 obtains ade2uate slee.1 or ingests three regular meals a da0. $. /he use of non.harmacologic treatments. )ehavioral .rocedures including biofeedbac, (both thermal and electrom0ogra.hic)1 sim.le rela;ation thera.01 autogenic training1 and .rograms teaching cognitive stress co.ing s,ills have been used successfull0 in migraineurs (Andrasi, et al "5&4* )lanchard "5&(* Andrasi, "55 ). 3. /he .harmacologic treatment of acute attac,s. +im.le analgesics and nonsteroidal anti-inflammator0 drugs are ca.able of reducing .ain in man0 .atients suffering from acute migraine attac,s. Hrgots (cafergot1 dih0droergotamine) are a mainsta0 of s0m.tomatic treatment1 but sumatri.tan (6mitre;) will most li,el0 change that role in the future. @arcotics and analgesicEsedative drugs should onl0 be .rescribed infre2uentl0 and in small 2uantities. /he0 should be used for a ma;imum of $ to 3 da0s .er wee,. /he use of steroids for the treatment of acute attac,s should be discouraged because of the cumulative nature of some of the side effects such as osteonecrosis.

4. /he long-term treatment with .ro.h0lactic medication to .revent recurring bouts. A considerable number of .otent medications (beta-bloc,ers such as .ro.ranolol and nadolol1 calcium channel bloc,ers such as vera.amil and diltia8em1 antide.ressants such as amitri.t0line and .ro8ac1 anticonvulsants such as val.roic acid1 and antiserotonergics such as meth0sergide) are available for the .revention of attac,s of migraine (+ilberstein "55 ). =reventive medications are ca.able of decreasing the fre2uenc0 and severit0 of migraine in most migraineurs. All .reventive drugs have side effects1 however1 and should be .rescribed with circums.ection. Authorities disagree about guidelines for administering .reventative medication. +ome .h0sicians .rescribe .ro.h0lactic drugs for .atients who have more than one headache each month. %thers feel that dail0 medication is warranted onl0 if the fre2uenc0 is greater than one headache .er wee,. 'regnancy Migraine im.roves during the second and third trimester of .regnanc0 in about ('< of .atients (7ance and Anthon0 "5 * Callaghan "5 &). ?owever1 the condition ma0 emerge during the first trimester in "!< to "'< of women without a histor0 of .receding migraine (Callaghan "5 &* Masse0 "5((). #nest"esia @o information is available. )e erences cited Amer0 3I1 3ael,ens B1 #an den )ergh #. Migraine warnings. ?eadache "5& *$ : !- . Andrasi, :. )ehavioral management of migraine. )iomed =harmacother "55 *'!:'$-(. Andrasi, :1 )lanchard H)1 @eff D:1 Rodicho, 7D. )iofeedbac, and rela;ation training for chronic headache: a controlled com.arison of booster treatments and regular contacts for long term maintenance. B Consult Clin =s0chol "5&4*'$: !5-"'. )lanchard H). 7ong-term effects of behavioral treatment of chronic headache. )ehav /her "5&(*"&:3('-&'. )lau B@. Migraine .rodromes se.arated from the aura: com.lete migraine. )r Med B "5&!*$&": '&- !. )lau B@. Resolution of migraine attac,s: slee. and the recover0 .hase. B @eurol @eurosurg =s0chiatr0 "5&$*4':$$3- . )lau B@. Adult migraine: the .atient observed. 6n )lau B@1 editor. Migraine: clinical and research as.ects. )altimore: Bohns ?o.,ins Jniv =r1 "5&(:3-3!. )oisen H. +tro,es in migraine: re.ort on seven stro,es associated with severe migraine attac,s. Dan Med )ull "5('*$$:"!!- . )reslau @1 Meri,angas I1 )owden C7. Comorbidit0 of migraine and maAor affective disorders. @eurolog0 "554*44(+u..l ():+"(-$$. Callaghan @. /he migraine s0ndrome in .regnanc0. @eurolog0 "5 &*"&:"5(-$!". Couch BR1 Diamond +. +tatus migrainosus: causative and thera.eutic as.ects. ?eadache "5&$*$3:54-"!". Dorfman 7B1 Marshall 3?1 Hn8mann DR. Cerebral infarction and migraine: clinical and radiologic correlations. @eurolog0 "5(5*$5:3"(-$$. :errari MD1 %din, B1 /a..arelli C1 #an Iem.en 9MB1 =ennings HBM1 )ru0n 93. +erotonin metabolism in migraine. @eurolog0 "5&5*35:"$35-4$. :rischberg )M. /he utilit0 of neuroimaging in the evaluation of headache in .atients with normal neurologic e;aminations. @eurolog0 "554*44:""5"-(. 9raham BR1 3olff ?9. Mechanism of migraine headache and action of ergotamine tartrate. Arch @eurol =s0chiatr0 "53&*35:(3(- 3. 9ronseth 9+1 9reenberg MI. /he utilit0 of the electroence.halogram in the evaluation of .atients .resenting with headache: a review of the literature. @eurolog0 "55'*4':"$ 3-(. ?eadache Classification Committee of the 6nternational ?eadache +ociet0. Classification and diagnostic criteria for headache disorders1 cranial neuralgias and facial .ain. Ce.halalgia "5&&*&(+u..l ():"-5 .

Bensen I1 /felt-?ansen =1 7aurit8en M1 %lesen B. Classic migraine. A .ros.ective recording of s0m.toms. Acta @eurol +cand "5& *(3:3'5- $. 7ance B3. :ift0 0ears of migraine research. Aust @ K B Med "5&&*"&:3""-(. 7ance B31 Anthon0 M. +ome clinical as.ects of migraine. A .ros.ective stud0 of '!! .atients. Arch @eurol "5 *"':3' - ". 7aurit8en M. =atho.h0siolog0 of the migraine aura. /he s.reading de.ression theor0. )rain "554*""(:"55$"!. 7immroth #1 Cutrer :M1 Mos,owit8 MA. @eurotransmitters and neuro.e.tides in headache. Curr %.in @eurol "55 *5:$! -"!. 7inet M+1 +tewart 3:. Migraine headache: e.idemiologic .ers.ectives. H.idemiol Rev "5&4* :"!(-35. 7inet M+1 +tewart 3:. /he e.idemiolog0 of migraine headache. 6n: )lau B@1 editor. Migraine: clinical and research as.ects. )altimore: Bohns ?o.,ins Jniv =r1 "5&(:4'"-((. 7i.ton R)1 +tewart 3:. H.idemiolog0 and comorbidit0 of migraine. 6n: 9oadsb0 =B1 +ilberstein +D1 editors. ?eadache. )oston: )utterworth-?einemann1 "55(:('-5'. Masse0 H3. Migraine during .regnanc0. %bstet 90necol +urv "5((*3$: 53- . Meri,angas IR. 9enetics of migraine and other headache. Curr %.in @eurol "55 *5:$!$-'. Meri,angas IR. 9enetic e.idemiolog0 of migraine. 6n: +andler M1 Collins 9M1 editors. Migraine: a s.ectrum of ideas. %;ford: %;ford Jniv =r1 "55!:4!-&. Mos,owit8 MA. )asic mechanisms of headache. @eurol Clin "55!*&:&!"-"'. @arbone MC1 7eggiadro @1 7a +.ina =1 Rao R1 9rugno R1 Musolino R. Migraine stro,e. ?eadache "55 *3 :4&"-3. %lesen B. +ome clinical features of the acute migraine attac,. An anal0sis of ('! .atients. ?eadache "5(&*"&:$ &-(". %.hoff RA1 /erwindt 9M1 #ergouwe M@1 et al. :amilial hemi.legic migraine and e.isodic ata;ia t0.e-$ are caused b0 mutations in the Ca$F channel gene CAC@7"A4. Cell "55 *&(:'43-'$. %ttman R1 7i.ton R). 6s the comorbidit0 of e.ile.s0 and migraine due to a shared genetic susce.tibilit0L @eurolog0 "55 *4(:5"&-$4. %ttman R1 7i.ton R). Comorbidit0 of migraine and e.ile.s0. @eurolog0 "554*44:$"!'-5. Richards 3. /he fortification illusions of migraines. +ci Am "5("*$$4:&&-5 . +elb0 91 7ance B3. %bservations on '!! cases of migraine and allied vascular headache. B @eurol @eurosurg =s0chiatr0 "5 !*$3:$3-3$. +ilberstein +D. Dival.roe; sodium in headache: literature review and clinical guidelines. ?eadache "55 *3 :'4(-''. +Aaastad %1 /orbAGrn A:1 +and /1 Antonaci :. Jnilateralit0 of headache in classic migraine. Ce.halalgia "5&5*5:("-(. +,0hGA %lesen /. =atho.h0siolog0 of the migraine aura: the s.reading de.ression theor0. )rain "55'*""&:3!(. +tewart 31 )reslau @1 Iec, =H. Comorbidit0 of migraine and .anic disorder. @eurolog0 "554*44(+u..l ():+$3-(. +tewart 3:1 7i.ton R)1 Celentano DD1 Read M7. =revalence of migraine headache in the Jnited +tates. Relation to age1 income1 race1 and other sociodemogra.hic factors. BAMA "55$*$ (: 4-5.

#an den )ergh #1 Amer0 3I1 3ael,ens B. /rigger factors in migraine: a stud0 conducted b0 the )elgian Migraine +ociet0. ?eadache "5&(*$(:"5"- . /he following information is .resented in standard ranges and categories to facilitate searching. :or more s.ecific demogra.hic information1 see the H.idemiolog01 Htiolog01 and )iological basis sections of this article. #ge: !$-!' 0ears "3-"& 0ears "5-44 0ears 4'- 4 0ears @one selectivel0 affected @one selectivel0 affected femaleMmale1 M$:" femaleMmale1 M":" famil0 histor0 ma0 be obtained famil0 histor0 t0.ical heredit0 ma0 be a factor

'opulation: *ccupation: Se+: ,amily History: Heredity:

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