Assessing and Treating Complex Migraine

FEBRUARY 17, 2012

There are several other types of what may be called migraine with complex/complicated aura:

• In children there are different types of migraine that are not necessarily “complicated migraine”, but what I would term “migraine equivalents.” These include abdominal migraine, characterized by bouts of pain in the abdomen lasting for hours, ending after the child falls asleep. It can be associated with nausea, occasional vomiting, flushing, and pallor. Triptans may help treat this condition if administered early enough.

• Vertigo is another migraine equivalent in children, although in my experience abdominal migraine is seen more frequently.

• Other forms of complex migraine include, as noted above, ophthalmoplegic migraine. In this disorder, patients may experience recurrent headache with migrainous characteristics, pain around the eye that can last for weeks or even months, associated with paresis (weakness) of one or more ocular cranial nerves, most commonly the third cranial nerve. There are no associated changes in MRI other than in the affected nerve. Some feel that this may be a recurrent demyelinating neuropathy rather than a variant of migraine.1

"The best treatment for difficult headache conditions is for the patient and the physician to work together to devise an individualized treatment plan that maximizes symptom relief and minimizes side effects."
–Gary W. Jay, MD, FAAPM, DAAPM

Familial hemiplegic migraine (FHM) is described as migraine with aura including motor weakness. For a diagnosis of FHM, the patient must have at least one first- or second-degree relative who has migraine with aura including motor weakness. FHM is a genetic problem; researchers have identified specific gene abnormalities associated with this condition, including mutations in the CACNA1A gene, the FHMI gene that encodes the pore-forming α 1A subunit of P/Q-type voltage-dependent neuronal calcium channels.2 A diagnosis of familial hemiplegic migraine requires that the patient has experienced at least two attacks that fulfill criteria 1 and 2:3

1. Aura consisting of fully reversible motor weakness and at least one of the following:
• Fully reversible visual symptoms, including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)

• Fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)

• Fully reversible dysphasic speech disturbance

2. And at least two of the following:
• At least one aura symptom develops gradually over ≥ 5 minutes and/or different aura symptoms occur in succession over ≥ 5 minutes

• Each aura symptoms lasts ≥ 5 minutes and < 24 hours.

• Headache lasting 4-72 hours that has two or more of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, and/or aggravation by or causing avoidance of routine physical activity. During the headache attack, the patient must experience at least one of the following symptoms: nausea and/or vomiting, photophobia and phonophobia. Headache attacks begin during the aura or follow the onset of aura within 60 minutes.

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