Disease Description (Causes and Symptoms)
- Disease name confirmation: Migraine is the medically accepted and accurate name.
- Causes/pathophysiology (summary)
- Although the exact mechanism is unknown, major theories include the vascular hypothesis (vasodilation due to changes in cerebral blood flow) and neurogenic inflammation (vasodilation and inflammation caused by vasoactive peptides released from nerve endings).
- There is a genetic predisposition, and a family history is common (e.g., genes associated with familial hemiplegic migraine have been reported).
- Main symptoms
- Prodrome: Changes in mood and behavior, fatigue, yawning, neck stiffness, etc., occurring several hours to days before an attack (about 30–40%).
- Aura: Visual, sensory, language, or motor symptoms (usually <1 hour). Visual flashes/scotomas and paresthesia are common (about 20% of people with migraine).
- Headache: Usually unilateral and pulsating, moderate to severe, lasting 4–72 hours. Worsens with physical activity and is accompanied by nausea/vomiting and photophobia (fear of light) and phonophobia (fear of sound).
- Postdrome: Fatigue, mood changes, cognitive decline, etc., after the headache resolves (may last several hours).
- Serious red flags (additional testing required): Sudden headache that reaches maximum intensity immediately (thunderclap headache), progressive neurological deficits, fever (suspected infection), headache after trauma, suspected bleeding in people taking anticoagulants, etc.
Treatment Methods
- Acute treatment (during an attack)
- Simple analgesics: Ibuprofen, naproxen, acetaminophen (for mild to moderate pain).
- Triptans: Sumatriptan, zolmitriptan, naratriptan, etc. (for moderate to severe attacks or when simple analgesics do not provide adequate control). Contraindicated or requiring caution in patients with coronary artery disease, severe vascular disease, or uncontrolled hypertension.
- Antiemetics: Metoclopramide, prochlorperazine, etc. (when oral medication is difficult due to nausea or vomiting).
- New acute options: 5-HT1F agonist (lasmiditan), gepants (CGRP receptor antagonists: rimegepant, ubrogepant) — approved and used in some countries.
- Prevention (when attack frequency or severity is high)
- First-line options: Propranolol and metoprolol (beta blockers), topiramate and valproic acid (anticonvulsants), amitriptyline (TCA).
- Biological treatment: CGRP-related monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) — effective for chronic or recurrent migraine.
- Botulinum toxin A (onabotulinumtoxinA): Preventive treatment for chronic migraine (headache on 15 or more days per month).
- Preventive use of gepants (such as rimegepant) may be considered for some indications.
- Nonpharmacological treatment/lifestyle management
- Regular sleep, stress management (cognitive behavioral therapy and biofeedback), regular meals, preventing dehydration, avoiding triggers (certain foods, caffeine, excessive alcohol consumption, etc.), and resting with a cold compress in a dark, quiet environment.
- Precautions
- Prevention of medication-overuse headache caused by excessive use of analgesics (depending on the patient, the risk increases with analgesic use on 10–15 or more days per month).
- Triptans are contraindicated in patients with coronary artery disease, severe vascular disease, or unstable angina, or require cardiovascular risk assessment.
- After starting a preventive medication, it may take several weeks to several months for its effects to appear.
Checklist Before an Outpatient Visit (Including Example Questions)
- Items/records to prepare
- List of medications currently being taken (including prescription and nonprescription medications, herbal medicines, and supplements)
- Headache diary (attack frequency, duration, pain intensity, accompanying symptoms, triggers, and medication response) — the most recent 1–3 months are recommended
- Previous test results (brain CT/MRI, blood tests, etc.) and previous medical certificates (if available)
- Family history (migraine, stroke, etc.) and comorbidities (hypertension, cardiovascular disease, etc.)
- Whether you are pregnant or planning a pregnancy, and whether you are breastfeeding
- Example questions to present to the doctor during the outpatient visit (for visit preparation)
- How can we be sure that this headache is migraine?
- Do I need preventive medication based on my headache pattern and frequency?
- Are there any interactions with the medications I am currently taking (e.g., antidepressants or antithrombotic agents)?
Examples of General Questions to Ask the Doctor
- What are the expected effects and side effects of this medication?
- During an acute attack, up to what point should I take the medication (timing of administration)?
- If I start preventive medication, when can I expect it to take effect, and how should I discontinue it?
- What is my level of risk for headaches caused by medication overuse (medication-overuse headache)?
- What treatment options can be used during pregnancy or breastfeeding?
- Do I need surgery or consultation with another specialist (such as an obstetrician-gynecologist or cardiologist)?
Examples of Disease-Specific Questions
- I frequently experience aura. Does this aura increase my future risk of stroke? (Migraine with aura has been reported in some studies to be associated with stroke risk — individual risk factors, such as smoking, oral contraceptive use, and hypertension, need to be assessed.)
- I have chronic migraine (headache on 15 or more days per month). I would like to know whether CGRP antibody treatment or botulinum toxin injections are appropriate, and the extent of insurance coverage and expected benefits.
(The doctor will present an individualized testing and treatment plan based on the materials provided during the visit and the headache diary. Immediate emergency evaluation is required if acute or atypical symptoms occur.)