Migraine Management

Introduction to Migraine

Migraine has a strong genetic component, with higher prevalence among people with affected first-degree relatives, according to the American Academy of Neurology 1
Estrogen fluctuations explain higher prevalence in women and menstrual-related migraines, as noted by the American College of Obstetricians and Gynecologists 1
Migraine headaches are primarily caused by a complex interplay of genetic predisposition and environmental triggers that affect the trigeminovascular system, leading to neurogenic inflammation and pain signaling in the brain 1

Dietary factors, such as certain foods (e.g., tyramine, nitrates), missed meals, alcohol, and caffeine, can trigger migraines, as reported by the American Academy of Family Physicians 2
Sensory stimuli, including bright or flickering lights, strong smells, and loud noises, can trigger migraine attacks 3, 2
Perfumes, fumes, and glare are additional triggers, as identified by the American Academy of Family Physicians 2
Hormonal changes, such as menstruation-related migraine and fluctuations in estrogen levels, can precipitate migraine attacks in genetically predisposed individuals 1, 3
Stress and stress relief, as well as sleep disruption, can also trigger migraine attacks 1, 3

Calcitonin gene-related peptide (CGRP) plays a critical role in migraine pathophysiology, contributing to trigeminal nerve pain and inflammation 4
Cortical spreading depression is implicated particularly in migraine with aura, triggering the trigeminovascular system and explaining visual and other aura symptoms 1
The hypothalamus is involved in prodrome symptoms and attack initiation, according to the American Academy of Neurology 1
The meningeal blood vessels are the site of neurogenic inflammation 1

CGRP-targeting therapies, including monoclonal antibodies and gepants that block CGRP signaling, are available, as reported by the American College of Physicians 5
Triptans act on serotonin receptors to inhibit pain transmission, as noted by the American Academy of Neurology 6
Preventive medications, such as antiseizure medications and beta-blockers, target neuronal hyperexcitability, according to the American College of Physicians 5
Understanding migraine pathophysiology has led to targeted treatments, including CGRP antagonists, CGRP monoclonal antibodies, and triptans that act on serotonin receptors 4

Migraine with aura is associated with an increased risk of cerebrovascular events, including ischemic stroke, particularly in women, as reported by the American Heart Association 7
Migraine with aura is also associated with a higher prevalence of white matter lesions in female migraineurs, according to the American Heart Association 7
Anatomical variants, such as circle of Willis variations, are more common in migraine with aura, as noted by the American Heart Association 7

Identification of individual triggers is important for management, and lifestyle modifications can help some patients avoid specific triggers 1
The American Academy of Neurology and other guideline societies recommend a comprehensive approach to migraine management, including accurate diagnosis, individualized treatment plans, and patient education 1, 4, 3
Medication overuse can lead to medication-overuse headache, which can be confused with chronic migraine 1, 8