Headache and migraine

Abstract

Headache is the most frequent reason for neurological consultation. Headaches can be divided into primary (no substrate can be demonstrated) and secondary. Primary headaches account for most of the consultations, with migraine as the most frequent and discapacitating. The precise etiology of the current forms of migraine is unknown, though genetic predisposition and ambient precipitants are involved. In contrast, migraine pathophysiology is rather well-known. While the generation of the attacks is central, hypothalamic, pain itself is due to the leptomeningeal release of neuropeptides, mainly CGRP, as a consequence of the activation of the trigemino-vascular system. The aura is secondary to a cortical spreading depression phenomenon. Migraine diagnosis is based in clinical criteria and normal examination. Migraine begins in childhood/adolescence, with attacks of moderate-severe, pulsating, hemicranial pain lasting 4–72 hours and with intolerance to light, sound and any movement. About one-third of migraine patients experience aura, usually containing positive visual symptoms or paraesthesias. Its management comprises always general measures and symptomatic medications (NSAIDs and/or triptans) and preventatives if there are more than 3 attacks per month, with beta-blockers and topiramate as first choices. For those patients with chronic migraine botulinum toxin type A is indicated.