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Review Article

Drug Therapy

A LASTAIR J.J. W OOD , M. D., Editor



IGRAINE is a common, chronic, incapac- itating neurovascular disorder, characterized by attacks of severe headache, autonomic
nervous systemdysfunction, and in some patients, an aura involving neurologic symptoms.1,2 Recent ad- vances in basic and applied clinical neuroscience3 have led to the development of a new class of selective se- rotonin (5-hydroxytryptamine [5-HT]) receptor ago- nists that activate 5-HT1B and 5-HT1D (5-HT1B/1D) re- ceptors and are known as the triptans; these agents have changed the lives of countless patientswith mi- graine. Despite such progress, migraine remains un- derdiagnosed and the available therapies underused.4

In this article, we review the current understanding of the epidemiology, pathophysiology, and treatment of migraine.

Migraine is characterized by episodes of head pain that is often throbbing and frequently unilateral and may be severe. In migrainewithout aura (previously known as common migraine), attacks are usually as- sociated with nausea, vomiting, or sensitivity to light, sound, or movement.5 When untreated, these at- tacks typically last 4 to 72 hours.6 A combination of features is required for the diagnosis, but not all fea- tures are present in every attack or in every patient (Table 1).
Migraine is defined as episodic attacks of headache lasting
4 to 72 hr
With two of the following symptoms:
Unilateral pain
Aggravation on movement
Pain of moderate or severe intensity
And one of the following symptoms:
Nausea or vomiting
Photophobia or phonophobia

These symptoms distinguish migraine from ten- sion-type headache, the mostcommon form of pri-
mary headache, which is characterized by the lack of associated features. Any severe and recurrent head- ache is most likely to be a form of migraine and to be responsive to antimigraine therapy.8 In 15 percent of patients, migraine attacks are usually preceded or accompanied by transient focal neurologic symptoms, which are usually visual; such patients havemigraine with aura (previously known as classic migraine).9 In a recent large, population-based study, 64 percent of patients with migraine had only migraine without au- ra, 18 percent had only migraine with aura, and 13 percent had both types of migraine (the remaining
5 percent had aura without headache). Thus, up to 31 percent of patients with migraine have aura on someoccasions,10 but clinicians who rely on the presence of aura for the diagnosis of migraine will miss many cases.
We find it useful to assess the severity and effects of migraine by asking about time lost because of mi- graine at work or school, in performing household work or chores, or in family, social, and leisure activ- ities. One can ask patients directly about temporary disability, have themkeep a diary, or get a quick but accurate estimate with the use of the Migraine Dis- ability Assessment Scale (MIDAS) (Table 2), a well- validated five-item questionnaire that is easy to use in practice.11
Although attacks of migraine may start at any age, the incidence peaks in early to mid-adolescence. In the United States and Western Europe, the one-year prevalence of migraine is11 percent overall: 6 percent among men and 15 to 18 percent among women.12-14
The median frequency of attacks is 1.5 per month, and the median duration of an attack is 24 hours; at least 10 percent of patients have weekly attacks, and 20 percent have attacks lasting two to three days.12

Thus, 5 percent of the general population have at least 18 days of migraine per year, and...
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