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Migraine

Migraine is characterized by recurrent headaches often in association with a number of symptoms like nausea, photophobia and phonophobia. Typically the headache is unilateral, throbbing and pulsating in nature and lasts from 2 to 72 hours.


Presentation

Migraine occurs in two forms. The first type is a migraine with an aura called classic migraine and the second form is a migraine without an aura called common migraine.

In the classic form of migraine, there is a phase of aura just before the headache appears. The most common aura observed is a visual aura. Patient reports of a temporary loss of vision partly or completely, flashes of light, objects appear to move, or shake. The other forms include difficulty in speaking, food cravings, getting an odd smell. Sometimes there is numbness starting from the hands and spreading upwards towards arms and gradually involving face, lips and tongue. These auras last for a few minutes before the headache appears.

The migraine without an aura presents with a unilateral or bilateral pain in head, usually beginning on the frontal or temporal side and spreading throughout the head [5]. The pain is usually pulsating or throbbing. The pain starts gradually and then becomes worse within 2 to 12 hours. Along with the head pain, symptoms such as severe nausea, vomiting, photosensitivity, blurriness of vision and sweating are also accompanied [6].

Fatigue
  • However, the pathophysiological concept behind this term is not undisputed and typical migraine premonitory symptoms such as fatigue and yawning, but also a typical association of attacks to circadian and menstrual cycles, all make the hypothalamus a[ncbi.nlm.nih.gov]
  • We evaluated in all patients the pericranial tenderness, anxiety and depression tracts, headache-related disability, sleep features, quality of life, allodynia and fatigue. We scored a total of 16,578 attacks, distributed in the entire day.[ncbi.nlm.nih.gov]
  • […] usually lasts from four hours to three days, typically begins on one side of the head but may spread to both sides, is often accompanied by nausea, vomiting, and sensitivity to light or sound, and is sometimes preceded by an aura and is often followed by fatigue[merriam-webster.com]
  • Side effects of beta-blockers include: Fatigue Depression Nausea Insomnia Dizziness Lowered blood pressure Calcium channel blockers can cause: Weight gain Constipation Dizziness Low blood pressure Tricyclic antidepressants are associated with: Weight[rxlist.com]
Pallor
  • Symptoms include abdominal pain without a gastrointestinal cause (may last up to 72 hours), nausea, vomiting, and flushing or paleness (pallor). Children who have abdominal migraine often develop typical migraine as they age.[healthcommunities.com]
  • Sensitivity to light, noise and odors Nausea and vomiting, stomach upset, abdominal pain Loss of appetite Feeling very warm (sweating) or cold (chills) Pale color (pallor) Feeling tired Dizziness Blurred vision Tender scalp Diarrhea (rare) Fever (rare[my.clevelandclinic.org]
  • […] light-headedness, and confusion. [2] Nausea occurs in almost 90% of people, and vomiting occurs in about one-third. [38] Many thus seek a dark and quiet room. [38] Other symptoms may include blurred vision , nasal stuffiness, diarrhea, frequent urination, pallor[en.wikipedia.org]
Vomiting
  • Nausea, vomiting, and anorexia of migraine may lead to mild to moderate thiamine deficiency and WE.[ncbi.nlm.nih.gov]
  • Vomiting, visual, or sensory disturbance and absent focal signs are more frequent in migraine. Identifying features of AIS and migraine guides neuroimaging in children with brain attack symptoms.[ncbi.nlm.nih.gov]
  • Nausea and vomiting are a frequent accompaniment of migraine and anti-nausea medications are frequently used in its management.[ncbi.nlm.nih.gov]
  • Within a few minutes of injection of subcutaneously of follitropin beta, a 27-year-old woman developed a feeling of fever, headache, nausea, vomiting dizziness, and a visual aura consistent with migraine syndrome.[ncbi.nlm.nih.gov]
  • Treating nausea and preventing vomiting If you have nausea without vomiting, your doctor may suggest medication to ease nausea called anti-nausea or antiemetic drugs . In this case, the antiemetic can help prevent vomiting and improve the nausea.[healthline.com]
Nausea
  • Nausea and vomiting are a frequent accompaniment of migraine and anti-nausea medications are frequently used in its management.[ncbi.nlm.nih.gov]
  • Nausea, vomiting, and anorexia of migraine may lead to mild to moderate thiamine deficiency and WE.[ncbi.nlm.nih.gov]
  • Five subjects (2.1%) discontinued due to adverse events, which included mild throat tightness (n   2), moderate hernia pain (n   1), moderate hypersensitivity (n   1), and 1 subject with mild nausea and moderate injection site swelling.[ncbi.nlm.nih.gov]
  • For nausea or vomiting, nasal sprays, rectal or parenteral forms of medications are used. In case of rebound headaches, opioid combinations, butalbital and butorphanol nasal sprays and combinations are used.[symptoma.com]
  • Within a few minutes of injection of subcutaneously of follitropin beta, a 27-year-old woman developed a feeling of fever, headache, nausea, vomiting dizziness, and a visual aura consistent with migraine syndrome.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Four members of the family had recurrent abdominal pain and/or motion sickness in childhood.[ncbi.nlm.nih.gov]
  • Although not common, the most prevalent migraine equivalent is “abdominal migraine”, which is characterized by recurrent episodes of vomiting and abdominal pain without headache.[headaches.org]
  • pain, dizziness, vertigo, or unilateral weakness or paralysis) and may be accompanied by headache abdominal migraine vestibular migraine In retinal migraine , repeated episodes of unilateral visual disorder occur with or without headache. — Sid Gilman[merriam-webster.com]
Diarrhea
  • The most common adverse events that led to discontinuation were injection site erythema (n   3), injection site induration (n   2), diarrhea (n   2), anxiety (n   2), and depression (n   2).[ncbi.nlm.nih.gov]
  • Signs and Symptoms Diagnosis Treatment Signs and symptoms of migraine headaches include: Abnormal body sensations, called paresthesias, such as tingling, numbing or prickling Diarrhea Dizziness or vertigo Nausea and vomiting Scalp tenderness Sensitivity[ucsfhealth.org]
  • Side effects of topiramate include: Weakness Fatigue Drowsiness Dizziness Confusion Difficulty concentrating Tingling of hands and feet Loss of appetite Diarrhea Impotence Weight loss The side effects associated with the herbals used for migraines include[rxlist.com]
  • Sensitivity to light, noise and odors Nausea and vomiting, stomach upset, abdominal pain Loss of appetite Feeling very warm (sweating) or cold (chills) Pale color (pallor) Feeling tired Dizziness Blurred vision Tender scalp Diarrhea (rare) Fever (rare[my.clevelandclinic.org]
Neck Pain
  • Migraineurs have a high prevalence of neck pain prior to or during headache attacks.[ncbi.nlm.nih.gov]
  • Other side effects of BOTOX include: dry mouth, discomfort or pain at injection site, tiredness, headache, neck pain, eye problems: double vision, blurred vision, decreased eyesight, drooping eyelids, swelling of eyelids, dry eyes; and drooping eyebrows[botoxchronicmigraine.com]
  • Symptoms can include: Feeling mentally dull, like your thinking is not clear or sharp Needing more sleep Neck pain Exams and Tests Your provider can diagnose migraine headache by asking about your symptoms and family history of migraines.[mountsinai.org]
  • Patients may also experience nausea, vomiting, anorexia, neck pain, dizziness, changes in hearing, light sensitivity, difficulty concentrating, facial numbness or weakness and other symptoms.[migrainepal.com]
Blurred Vision
  • Migraines often come with side effects like nausea and blurred vision, and they often affect just one side of the head. The word comes from the Greek hemi-, "half" and kranion, "skull."[vocabulary.com]
  • The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice,[botoxchronicmigraine.com]
  • vision – 44 percent Aura – 36 percent Vomiting – 29 percent Other symptoms include: Sensitivity to smell Stiff neck Dizziness or dizzy spells Cloudy vision or other vision changes Weakness[migraine.com]
  • You should ALWAYS call your health care provider when: Your headache is accompanied by a fever Your headache persists for more than a few hours or returns frequently You are experiencing blurred vision It is ALWAYS important to let your health care provider[americanpregnancy.org]
Photophobia
  • At 2 h postdose, DFN-11 was also significantly superior to placebo for freedom from photophobia (P     0.0056) and phonophobia (P     0.0167).[ncbi.nlm.nih.gov]
  • […] respectively, pain freedom rates were 57.6%, 64.6%, 61.6%, and 66.3%; pain relief rates were 83.4%, 88.4%, 84.1%, and 81.7%; most bothersome symptom (MBS)-free rates were 69.0%, 76.5%, 77.7%, and 74.7%; nausea-free rates were 78.1%, 84.6%, 86.5%, and 85.7%; photophobia-free[ncbi.nlm.nih.gov]
  • […] patients in US and 32.5 million patients in the EU Migraine affects 6% of men and 18% of women - often hormonally related There is a strong genetic component in 70% of migraine sufferers Migraine attacks are characterized by headache, nausea/vomiting, photophobia[tevapharm.com]
  • Other symptoms and signs of migraines Many people describe their headache as a one-sided, pounding type of pain, with nausea and sensitivity to light, sound, or smells (known as photophobia, phonophobia, and osmophobia).[medicinenet.com]
Scotoma
  • […] across the visual field … — Natalie Angier b : a condition that is a variant form of the typical migraine but in which headache is absent or not a prominent symptom: (1) : a condition in which an aura involving visual disturbances (such as diplopia , scotoma[merriam-webster.com]
  • {C} {C} Example of a central scotoma as described by a person who experiences migraines. Note the visual loss in the center of vision. {C} {C} Another example of a central scotoma as described by a person who experiences migraine headaches.[emedicinehealth.com]
  • Most auras are visual and are described as bright shimmering lights around objects or at the edges of the field of vision (called scintillating scotomas) or zigzag lines, castles (teichopsia), wavy images or hallucinations.[healthcommunities.com]
Diplopia
  • […] geometric forms across the visual field … — Natalie Angier b : a condition that is a variant form of the typical migraine but in which headache is absent or not a prominent symptom: (1) : a condition in which an aura involving visual disturbances (such as diplopia[merriam-webster.com]
  • […] language problems problems moving or weakness, which may last up to 72 hours brainstem symptoms, which includes: difficulty talking or dysarthria (unclear speech) vertigo (a spinning feeling) tinnitus or ringing in the ears hypacusis (problems hearing) diplopia[healthline.com]
  • Basilar Migraine or Basilar Artery Migraine (BAM ) Basilar Migraine , also known as Bickerstaff ‘s syndrome(1961), consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual symptoms in both hemifields of both eyes, diplopia[dizziness-and-balance.com]
Eye Pain
  • Eye pain, which is different from sensitivity to light, is not a common component of migraine. If eye pain is persistent, or if eye pain is present and accompanied by blurred vision or loss of vision, then prompt evaluation is recommended.[medicinenet.com]
  • Most often, the vision is affected and can include any or all of the following: Temporary blind spots or colored spots Blurred vision Eye pain Seeing stars, zigzag lines, or flashing lights Tunnel vision (only able to see objects close to the center of[mountsinai.org]
Tenderness of the Scalp
  • People may also experience tenderness of the scalp, neck and shoulder muscles, the Mayo Clinic outlines. Headaches are classified into two categories: episodic and chronic. Episodic tension headaches can last anywhere from 30 minutes to a week.[globalnews.ca]
  • […] of the scalp may occur as can neck stiffness. [39] Associated symptoms are less common in the elderly. [40] Rarely, an aura occurs without a subsequent headache. [31] This is known as an acephalgic migraine or silent migraine; however, it is difficult[en.wikipedia.org]
Facial Numbness
  • Patients may also experience nausea, vomiting, anorexia, neck pain, dizziness, changes in hearing, light sensitivity, difficulty concentrating, facial numbness or weakness and other symptoms.[migrainepal.com]
Headache
  • There were 168/412 (40.8%) patients with headaches in the FA group compared to 368/1691 (21.8%) patients with headaches in the no FA group (OR 4.68; P   0.002).[ncbi.nlm.nih.gov]
  • A previously healthy 21-year-old white woman presented with a severe headache and was diagnosed with severe migraine headache disorder. She initially was treated with standard migraine headache medications without symptomatic improvement.[ncbi.nlm.nih.gov]
  • Patients with comorbid fibromyalgia and migraine report more depressive symptoms, higher headache intensity, and are more likely to have severe headache related disability as compared to controls without fibromyalgia.[ncbi.nlm.nih.gov]
  • Current headache forecasting models represent an important first step in accurately predicting future headache activity.[ncbi.nlm.nih.gov]
  • International Headache Society (IHS) has placed this form of headache among the headaches disorders of homeostasis. We found a case of new-onset HDH in old uremic man, presenting with migraine aura features.[ncbi.nlm.nih.gov]
Aura
  • There is limited literature on prolonged aura (PA - defined as an aura including at least one symptom for  1 h and   7d), and there are no prospective studies.[ncbi.nlm.nih.gov]
  • Visual auras are the most common auras of migraine, and migraine is considered as the most common cause of transient vision loss in young patients. Sensory auras are the second most common migrainous auras.[ncbi.nlm.nih.gov]
  • The resultant symptoms may semiologically mimic visual aura. Migraine-like visual aura in this patient was successfully treated with dabigatran.[ncbi.nlm.nih.gov]
  • This case report of migraine with multiple sensory auras spanning somatosensory, auditory, and olfactory modalities offers novel insights into the pathophysiology of migrainous auras.[ncbi.nlm.nih.gov]
  • Here, we prove the epileptic origin of the visual auras, which have been misdiagnosed as migraine or migralepsy before.[ncbi.nlm.nih.gov]
Stroke
  • Major adverse cardiovascular and cerebrovascular events (MACCE), stroke (ie, ischaemic, haemorrhagic or non-specified), myocardial infarction (MI) and all-cause mortality. The outcomes were reported at the longest available follow-up.[ncbi.nlm.nih.gov]
  • The article also discusses the clinical implications of migraine as a risk factor for stroke along with possible treatment recommendations.[ncbi.nlm.nih.gov]
  • To estimate the strengths of association between clinical features and migraine or arterial ischaemic stroke (AIS) in children presenting to the emergency department.[ncbi.nlm.nih.gov]
  • Some strokes cause a sudden severe headache, which could be mistaken for migraine. There’s also a rare type of stroke called a migrainous stroke that causes lasting neurological symptoms.[bupa.co.uk]
  • A contrast-enhanced magnetic resonance imaging of the brain was performed which revealed findings suggestive of stroke-like migraine attacks after radiation therapy (SMART) syndrome.[ncbi.nlm.nih.gov]
Dizziness
  • Within a few minutes of injection of subcutaneously of follitropin beta, a 27-year-old woman developed a feeling of fever, headache, nausea, vomiting dizziness, and a visual aura consistent with migraine syndrome.[ncbi.nlm.nih.gov]
  • The figure above shows the distribution of migraine with dizziness in a subset of patients from the dizziness practice of the author .[dizziness-and-balance.com]
  • The most common adverse effects noted included somnolence, dizziness and behavioural effects but generally did not require discontinuation.[ncbi.nlm.nih.gov]
  • A vestibular migraine can cause vertigo, dizziness, nausea and vomiting with or without the throbbing headache that is typical of most migraines .[hopkinsmedicine.org]
Confusion
  • A middle-aged man presented with intermittent episodes of a brief sensation of explosion in the head, visual flashing, vertigo, hearing loss, tinnitus, confusion, ataxia, dysarthria, and bilateral visual impairment followed by migraine headache.[ncbi.nlm.nih.gov]
  • The ACC plays an important role in the frontal attentional control system and acute confusion. This dysfunction of the dorsal ACC might represent an important ACM pathophysiology.[ncbi.nlm.nih.gov]
  • Tension headaches are sometimes confused with migraine. These are the common headaches that most people have from time to time. See separate leaflet called Tension Headache for more details .[patient.info]
  • You might feel: Elated Drained and washed out Confused Moody Dizzy Sensitive to light and sound See Your Doctor Immediately If: You have abrupt, severe headaches. Your headaches begin for the first time after age 50.[m.webmd.com]

Workup

Migraine is diagnosed clinically [9]. Blood tests are not usually helpful. An MRI is only advised in cases where the auras are prolonged and persistent or in cases of post traumatic migraine. MRI detects white mater abnormalities.

Slowing
  • After 15minutes, posterior slow waves appeared over the migrainous hemisphere, spreading progressively towards anterior regions: first the central region (5minutes after onset of contralateral hemiplegia), then the frontal region and over both hemispheres[ncbi.nlm.nih.gov]
  • Acute confusional migraine (ACM) shows typical electroencephalography (EEG) patterns of diffuse delta slowing and frontal intermittent rhythmic delta activity (FIRDA).[ncbi.nlm.nih.gov]
  • In contrast to BPA, a slow component of waveforms related to the skin redness changed significantly less than BPA highlighting the latter parameter as the potential sensitive biomarker of capsaicin-induced activation of the blood flow.[ncbi.nlm.nih.gov]
  • And they're the result of your brain's visual cortex ramping up and slowing down.[prevention.com]
  • The general principle observed while giving a prophylactic is to start slow and increase the dose gradually and to get a trial of 2 to 3 months done before administration.[symptoma.com]

Treatment

Acute attacks are treated with drugs such as aspirin, acetaminophen or NSAIDs such as ibuprofen. Other sets of drugs include class of triptans like zolmitriptan, almotriptan and frovatriptan. Certain ergot derivatives such as ergotamine and tartrate also help in treating migraine. They are contraindicated in patients with underlying heart disease or high blood pressure.

The acute treatment lasts for maximum 2 to 3 days per week. For nausea or vomiting, nasal sprays, rectal or parenteral forms of medications are used. In case of rebound headaches, opioid combinations, butalbital and butorphanol nasal sprays and combinations are used [4] [6].

Prognosis

The prognosis of migraine is variable and is poorly studied. The long term prognosis studied of a recent population showed 10% complete remission and 84% of partial remission. It was also found that the remission occurs as the age progresses and psychological makeup of the individual highly influences the persistence of the migraine with regards to its frequency and intensity [4].

Etiology

Though the exact cause for migraine remains unknown, there are certain theories postulated as its probable causes. The most common factor thought to initiate migraine is a complex dysfunction within the central nervous system. The neurotransmitter called serotonin is an important factor causing this dysfunction. It was observed that patients with migraine have significantly low levels of serotonin in their brains. Also, studies confirm that people on antidepressants tend to have a rise in serotonin levels which reduces the frequency of migraine.

Another factor is melatonin. Melatonin is an active metabolite of serotonin. Deficiency of this metabolite triggers migraines. A genetic link confirms the inheritance of the disease. It has been confirmed that individuals having a DNA variant on chromosome 8 between genes called PGCP and MTDH/AEG-1 has been related to carry a greater risk of migraine. The estimated theory for the pathogenesis is that a neurotransmitter called glutamate regulated by the DNA variant gets accumulated in the brain resulting into migraine.

Finally, the trigger factors which contribute to the cause of these attacks are dietary factors which include irregular meals, fasting for long hours, having cheese, chocolates, caffeine, foods containing an ingredient called tyramine, and certain citrus fruits.

Environmental factors include loud noises, strong smell exposure, direct exposure to glaring lights or VDU screens, red wine, head trauma, motion sickness, weather changes, cold stimulus such as ice creams and smoke. Psychological factors include excess stress, anxiety, depression, and lack of sleep. Certain medications linked with migraine triggers include oral contraceptive pills [1].

Migraine also affects women in large proportion suggesting a hormonal link. The drop in estrogen level at the luteal phase of the menstrual cycle appears to be the likely trigger to migraine.

Epidemiology

The average prevalence of migraine in a year is about 18% in women and 6% in males. Statistics reveal that the age in which migraine attacks are commonly observed is between 25 to 50 years. Attacks before the age of 20 years are accounted to be 50% and that above 50 years are barely 2%.

Individuals with a positive family history are at a greater risk of suffering from migraine, its incidence being 70%. Lifetime prevalence accounts to 20% in females and 8% in males. In the United States, the prevalence among the low income groups is more than those with a high income. It is common amongst the Canadians, fair among the African Americans and lowest among the Asian Americans [2].

Sex distribution
Age distribution

Pathophysiology

During the twentieth century, vascular dysregulation was believed to result in migraine. According to this hypothesis, transient vasoconstriction of the blood vessels resulted into aura, preceding migraine and the actual pain resulted due to rebound vasodilatation. This hypothesis had evidence based on certain vasodilating drugs such as nitroglycerin, which caused pain and vasoconstrictor drugs like ergotamine which relieved the attack.

Currently, neuronal dysfunction is considered as the most possible primary factor in the pathophysiology of migraine. This includes activation of trigeminovascular system, cortical spreading depression and neuronal sensitization.

Activation of trigeminovascular system: It involves sensory neurons from the trigeminal ganglion and upper cervical dorsal roots. These innervate the dural vascular structures such as the Dura mater and cerebral vessels [3]. These nerve fibers then ascend from the trigeminal nucleus to the sensory cortex via the thalamus. Thereafter, the pain occurs in the regions supplied by the trigeminal nerve.

Cortical spreading depression: This self-propagated wave spreads slowly across the entire span of the cerebral cortex reducing the bionueronal activity. It leads to inflammatory changes by activating the neurons in the trigeminal nucleus caudalis. This produces headache via the reflex actions of the central and peripheral nervous systems.

Neuronal sensitization: This is a process in which the neurons become responsive to both nociceptive and non-nociceptive stimulation. Pain is caused due to peripheral sensitization in the primary afferent neuron and central sensitization of the higher order neurons of the spinal cord [4].

Prevention

There are some medicines which help prevent the attacks of migraine. These include beta blockers such as propanolol and timolol, calcium channel blockers like verapamil and antidepressants such as amitripyline or venlafaxine [7]. The general principle observed while giving a prophylactic is to start slow and increase the dose gradually and to get a trial of 2 to 3 months done before administration.

Certain lifestyle changes are highly recommended, in order to reduce and prevents the frequency and intensity of migraine attacks [8]. These include eating healthy foods, maintaining adequate amount of sleep daily without altering its timings, to avoid any conditions which are known to trigger migraine, reduce alcohol, meditation and limiting stress and worry [10] [11].

Summary

The word migraine is derived from a Greek word hemikrainia. This term was translated to French and called migraine.

Migraine is a chronic nervous system disorder characterized by recurrent headaches, intense in character. About 28 million people in United States suffer from migraine. About 25% of migraine sufferers experience a pre-migraine phenomenon called aura.

Patient Information

A migraine comprises of an intense unbearable headache which is throbbing and pulsating in character. This is usually accompanied by sensation of nausea, vomiting and a heightened sensitivity to light with or without audio-visual disturbances.

The migraine attacks can stay for few minutes to hours or even for days together. Some of these attacks are preceded by aura such as flashes of light before eyes, altered consciousness or numbness of limbs. Stress, fasting for long hours, lack of sleep are found to trigger migraine. Hence these lifestyle changes are advised to prevent migraine [11]. Diagnostic tests are of little use in diagnosing a migraine and prognosis is generally good.

References

Article

  1. Allais G, Gabellari IC, De Lorenzo C, Mana O, Benedetto C. Oral contraceptives in migraine. Expert Rev Neurother. Mar 2009;9(3):381-93.
  2. Cutrer, FM. Pathophysiology of migraine. Semin Neurol. 2010 Apr; 30(2):120-30.
  3. Spierings EL. Pathogenesis of the migraine attack. Clin J Pain. 2003 Jul-Aug;19(4):255-62.
  4. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of Migraine Headache in the United States Relation to Age, Income, Race, and Other Sociodemographic Factors. JAMA. 1992;267(1):64-69.
  5. Pietrobon D, Striessnig J. Neurobiology of migraine. Nat Rev Neurosci. 2003 May 1; 4(5)386–398.
  6. Skaer TL. Clinical presentation and treatment of migraine. Clin THer. 1996 Mar-Apr;18(2):229-45; discussion 228.
  7. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Neurology. 2012 Apr 24;78(17):1337-45.
  8. Elrington G. Migraine: diagnosis and management. J Neurol Neurosurg Psychiatry. 2002 Jun; 72 Suppl 2:ii10-ii15.
  9. Hildreth CJ, Lynm C, Glass RM. Migraine Headache. JAMA. 2009 June 24; 301(24).
  10. Goadsby PJ. Stress and migraine: something expected, something unexpected. Neurology. 2014 April 22;82(16)1388-9.
  11. Lipton RB, Buse DC, Hall CB, Tennen H. Reduction in perceived stress as a migraine trigger Testing the “let-down headache” hypothesis. Neurology. 2014 April 22; 82(16): 1395-1401.

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Last updated: 2017-08-09 18:11