Neurology
Migraine
편두통
Pulsatile unilateral headache from trigeminovascular activation
- How common
- Women 18%, men 6%
- Typical age
- Peak 20–40s
What is it?
Cortical spreading depression activates trigeminal neurons → CGRP release, neurogenic inflammation, vasodilation.
Commonly affected: Unilateral temporal/orbital (V1 distribution)
How it develops
- Cortical spreading depressionWave of cortical activity starting occipitally (aura)
- Trigeminal activationV1 trigeminal nerve activated
- CGRP releaseDural vessel dilation, plasma extravasation
- Central sensitizationThalamic and cortical pain amplification
Symptoms
- Pulsating headacheUnilateral, lasting 4–72 hours
- Nausea/vomitingCommon during attacks
- Photo/phonophobiaHypersensitive to light and sound
- Visual auraZigzag, scintillation, scotoma; 5–60 min
- Worse with activityWorsens with routine activity
How it is examined
- ICHD-3 criteria≥5 attacks + 2 of 4 characteristics
- Neurological examShould be normal (focal signs → image)
- Red flags (SNOOP)New onset >50, weight loss, focal signs
Imaging
Migraine is clinical; plain imaging not needed.
- Clinical diagnosis
Brain MRI if red flags or atypical features (rule out secondary causes).
- Normal
- Punctate WM hyperintensities (uncertain significance)
Non-surgical care
- Acute: TriptanSumatriptan/rizatriptan early
- NSAID + antiemeticNaproxen + metoclopramide
- CGRP receptor antagonistGepants (rimegepant, ubrogepant)
- Prevention: beta-blockerPropranolol if ≥4 attacks/month
- LifestyleRegular sleep/meals, avoid triggers
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Refractory chronic migraine, medication failure
Procedures that may be discussed
- CGRP mAbs (erenumab, fremanezumab)
- Botulinum toxin A (chronic migraine)
- Occipital nerve stimulation
Outlook
Most controlled with medication; chronification reduces quality of life.