One accepts that the headache of migraine may be almost exclusively on one side of the head but the invariant occurrence of migraine-like headache on the same side of the head increases the likelihood of an underlying arteriovenous malformation (AVM) or other structural lesion. R.D. Adams, who studied more than 1,200 patients with AVM found that the headaches, which occurred in more than 30 percent of these individuals, usually did not include the other features of either migraine or cluster headache. However, in about 5 percent, the headaches were associated with visual aura, making them indistinguishable from migraine with aura. In most, the AVM was in the occipital region and on the side of the headache. Approximately half of the patients with AVM and migraine had a family history of migraine. It is unclear to us if AVM can be regarded as an acknowledged cause of recurrent migraine-like headache. It is, of course, possible that given the ubiquity of migraine in the population, that the association is coincidental.
Treatment of Migraine
This topic may be divided into two parts—control of the individual acute attack, and prevention that includes both the use of medications and of lifestyle modifications. The time to initiate treatment of an acute attack is during the neurologic (visual) prodrome or at the very onset of the headache (see below). If the headaches are mild, the patient may already have learned that aspirin, acetaminophen, or another nonsteroidal anti-inflammatory drug (NSAID) will suffice to control the pain. Insofar as a good response may be obtained from one type of NSAID and not another, it may be advisable to try two or three preparations in several successive attacks of headache and to use moderately high doses if necessary. The combination of aspirin or acetaminophen, caffeine, and butalbital, although popular with some patients, is usually incompletely effective if the headache is severe and is also capable of causing dependence. Numerous other medications have proved effective and each has had a period of popularity among neurologists and patients.
Because of the differing modes of absorption the ideal timing differs for administration of each type of preparation. The ostensible goal is attain a high concentration of the drug at the onset of headache. For severe attacks of migraine headache, sumatriptan or one of the other serotonin agonist “triptans” in this class (e.g., zolmitriptan, rizatriptan, naratriptan, almotriptan, eletriptan, and frovatriptan), or the ergot alkaloids, ergotamine tartrate, and particularly dihydroergotamine (DHE), are the effective forms of treatment and are best administered early in the attack, ideally just after a visual aura or at the onset of headache. Patients with waning visual auras should be advised to wait to self-administer subcutaneous serotonin agonists until the headache begins. Clinical experience and the study by Bates and colleagues suggests that the subcutaneous triptans are ineffective in preventing headache if given during the aura; they are however, probably safe (see below). In contrast, the slightly slower acting nasal spray or the even slower acting oral formulations are often ineffective if given too long after the start of headache. Patients have therefore learned to administer the nasal and oral preparations during the aura and the subcutaneous drugs as close to the onset of headache as possible.