10 Chapter 1 CHARACTERISTICS AND DIAGNOSIS OF MIGRAINE Migraine is a multifactorial episodic brain disorder characterised by recurring headache attacks. Diagnosis is based solely on clinical characteristics. Typically, the headache presents with a throbbing quality, moderate to severe pain intensity, unilateral localization, and worsening with routine physical activity, lasting up to 72 hours.1 In addition to the headache, attacks are accompanied by photophobia and phonophobia or nausea or vomiting. These diagnostic criteria are outlined in the International Classification of Headache Disorders, third edition (ICHD-3), and summarized in Table 1.1 About one third of patients experience an aura prior to or during the headache phase (migraine with aura). The aura may include visual, sensory, speech/language and (rarely) motor symptoms. It nearly always begins with visual symptoms, in which patients see scotomas, glitter, lightning, spots or other figures. These symptoms gradually expand in minutes, and two or more aura symptoms may also occur consecutively. Each individual aura symptom lasts from 5 to 60 minutes. At least one aura symptom is often present unilaterally. The phase between aura symptoms and headache usually lasts up to 60 minutes, but an aura can also occur without a headache (migraine with aura without headache). Thus, migraine is a heterogeneous disorder with multiple subtypes. In the ICHD-3, a distinction is also made between episodic and chronic migraine. Chronic migraine is defined as headache on ≥15 days per month for ≥3 months. Among them, headaches on ≥8 days per month must fulfill the criteria for a migraine day.1 Migraine is better understood as a cyclical brain disorder that involves at least four distinct phases: interictal, preictal, ictal, and postictal.2 In the preictal phase, a large proportion of patients with migraine experience prodromal symptoms before the headache or aura occurs, such as fatigue, yawning, cravings for certain foods or a stiff feeling in the neck. These can occur as early as 48 hours before the headache or aura phase occurs and are most likely the result of hypothalamic activation.3 Since many women report fatigue and cravings for certain foods, such as chocolate, during this prodromal phase, it often resembles the premenstrual phase in terms of symptomatology.4 The ictal phase is the most well defined and follows the definition of a migraine attack, lasting from 30 minutes up to several days. The postictal or the postdromal phase is the period after the headache, characterized by symptoms
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