Pain Management

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Assessing and Treating Complex Migraine



Proper diagnosis and treatment requires that physicians and patients understand the symptoms and clinical presentation of this complicated migraine condition.

The first issue to note when discussing this topic is nosological. That is, the term “complicated migraine” is not typically used by headache specialists, but it may be used by other physicians or by patients. The terms “complex migraine” or “atypical migraine” are now used in its stead. The National Headache Foundation (www. headaches.org) describes complicated/complex migraine as those migraine headaches associated with extended or exaggerated visual migrainous auras. Complex migraine has also been defined as referring to attacks of prolonged aura symptoms that could last hours to days, or situations in which patients develop ophthalmoplegic migraine, which is associated with partial paralysis of the cranial nerves used to move the eye. Still another definition equates a cerebral infarction with complex migraine. Given the existence of multiple definitions describing a range of clinical characteristics, it should be obvious that there is not a real consensus regarding this term. The reality is that atypical or complex migraine comes in several varieties, several major forms of which we’ll discuss in this article.

Soon after I started practice as a headache and pain specialist, I had a 24-year-old female patient with migraine with visual aura who smoked and took estrogenic birth control pills (BCP). She stroked out the upper-left quadrant of her visual fields. This experience changed the way I treated migraine with aura. Even though some headache specialists disagree, I would not treat a migraine-with-aura patient who smoked and took BCPs. Some physicians didn’t think the combination would create problems. I felt differently.

Basically, after an aura lasting 5 to 60 minutes or so, during which time a neurological aura begins, a severe headache starts.

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