Triptans for Migraine Prodrome

CLINICAL HISTORY A 43-year-old woman has a history of recurrent migrainous headaches since aged 7 years. She develops blurred vision, goose bumps on her arms, slight nausea, clear nasal drainage, and a “tight” feeling in the right superior trapezius area, followed the next day by severe, incapacitating, right-sided headache with associated nausea and light sensitivity, lasting 3 days. These episodes have been occurring once monthly for the last 4 years, at varying points throughout her menstrual cycle. She is not aware of any triggers. She does not have neck pain at other times. Acute treatment with ibuprofen, acetaminophen, Excedrin, or Midrin has not helped. Neurologic examination is normal. Questions.— How common is migrainous prodrome, and what clinical features may be present? What is the pathophysiology of prodrome? Would triptan therapy during the prodrome be likely to be beneficial? EXPERT COMMENTARY This patient suffers from migraine without aura. The International Headache Society uses the term premonitory to describe symptoms that may precede headache by up to 48 hours, but some authors prefer the term prodrome. Prodrome should be distinguished from migraine aura, with the latter involving focal neurologic symptoms which typically develop gradually over 5 to 20 minutes, last less than 60 minutes, and are followed by headache within an hour. 1