Rose Nina-Estrella*, M.D. , Ph.D., Ana Delia Figueroa*, M.D.
Migraine is one of the primary headaches most important and best studied. The most common primary headaches are tension-type headache, cluster headache and other primary headaches. Migraine is a common disabling primary headache disorder. Epidemiological studies have documented its high prevalence and high socio-economic and personal impacts. In the Global Burden of Disease Survey 2010, it was ranked as the third most prevalent disorder and seventh-highest specific cause of disability worldwide [1].
The diagnosis of migraine is based on patient history and the International Headache Society diagnostic criteria are that patients must had at least 5 headache attacks that lasted 4–72 hours and that the headache must have had at least 2 of the following characteristics: [1] unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity. Also, during the headache the patient must have had at least 1 of the following: nausea and/or vomiting, photophobia and phonophobia. Finally, these features must not have been attributable to another disorder [1].
 The classification of migraine in a brief review is as follows: [2]
Migraine without aura (formerly, common migraine)
Probable migraine without aura
Migraine with aura (formerly, classic migraine)
Probable migraine with aura
Chronic migraine
Chronic migraine associated with analgesic overuse
Childhood periodic syndromes that may not be precursors to or associated with migraine
Complications of migraine
Migrainous disorder not fulfilling above criteria
The signs and symptoms of migraine are describe in typical symptoms: pulsatile headache, with moderate to severe pain that intensifies with movement or physical activity, unilateral pain in the frontotemporal and ocular area, but the pain may be felt anywhere around the head or neck, pain builds up over a period of 1–2 hours, progressing posteriorly and becoming diffuse, headache lasts 4–72 hours, nausea (80%) and vomiting (50%), including anorexia and food intolerance, and light-headedness, sensitivity to light and sound [2].
The features of migraine aura are as follows: precede or accompany the headache phase or may occur in isolation, develops over 5–20 minutes and lasts less than 60 minutes, most commonly visual but can be sensory, motor, or any combination of these, visual symptoms may be positive or negative and the most common positive visual phenomenon is the scintillating scotoma, an arc or band of absent vision with a shimmering or glittering zigzag border. Also they are physical findings during a migraine headache [2]. Migraine treatment involves acute (abortive) and preventive (prophylactic) therapy. Patients with frequent attacks usually require both. The acute (abortive medications) has the purpose to reverse or stop the progression of, a headache. It is most effective when given within 15 minutes of pain onset and when pain is mild [3].Â
The abortive medications include the following: Selective serotonin receptor (5-hydroxytryptamine–1, or 5-HT1) agonists (triptans), analgesics, ergot alkaloids (eg, ergotamine, dihydroergotamine [DHE]), nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics and combination products. The preventive medications are prescribed in the frequency of migraine attacks is greater than 2 per month, duration of individual attacks is longer than 24 hours, the headaches cause major disruptions in the patient's lifestyle, migraine variants such as hemiplegic migraine or rare headache attacks producing profound disruption or risk of permanent neurologic injury[4].
 The prophylactic medications include the following: antiepileptic drugs, beta blockers tricyclic antidepressants, calcium channel blockers, selective serotonin reuptake inhibitors (SSRIs), NSAIDs, serotonin antagonists, botulinum toxin ,calcitonin gene-related peptide (CGRP) inhibitors [2]. There are other measures to considered in the migraine treatment: reduction of migraine triggers ( eg.,fatigue, strees, certain foods, insomnia), no pharmacologic therapy and integrative medicine.
Case Summary
A 64 year old female presented with 50 years history of recurrent episodes of migraine headache of unilateral severe pain predominantly left hemisphere and localized pain in the frontotemporal and ocular area, but the pain may be felt anywhere around her head or neck. Most of the migraine attacks without aura, but sometimes in some episodes associated with visual or sensory symptoms (aura). She presented the most common visual symptom a scintillating scotoma or a band of absent vision, that arise most often before the head pain occurred during or afterward. This patient has a strong genetic component, her both parents suffered migraine headache with aura. Duration of pain was about 3 days lasting from 24 to 72 hours. Attacks came almost 3-4 times in a week, predominantly in the morning after breakfast or evening, accompanied with some of the typical symptoms: nausea, vomiting, food intolerance, sensitivity to light and sound. She received pharmacologic treatment during her life in acute attacks and preventive with: selective serotonin receptor, triptans, ergot alkaloids (eg, ergotamine, dihydroergotamine [DHE]), analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), but never with non- pharmacologic, like neurostimulation , specific with repetitive trasncraneal magnetic stimulation.
On failure of medical management during her life the patient arrived in our outpatient psychiatric clinic, knowing that we have a non-invasive brain stimulation (NIBS) technique such as repetitive transcranial magnetic stimulation (rTMS) ( first in the country). She was seeking for a new option of treatment for her migraine attacks. This method (rTMS) is emerging as a potential clinical intervention against migraine [5].
 She received the informed consent and accepted to be followed as a case study. She was evaluated, just to be cleared in other possible causes of headache and excluded psychiatric conditions with Hamilton Rating Scale tests for depression and anxiety, [6][7]. Also were indicated laboratory tests and all were normal. We confirmed her diagnosis of migraine without aura based on her history and according to diagnostic criteria established by the International Headache Society.
 The Neuro-MS/D magnetic stimulator for repetitive transcraneal magnetic stimulation (rTMS) was used. The stimulation parameters protocol were set at a low frequency: 1Hz, power MT : 90 % , left dorsolateral prefrontal cortex (DLPFC) , number of pulses per session: 1,025 pulses , number of session : 20 sessions (four weeks) and the Hot spot of the patient: MT:43%.
The rTMS treatment was carried out in the month of July 2019 and was applied as a preventive migraine treatment. Prophylactics medication was not prescribed when she was on rTMS therapy. The patient was asked to make a daily record of her symptoms during the four weeks of rTMS treatment (Table 1).
The patient was followed weekly during the rTMS treatment with a good response with respect to number of attacks/ day. The patient presented her first migraine attack 10 weeks after the rTMS, she referred that was less severe and last for two hours, she treated with analgesics.
 In 10 October 2019 started the patient the maintenance of the rTMS treatment, two sessions per week until complete 10 sessions in 15 November 2019.  During the maintenance of the rTMS she presented no migraine attacks. Â
Our patient showed acute and long term improvement with rTMS as evidenced by one migraine attack presented in 5 months of treatment with r TMS . Finally the patient  decreased numbers of attacks/days, no migraine attacks for 10 weeks and decreased in hours of the only migraine episode that suffered. Also during and after the 10 sessions of maintenance of the rTMS there were no migraine attacks. She expressed to us the great satisfaction she feels with the results achieved by this r TMS treatment.