FN: Migraine Flashcards
Epi
8% prev
F:M = 2:1
Risk factors
Obesity
PFO
Pathophysiology
- Vascular: cerebrovascular constriction - aura, dilatation - headache
- brain: spreading cortical depression
- Inflammation: activation of CN V nerve terminals in meninges and cerebral vessels
Triggers
CHOCOLATE Cheese OCP Caffeine alcohOL Anxiety Travel Excercise
Symptoms
Headaces
Prodrome
Aura
Headache types
- Aura lasting 15-30min then unilateral throbbing headache
- Phono/photophobia
- n/v
- Allodynia
- Often premenstrual
Prodrome (50%): preced migraine by hrs - days
- yawning
- Food cravings
- Changes in sleep, appetite or mood
Aura (20%): precedes migraine by mins and my persist
- visual: distortion, lines, dots, zig-zags, scotom, hemianopia
- Sensory: parasthesia (fingers - face)
- Motor: dysarthria, ataxia, ophthalmoplegia, hemiparesis (hemiplegic migraine)
- Speech: dysphasia, paraphasia
Classification
- Migraine with aura (classical migraine)
2. Migraine w/o aura (common migraine)
Diagnostic criteria
- Typical aura + headache, or
- > 5 headaches lasting 4-72h with either n/v or photo/phonophobia + >2 of:
- Unilateral
- Pulsating
- Interferes with normal life
- Worsened by routine activity
Differential
- cluster/tension headache
- Cervical spondylosis
- HTN
- Intracranal pathology
- Epilepsy
Treatment acute episode
1st: paracetamol + metoclopramide/doperidone
2nd: NSAID (e.g. ketoprofen) + M/D
3rd: rizatriptan - CI: IHD, uncontrolled HTN, SSRIs
4th: ergotamine
Prophylaxis
Avoid triggers
1st: propanolol, topiramate
2nd: Valporate, pizotifen (increased wt), gabapentin
Rule out diagnosis – Red flags
Onset after 50 (migraine does not usually come on at this age) Sudden onset (SAH) Hx of cancer metastesis Progressivaly worsening over days (abcess/tumour?) Waking patient at night (tumour) Early morning vomiting (Raised ICP) Unilateral loss of power (stroke) Seizure (tumour) Weight loss (tumour or cerebral TB) Altered consciousness (meningitis) Fever (meningitis) Immunodeficiency
Exam
Pulse and BP Optic fundi (papiloedema warrants urgent admission) Test for neck stiffness Palpate scalpe for tenderness Examine cranial nerves Neuro exam on limbs
Management
• Reassure and relieve anxiety
• Avoid precipitating dietary factors
• Trial a different contraceptive
• Simple analgesia (overuse can lead to rebound)
• Anti-emetics (domperidone or metaclopramiede)
• Triptans
Accupuncture
• Reassure and relieve anxiety
• Avoid precipitating dietary factors
• Trial a different contraceptive
• Simple analgesia (overuse can lead to rebound)
• Anti-emetics (domperidone or metaclopramiede)
• Triptans
Accupuncture
- Reassure
- Avoid dietary factors
- Try different COP
- NSAIDS
- Anti-emetics
- Triptans
- Acupuncture?
Triptans advise
Sumitriptan is available over the counter 50 mg dosage
when to consider prophylaxis
Prophylaxis is considered if >2 attacks per month or if attacks are particularly severe/prolonged
Prophylaxis
firstline
Propranolol
Prophylaxis second line
: Tricyclic or anti-epileptic drugs (sodium valproate or topiramate) are second line.
Propranolol for the use
Proven efficacy
Also treats hypertension and anxiety
Propranolol against the use
Contra-indicated by asthma and peripheral vascular disease
Amitriptyliine for the use
Also treats insomnia and depression
