GP - Migraine Flashcards
What is migraine?
A common primary headache disorder characterised by unilateral pulsating/ throbbing headache associated with photophobia, phonophobia, N&V +/- aura
How long does migraine usually last?
4 - 72 hrs
Headaches are divided into primary headaches and secondary headaches. Define each of them
Primary headache is one that occurs without any underlying cause
Secondary headache is one that occurs secondary to an underlying local or systemic pathology e.g. intracerebral haemorrhage, malignancy, or infection
Some patients with migraine may experience aura.
What is aura?
Please list 3 things you would see in a migraine aura?
Aura is transient focal neurological symptoms.
Visual symptoms e.g. zigzag lines, scotoma
Sensory symptoms e.g. pins and needles
Speech/ language symptoms e.g. dysphasia
How many days are in episodic migraine?
< 15 days
How many days are in chronic migraine?
>/= 15 days/ month for more than 3 months
What is the pathophysiology of Migraine?
Not understood
Give 5 things that may precipitate/ trigger migraine?
Stress (most common)
Too much caffeine
Certain foods e.g. chocolate, cheese, wine, tomato
Lack of sleep
Lack of exercise
Skipped meals
Menstruation
Is migraine more common in men or women?
Women
What age range does migraine affect?
25 - 55 yrs old
What is the prognosis of migraine?
Migraine improves with increasing age
(In women, it often gets better after menopause)
Give 3 complications of migraine
Impaired quality of life - underperformance at school/ work
Medication overuse headache
Chronic migraine
Status migrainosis - a debilitating migraine attack lasting > 72 hrs
Seizures triggered by migraine with aura
Increased risk of both ischaemic and haemorrhagic strokes
What is the diagnostic criteria for migraine without aura?
At least 5 attacks with the following, with NO aura/ neurosensory symptoms:
Unilatera, pulsating/ throbbing pain
Photophobia (patients often enter a dark room), phonophobia, N&V
Aggravated by or causing avoidance of routine activities of daily life e.g. walking or climbing stairs
Headache lasting 4-72 hrs
What is the diagnostic criteria for migraine with aura?
At least 2 attacks with the following:
One or more typical fully reversible aura symptoms e.g. visual symptoms (zigzag lines, scotoma), sensory symptoms (pins and needles), speech/ language symptoms (dysphasia)
Each aura symptom lasts 5-60 minutes; at least one aura symptom is unilateral; The aura is accompanied or following within 60 minutes by headache
What examinations would you carry out as a GP?
BP, temperature
Fundoscopy to rule out hypertension (papilloedema)
CNS and PNS examination to rule out intracranial malignancy and haemorrhage
Examination of the neck to rule out superior vena cava syndrome
Examination of the temporal arteries to rule out GCA (esp if age > 50)
What conditions must you rule out in migraine?
How would you rule them out?
Meningitis -headache, neck stiffness, photophobia, fever, non-blanching rash (if meningococcal), Kernig sign, Brudzinski’s sign
GCA - visual symptoms (amaurosis fugax), jaw claudication and tongue numbness, tenderness on combing hair, tender pulseless engorged (bead-like) temperal artery; raised ESR + temporal artery biopsy to rule out
Space-occupying lesion - symptoms depend on the site e.g. seizures, visual symptopms if occipital region, speech and language difficulties if temporal, loss of consciousness, balancing and gait problems, neurological deficit (e.g. barbinski sign)
Raised ICP - thunderclap headache in SAH; Cushing’s triad (widened pulse pressure, bradycardia, irregular breathing)
Other forms of headaches - tension (constricting type of pain across the entire head and bilateral), cluster (retro-orbital with parasympathetic symptoms), trigeminal neuralgia (tingling pain on light touch of the CNV1 territory), sinusitis (pain over sinus areas that is worse when bending forward)
What advice would you give to a patient with migraine?
Advice:
- Advise to keep a headache diary
- Advise to avoid triggers e.g. less stress, less coffee consumption, avoid eating chocolate and cheese, better sleep hygiene, more exercise, don’t skip meals
- Medication-overuse headache is often seen in people with migraine, advise to restrict medication use to a maximum of 2 days/ week
- Advise the patient that if they have aura, triptans should be taken at the start of the headache and not at the start of the aura
- Ensure that women who have migraine with aura are not using COCP
What pharmacological treatment can you give to the patient with migraine?
Simple analgesia - paracetamol, NSAIDs
Triptans - 1st line Oral sumatriptan
Anti-emetic - metoclopramide (not to be used regularly due to extrapyramidal side effects i.e. parkinsonism, dystonia)
What is the contraindication of metoclopramide
Bowel obstruction
When should you arrange follow up?
in 2-8 weeks
What preventative treatment can you offer as a GP?
Propranolol/ topiramate
When should you refer a patient with migraine?
Serious cause is suspected
Status migrainosus
Complication of migraine
Atypical migraine
Diagnosis uncertainty
