GP - Migraine

Question 1

What is migraine?

Answer 1

A common primary headache disorder characterised by unilateral pulsating/ throbbing headache associated with photophobia, phonophobia, N&V +/- aura

Question 2

How long does migraine usually last?

Answer 2

4 - 72 hrs

Question 3

Headaches are divided into primary headaches and secondary headaches. Define each of them

Answer 3

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

Question 4

Some patients with migraine may experience aura.

What is aura?

Please list 3 things you would see in a migraine aura?

Answer 4

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

Question 5

How many days are in episodic migraine?

Answer 5

< 15 days

Question 6

How many days are in chronic migraine?

Answer 6

>/= 15 days/ month for more than 3 months

Question 7

What is the pathophysiology of Migraine?

Answer 7

Not understood

Question 8

Give 5 things that may precipitate/ trigger migraine?

Answer 8

Stress (most common)

Too much caffeine

Certain foods e.g. chocolate, cheese, wine, tomato

Lack of sleep

Lack of exercise

Skipped meals

Menstruation

Question 9

Is migraine more common in men or women?

Answer 9

Women

Question 10

What age range does migraine affect?

Answer 10

25 - 55 yrs old

Question 11

What is the prognosis of migraine?

Answer 11

Migraine improves with increasing age

(In women, it often gets better after menopause)

Question 12

Give 3 complications of migraine

Answer 12

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

Question 13

What is the diagnostic criteria for migraine without aura?

Answer 13

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

Question 14

What is the diagnostic criteria for migraine with aura?

Answer 14

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

Question 15

What examinations would you carry out as a GP?

Answer 15

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)

Question 16

What conditions must you rule out in migraine?

How would you rule them out?

Answer 16

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)

Question 17

What advice would you give to a patient with migraine?

Answer 17

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

Question 18

What pharmacological treatment can you give to the patient with migraine?

Answer 18

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)

Question 19

What is the contraindication of metoclopramide

Answer 19

Bowel obstruction

Question 20

When should you arrange follow up?

Answer 20

in 2-8 weeks

Question 21

What preventative treatment can you offer as a GP?

Answer 21

Propranolol/ topiramate

Question 22

When should you refer a patient with migraine?

Answer 22

Serious cause is suspected

Status migrainosus

Complication of migraine

Atypical migraine

Diagnosis uncertainty