Headaches Flashcards
What is the definition of a migraine?
Migraine is a chronic, genetically determined, episodic neurological disorder that usually presents in early-to-mid life.
Epidemiology of migraines
- Second most common primary headache
- Migraine is a common condition with a global prevalence of 14.7%
- F>M
- In 90% onset is before 40yrs
Risk factors for migraines
- Family history
- Female gender: migraines are three times more common in women
- Obesity
- Other important triggersinclude tiredness, lack of food, dehydration, menstruation, red wine and bright lights
- Pathophysiology
Pneumonic for triggers of Migraines
CHOCOLATE
CHOCOLATE
- Chocolate
- OralContraceptive
- Alcohol
- Anxiety
- Travel
- Exercise
Types of migraines
- Migraine without aura
- Migraine with aura
- Silent migraine(migraine with aura but without a headache)
- Hemiplegic migraine
What are classic migraines preceded by?
an aura, however, these only occur in one-third of patients.
What is the theory around ‘aura’
aura was due to cerebral vasoconstriction, whilst the subsequent headache occurred due to reflex vasodilatation.
What are the headaches in migraines due to?
- During aura serotonin levels increase causing vasoconstriction
- During the attack serotonin levels decrease lower than normal which triggers vasodilation
What is aura thought to occur due to?
cortical spreading depression, which is a propagating wave of depolarisation across the cerebral cortex causing the brain to become hypersensitive to certain stimuli
5 stages of migraines
- Premonitoryorprodromalstage (can begin 3 days before the headache)
- Aura(lasting up to 60 minutes)
- Headachestage (lasts 4-72 hours)
- Resolutionstage (the headache can fade away or be relieved completely by vomiting or sleeping)
- Postdromalorrecoveryphase
Clinical manifestations of migraines
-
Severe, unilateral, pulsating headache lasting up to 72 hours
- In children, migraines are more commonly bilateral,
- Nausea and vomiting
-
Photophobia and phonophobia
Typical aura: develops over 5 minutes, lasts 5-60 minutes and is fully reversible
Atypical aura: may last more than 60 minutes - Visual symptoms affectingoneeye
- Poor balance (e.g. vestibular migraine)
- Decreased level of consciousness
Diagnostic criteria for migraine with aura and without aura
Look it up
Investigations to rule out pathology of migraines
- CT or MRI head: rule out the cause of a secondary headache, such as a subarachnoid haemorrhage
- ESR: exclude giant cell arteritis
Differential diagnosis for migraines
- Stroke: hemiplegic migraines can mimic strokes
- Primary headaches
- Migraines
- Trigeminal autonomic cephalalgias
- Other primary headache disorders
- Secondary headaches
- Trauma
- Idiopathic intracranial hypertension
- Subarachnoid haemorrhage
- Space occupying lesion
- Giant cell arteritis
- Infection
- Drugs and medications
- Venous sinus thrombosis
- Malignant hypertension
- Temporomandibular disorder
first line prophylaxis for migraines ?
propranolol
Acute management of migraines
-
Analgesia
- Ibuprofen or aspirin or paracetamol
-
Oral triptan alone+/- paracetamol or an NSAID
- Oral sumatriptan is the first choice triptan (5-HT receptoragonist - mimic serotonin to cause vasoconstriction)
- Consider a nasal triptan over an oral triptan in peopleaged 12 to 17 years old
- Antiemetic:consider metoclopramide or prochlorperazine
- Avoid opiates: due to the risk of medication-overuse headache, dependence, and worsening nausea
Chronic management of migraines
- Headache diary:document headache frequency to illicit triggers
- Avoid triggers
-
Prophylaxis (pharmacological):
- Propranololis considered first-line
- Topiramate: contraindicated in pregnancyas it isteratogenicand reduces oral contraceptive efficacy
- Amitriptyline:low-dose may be considered
- Frovatriptanorzolmitriptan: for predictable menstrual migraines
-
Prophylaxis (non-pharmacological):
- Mindfulness:alternatives include meditation and CBT
- Acupuncture: if bothpropranololandtopiramateare ineffective or unsuitable
- Riboflavin (vitamin B2): **may be effective in some people, but avoid in pregnancy
Complications of migraines
- Depression
- Status migrainosus: a severe, debilitating migraine lasting for more than 72 hours that may warrant admission
Prognosis of migraines
- The prognosis associated with episodic migraine is generally good with treatment, whilst the frequency of headaches is thought to decrease with age.
What is the tension headache definition?
Tension-type headaches is a common primary headache disorder and can be either episodic or chronic.
Epidemiology of tension headaches
- Very common: most common primary headache
- Onset tends to be in a patients’ 20’s
- Most common between ages of 20-39
- Gradually becomes less common with advancing age
characteristis features of tension headaches
often described as a ‘tight band’ around the head or a pressure sensation. Symptoms tend to be bilateral, where as migraine is typically unilateral
tends to be of a lower intensity than migraine
not associated with aura, nausea/vomiting or aggravated by routine physical activity
may be related to stress
may co-exist with migrain
RFs for tension headaches
- Stress
- Bad posture
- Sleep deprivation
- Eye strain
- Depression
- Alcohol
- Skipping meals
- Dehydration