Lec 65 Migraines

Question 1

Can symptoms differentiate between primary and secondary headache?

Answer 1

symptoms alone cannot differentiate!

Question 2

What are IHS criteria for migraine without aura?

Answer 2

• at least 5 attacks
• attacks last 4-72 hrs
• headache with 2 of: unilateral, pulsating, moderate/severe, avoidance of physical activity
• during headache N/V and/or photophobia
• not attributed to another disorder

Question 3

What are criteria for migraine with aura?

Answer 3

• headache same as non-aura PLUS
• aura has no motor weakness and consists of: fuly reversible visual OR sensory symptoms OR dysphasic speech
• homonymous visual symptoms OR unilateral sensory symptoms OR develops over 5 minutes

Question 4

When does aura occur?

Answer 4

can be before, during, or without headache

Question 5

are migraines unilateral or bilateral? how long does it last?

Answer 5

usually unilateral

lasts 4-72 hours

Question 6

What is episodic vs chronic migraine?

Answer 6

episodic = less than 15 days per month
chronic = more than 15 days per month

Question 7

What percent of migraine pts have auras?

Answer 7

~ 20%

- most common = visual

Question 8

What is CSD?

Answer 8

cortical spreading depression = wave of neuronal depolarization followed by suppression neuronal activity with corresponding blood flow change moved across cortex at 3mm/min

linked to migraine course/clinical feat

Question 9

What is prevalence of migraine?

Answer 9

43% of women, 18% of men likely associated with estrogen

– pre-puberty = equal between sexes

Question 10

What causes migraine? triggers?

Answer 10

migraine is hereditary polygenic

migraine has many triggers = exertion, dietary, sleep disturbances, head trauma, hormones, meidcation

Question 11

What diseases have co-morbidity with migraine?

Answer 11

mitral valve prolapse, stroke, epilepsy, sever psychiatric

Question 12

What is association vascular changes and migraine?

Answer 12

vascular changes occur but they are not primary cause

migraine aura associated with vasoconstriction, headache with vasodilation

researches debating the relationship

Question 13

What type of blood flow before/during headache?

Answer 13

• aura/migraine begin during hypo-perfusion phase
• then get hyper-perfusion as headache continues
• hyper-perfusion may outlast headache apin

Question 14

How can you provoke CSD?

Answer 14

chemical, electrical, mechanical stimuli

Question 15

What is role of CSD in migraine?

Answer 15

plays an important role in genesis of migraine attack [but not exclusive to migraine]

Question 16

Can you feel sensation of brain parenchyma?

Answer 16

NO! but you can feel it from dura mater/vessels, blood vessels, and CNs

Question 17

What innervates intracranial contents about the tentorium cerebelli?

Answer 17

trigeminal nerve

Question 18

What innervates intracranial contents below the tentorium cerebelli?

Answer 18

CN2, 3, 7, 9, 10

Question 19

What are 2 common misdiagnosis of pts who have migraine

Answer 19

tension headache: pt with neck pain = due to referred pain by CN V

sinus headache = pt with tearing, rhinorrhea, nasal congestion cause by trigeminal-ANS reflex

Question 20

What is the trigeminocervical complex?

Answer 20

• runs from the medulla down into C3 where blends gradually into cervical dorsal horns
  receives fibers from upper cervical roots and sends them to thalamus and collateral to ANS nuclei in brainstem and hypothalamus
• thalamic neurons project to S1 and limbic
• TNS also synaptically connects to parasympathetic superior salivatory nucleus [SSN] in pons

Question 21

What innervates meningeal vessels?

Answer 21

parasympathetic superior salivatory nucleus [SSN] in pons via greater superficial petrosal

Question 22

What is important about TNC as a convergence of different sensory info?

Answer 22

• pain from face and head referrred to neck

- pain from neck referred to face V1 distribution

Question 23

When is ipsilateral greater occipital nerve [at C2] tender? importance for treatment?

Answer 23

during migraine OR cluster headache

• give occipital nerve block at C2 to terminate acute headache

Question 24

What happens to midbrain during migraine attack?

Answer 24

• periaqueductal gray in midbrain is activated

Question 25

What are premonitory symptoms?

Answer 25

• symptoms that occur hours to day before a migraine attack [irritability, food cravings, fatigue, excess yawning, etc]
• suggest hypothalamic involvement

Question 26

What is the cortical spreading depression [CSD] theory of migraines?

Answer 26

• wave of neuronal depolarization moves 3 mm/min through cortex accompained by transiet hyperemia then oligemia and suppression of neuronal activity
• Ca waves propagate through glia affecting vascular activity
• as wave of depolarization moves, release inflammatory factors [NO, H, K, arachadonic acid] –> activates meningeal nociceptors + trigeminal neurons release stuff –> pain, inflammation

Question 27

What is the trigeminovascular reflex?

Answer 27

occurs with CSD

trigeminal neurons that supply dural vessels release CGRP [calcitonin gene-releated peptide], substance P and neurokinin A] –> vessel dilation and inflamation –> “peripheral sensitization” of trigeminal neuron –> carries pain centrally

Question 28

What is the trigeminoparasympathetic reflex?

Answer 28

through polysnaptic connects with SSN, parasympathetic fibers innervating dural vessels release ACh, NO, VIP [vasoactive intestinal polypeptide] –> miosis, ptosis, red eye, lacrimation, rhinorrhea

Question 29

What happens if you treat during early stage of attack when there is only peripheral sensitization?

Answer 29

migraine can be fully termianted

Question 30

What is peripheral vs cetnral sensitization?

Answer 30

peripheral = activation of first order trigeminal neuron

central = activation of sexond and third order trigemino-thalamic and thalamo-cortical neruons
- glutamatergic and NO transmission involved

Question 31

What is clinical manifestation of central sensitization?

Answer 31

cutaneous allodynia = scalp tenderness, facial, neck or extremity pain, response to non=painful stimuli, hair hurts

usually occur as duration of attack increases and in chronic rather than episodic migraine

Question 32

What do you use to treat migraine once reaches central sensitization stage?

Answer 32

can’t use triptan drugs

may be able to use NSAIDs

Question 33

What are the genetics of migraine?

Answer 33

usually polygenic

rare monogenic forms exist = familial hemiplegic migraine [FHM], autosomal dominant

Question 34

What are signs of a tension headache?

Answer 34

• pressing
• steady
• bilateral
• not aggravated by activity
• little nausea/photophobia/phonophobia
• lasts 30 min to 7 days = can be constant

Question 35

What is IHS criteria for sinus headache?

Answer 35

secondary diagnosis resulting from acute sinusitis
requires: purulent nasal discharge, pathologic sinus findings

chronic sinusitis = not a thing

Question 36

What is association migraine with aura and stroke?

Answer 36

risk of stroke in pt with migraine with aura is similar to those with DM, obesity, HTN

Question 37

Is migraine progressive?

Answer 37

in small subset of patients frequency of attack and duration of migraines with aura increase