Migraine

Question 1

Prevalence

Answer 1

Migraine, or the ‘sick headache’, is derived from the Greek word meaning ‘pain involving half the head’.

• It affects at least 1 person in 10
• more common in females (18% of women, 6% men)
• peaks between 20 and 50 years.

Question 2

Types

Answer 2

The best known are

1. classic migraine (headache, vomiting and aura)
2. common migraine (without the aura)

Question 3

Types of vascular headache

Answer 3

1. Common migraine (aura is vague or absent)
2. Classic migraine
3. Complicated migraine
4. Unusual forms of migraine:

• hemiplegic
• basilar
• retinal
• migrainous (vestibular) vertigo
• migrainous stupor
• ophthalmoplegic
• migraine equivalents
• status migrainosus

1. Cluster headache
2. Chronic paroxysmal hemicrania
3. Menstrual migraine
4. Lower half headache
5. Benign exertional-sex headache (beware of SAH)
6. Miscellaneous (e.g. icepick pains, ‘ice-cream’ headache)

Question 4

Clinical features (classic migraine)

Answer 4

Site: temporofrontal region (unilateral) ; can be bilateral

Radiation: retro-orbital and occipital

Quality: intense and throbbing

Frequency: 1 to 2 per month

Duration: 4 to 72 hours (average 6–8 hours)

Onset: paroxysmal, often wakes with it

Offset: spontaneous (often after sleep)

Precipitating factors: tension and stress (commonest)

Aggravating factors: tension, activity Relieving factors: sleep, vomiting

Associated factors: nausea, vomiting (90%) irritability aura

— visual 25% (scintillation, scotoma, hemianopia, fortification)

— sensory (unilateral paraesthesia)

Other pointers: abdominal pain in childhood; family history of migraine, asthma and eczema

Question 5

IHS3 criteria for common migraine

Answer 5

1. Pt should have had at least 5 attacks fulfilling criteria B and D.
2. The headaches last 4–72 hours.
3. The headache must have at least two of the following:
4. unilateral location
5. pulsing quality
6. moderate or severe intensity, inhibiting or prohibiting daily activities
7. headache worsened by routine physical activity
8. The headache must have at least two of the following:
9. nausea and/or vomiting
10. photophobia and phonophobia
11. Not attributable to another disorder

Question 6

IHS3 criteria for migraine with typical aura (classic)

Answer 6

1. At least two attacks fulfilling criteria B and C.
2. One or more of the following fully reversible aura symptoms:
3. Visual
4. Sensory
5. speech and/or language
6. motor
7. brainstem
8. retinal.
9. At least two of:
10. at least one aura symptom spreads gradually over at least 5 minutes
11. each aura symptom lasts 5–60 minutes
12. at least one symptom is unilateral
13. headache follows aura within 60 minutes
14. Not attributable to another disorder including TIA

Question 7

The most common trigger factor is

Answer 7

stress

Question 8

Migrainous trigger factors

Answer 8

Exogenous:

1. Foodstuffs—chocolate, oranges, tomatoes, citrus fruits, cheeses, gluten sensitivity (possible)
2. Alcohol—especially red wine
3. Drugs—vasodilators, oestrogens, monosodium glutamate, nitrites (‘hot dog’ headache), indomethacin, OCP
4. Glare or bright light* (32%)
5. Emotional stress* (63%)
6. Head trauma (often minor) (e.g. jarring—‘footballer’s migraine)
7. Allergen
8. Climatic change
9. Excessive noise
10. Strong perfume

Endogenous:

1. Tiredness, physical exhaustion, oversleeping
2. Lack of sleep
3. Stress, relaxation after stress—‘weekend migraine’
4. Exercise/physical stress
5. Hormonal changes — puberty — menstruation* — climacteric — pregnancy
6. Hunger
7. Familial tendency
8. ?Personality factors

* Most common

Question 9

Management

Answer 9

Patient education:

Explanation (especially if bizarre visual and neurological symptoms) and reassurance about the benign nature of migrain.

An individual treatment plan including a migraine action plan should be devised.

Question 10

Counseling and advice

Answer 10

Avoid known trigger factors, e.g. physical or emotional stress, lack of sleep, bright lights

Diet: keep a diary—Consider a low amine diet: chocolate, cheese, red wine, walnuts, tuna, Vegemite, spinach and liver

Practice a healthy lifestyle, relaxation programs, meditation techniques and biofeedback training

Be open to non-drug therapies (e.g. trial of acupuncture, hypnotherapy).

Question 11

Treatment of the acute attack, general approach

Answer 11

• Commence treatment at earliest impending sign.
• Mild headaches may require no more than conventional treatment with ‘two aspirin (or paracetamol), and a good lie down in a quiet dark room’.
• Rest in a quiet, darkened, cool room.
• Place cold packs on the forehead or neck.
• Avoid drinking coffee, tea or orange juice.
• Avoid moving around too much.
• Do not read or watch television.
• For pts who find relief from simply ‘sleeping off’ an attack, consider prescribing temazepam 10 mg or diazepam 10 mg in addition to the following measures
• For moderate attacks use oral ergotamine or sumatriptan and for severe attacks use injection therapy.
• Avoid pethidine and other opioids.

Question 12

Medication (if necessary)

Answer 12

First signs of attack:

1st line:

• soluble aspirin, e.g. Dispirin Direct 2–3 tabs or paracetamol/ibuprofen co 2 tabs (o) + metoclopramide 10 mg (o)
• if nausea a feature + a triptan or consider NSAIDs (e.g. ibuprofen, diclofenac rapid)
• avoid opioids

2nd line:

• a triptan agent—sumatriptan 100 mg (o) or 6 mg (SCI) or nasal spray 10–20 mg per nostril or
• zolmitriphan 2.5–5 mg (o) repeat in 2 h if nec. or
• naratriptan 2.5 mg (o) repeat in 2–4 h if nec.
• rizatriptan 10 mg wafer, repeat in > 2 hrs if nec. or other triptan

​Established attack:

• metoclopramide 10 mg (2 mL) IM or IV or
• prochlorperazine 12.5 mg IM or 25 mg rectally

The severe attack:

• metoclopramide 10 mg IV or
• prochlorperazine IV or chlorpromazine IM.
• Prochlorperazine causes less sedation and less postural hypotension than chlorpromazine.
• Funded by POAC.
• Stock benztropine in case of acute dystonic reaction

Practice tip for severe classic migraine:

IV chlorpromazine + 1 L IV N saline in 30 mins + oral soluble aspirin + a triptan

Question 13

Triptans

Answer 13

• Ineffective during aura.
• 20 to 50% of pts who initially respond will have a rebound headache within 48 hours.
• Repeat after 2 hours if headache recurs, but not if initial dose was ineffective.
• If used > twice a week, there is increasing risk of medication overuse headache.
• Sumatriptan, 50 mg to 100 mg orally at onset, up to maximum 300 mg per day.
• 6 mg can be given subcutaneously if nausea or vomiting.
• Rizatriptan 10 mg (tablet or wafer) at onset, up to maximum 30 mg per 24 hours.
• Zolmitriptan 5 mg nasal spray is rapidly absorbed from the nasopharynx, and useful if N&V. It is not funded, no prescription is required, and can be purchased from the pharmacy.

Avoid ergotamine due to side-effects and rebound headaches.

Caution: Do not use ergotamine preparations if sumatriptan used in previous 6 hours, and do not use sumatriptan if ergotamine preparations used in previous 24 hours.

Question 14

Prophylaxis Ry

Answer 14

for >2 or 3 attacks per mth

Titrate slowly and trial each medication for 2 to 3 months.

Choice of prophylaxis is individually determined.

Consider gradual withdrawal after 6 months of effective prophylaxis.

Ensure medication is available for acute attacks

Question 15

Medication as prophylaxis

Answer 15

Beta blockers

Propranolol immediate release.

• Start on low dose e.g., 10 mg to 40 mg OD or BD
• slowly increase to usual maintenance dose of 80 to 240 mg a day.
• Maximum 240 mg per day.

Nadolol – 40 mg to 160 mg once a day.

• Useful if comorbid anxiety.
• Avoid if on rizatriptan or halve rizatriptan dose.

Tricyclics

Amitriptyline –

• start with 10 mg and increase slowly as tolerated up to 100 mg at night.
• Useful if comorbid depression, tension type headache or sleep disturbance.

Topiramate – start with 25 mg a day and increase by 25 mg a week to 50 mg to 100 mg BD.

Sodium valproate

• Initially 200 mg twice a day, increasing gradually to 1.2 to 1.5 g a day in divided doses.
• Avoid in women of childbearing age due to the teratogenicity and association with developmental delay.

Pizotifen

• Start at 0.5 mg at night and increase to usual dose of 1.5 mg at night or in 3 divided doses.
• Maximum daily dose 4.5 mg in 3 divided doses.
• Its use is limited due to the side-effects of drowsiness and weight gain.

Other options

Verapamil and Lamotrigine – some evidence for effectiveness in migraine with aura.

SSRIs – evidence is inconclusive but evidence for venlafaxine 150 mg once a day.

Gabapentin 300 mg a day initially, increasing gradually to maximum 2.4 g a day according to response (unapproved).

Botox – evidence of benefit when headache present at least 15 days a month. Currently only available privately.

Question 16

If headache recurs within the same episode, despite initial response, consider ?

Answer 16

relapse treatment options

• Repeat previously used analgesics or triptans if these were initially effective.
• Limit use of acute migraine therapy to 2 days per week, due to the risk of medication overuse headache.

Question 17

Menstrual Migraine Guidelines

Answer 17

Select the initial drug according to the patient’s medical profile:

• if low or normal weight—pizotifen
• if hypertensive—a beta blocker
• if depressed or anxious—amitriptyline
• if tension—a beta blocker
• if cervical spondylosis—naproxen
• food-sensitive migraine—pizotifen
• menstrual migraine—naproxen or mefenamic acid or ibuprofen or oestradiol transdermal gel
• Each drug should be tried for 2 months before it is judged to be ineffective.
• Amitriptyline 50 mg nocte can be added to propranolol, pizotifen (beware of weight gain) or methysergide and may convert a relatively poor response to very good control

Question 18

Menstrual migraine management

Answer 18

First, try the acute and prophylactic treatments above, then consider:

Naproxen 500 mg BD, beginning before menstruation and continuing through the risk period.

Peri-menstrual oestrogen for prophylaxis:

1) For migraine without aura and who have other indications for using a combined oral contraceptive (COC):

• Give continuous administration of an oestrogen-progesterone oral contraceptive.
• By skipping the placebo pills, patients can avoid the monthly abrupt decline in oestrogen which may trigger migraine.
• Recommend placebo pills every 3 to 4 months and have a withdrawal bleed.
• To reduce the risk of triggering a migraine while on the placebo pills, give either 10 to 20 micrograms oral ethinylestradiol once a day, or oral estradiol (2 mg once a day), or transdermal estradiol 1 to 2 mg a day.

2) For women with a natural cycle, who do not need or wish to use a COC, either:

• apply a 50 to 100 microgram oestrogen patch about 3 days before the anticipated onset of bleeding, and leave in place for 7 days (this is not fully funded), or
• give 2 mg estradiol valerate (Progynova – fully funded) daily for 7 days, again starting 3 days before the period.

If these methods of prophylaxis are ineffective, request non-acute neurology assessment.

Question 19

Transformed migraine definition

Answer 19

This describes the progressive increase in frequency of migraine attacks until the headache recurs daily.

The typical migraine features become modified so that the pattern resembles that of tension headache

• but with the unilateral situation of migraine.

Analgesic abuse can transform episodic migraine into chronic daily headache.

Question 20

Request acute neurology assessment if:

Answer 20

migraines do not respond to the above management.

migraine diagnosis is in doubt.

Question 21

Migraine in pregnancy and breastfeeding, Mnagement

Answer 21

Paracetamol can be used throughout pregnancy and breastfeeding.

NSAIDs:

• Avoid in the third trimester to avoid fetal renal damage and patent ductus.
• Short-acting e.g., ibuprofen can be used in the first and second trimester.

Metoclopramide is unlikely to cause harm through pregnancy and breastfeeding.

Triptans and caffeine + ergotamine are contraindicated in pregnancy.

Triptans are not contraindicated in breastfeeding.

Propranolol – beta blocker with best evidence of safety during pregnancy

Amitriptyline – lowest effective dose may be used

Question 22

Facial migraine (lower half headache)

Answer 22

Migraine may rarely affect the face below the level of the eyes,

• causing pain in the area of the cheek and upper jaw.

It may spread over the nostril and lower jaw.

Pain is dull and throbbing and nausea and vomiting are commonly present.

Treatment is as for other varieties of migraine.