Migraine

Question 1

When does migraines usually present?

Answer 1

early to midlife

Question 2

How serious are migraines?

Answer 2

• Chronic episodic
• Severe effect on quality of life
• Some menstrual migraine

Question 3

How common are migraines?

Answer 3

• 6th most common disease worldwide
• second most disabling disease
• More common in women post puberty

Question 4

What are RF for migraine?

Answer 4

1. FHx of migraine
2. Female sex
3. Obesity
4. Stressful life events
5. Medication overuse
6. Sleep disorders

Question 5

What acronym is used to remember partial triggers for migraines?

Answer 5

CHOCOLATE

Question 6

What does CHOCOLATE stand for?

Answer 6

chocolate
hangovers
orgasms
cheese/caffiene
oral contraceptives 
lie-ins
alcohol
travel 
exercise

Question 7

What are common symptoms and signs of migraine?

Answer 7

1. Prolonged headache: 4-72hr
2. Visual disturbance
3. Nausea
4. Vomiting
5. Photophobia or phonophobia
6. Headache worse with activity

Question 8

How long is an aura?

Answer 8

15-30 mins then unilateral throbbing headache

Question 9

Can you have migraines without aura?

Answer 9

episodic severe headaches without aura, often premenstrual unilateral with nausea vomiting

Question 10

What are different parts of an aura?

Answer 10

1. visual chaotic disorting
2. Somatosensory
3. Motor
4. speech

Question 11

What is prodrome?

Answer 11

recedes headache by hours to days: yawning, craving, mood/sleep change

Question 12

What are possible DDx for migraine?

Answer 12

1. Tension headaches
2. Cluster headache
3. Medication overuse headache
4. SAH
5. Headache after head or neck trauma
   Etc

Question 13

What investigations are used for migraine?

Answer 13

clinical diagnosis

Question 14

What is the diagnostic criteria for migraines?

Answer 14

if no aura: >5 headaches lasting 4-72hrs with nausea/vomiting or photophobia and any two of unilateral, pulsating, impairs or worsened by routine activity

Question 15

What is treatment for acute bad migraine?

Answer 15

1st line: rescue therapy e.g. metoclopramide 10-20mg IV

• hydration
• High-flow oxygen
• IV corticosteroid

Question 16

What is the treatment for mild to moderate migraines (not preggers)?

Answer 16

1st line: NSAIDs
Anti-emetic
2nd line: paracetamol monotherapy
3rd line: aspirin

Question 17

What is the treatment for severe migraine?

Answer 17

1st line: triptan e.g. almotriptam 6.25mg to 12.5mg orally with paracetamol or NSAIDs and can use anti-emetic

Question 18

What anti-emetic should not be used regularly?

Answer 18

metoclopramide regularly as extrapyramidal side effects

Question 19

What is ongoing treatment for migraine?

Answer 19

trigger avoidance and non-pharm therapies

Question 20

What are possible preventative drugs for migraine?

Answer 20

1. Topiramate
2. Amitriptyline
3. Magnesium
4. Triptan
5. Anticonvulsant – NOT gabapentin
6. Beta-blocker: e.g. propananol
7. Tricyclic antidepressant
8. CCB
9. Antidepressant
10. Calcitonin gene-related peptide antagonist
11. Botulin toxin A

Question 21

How would you treat pre-menstrual migraine?

Answer 21

if uncontrolled and predictable onset – frovatriptam or zolmitriptan

Question 22

What are possible complications of migraine?

Answer 22

1. Complications of pregnancy
2. Status migrainosus (more than 72hr)
3. Migrainous infarction
4. Migraine-triggered seizure
5. Depression

Question 23

Why can you not prescribe opiods with migraine?

Answer 23

are pro-nociceptive, prevent reversal of migraine central sensitization, and interfere with triptan effectiveness

Question 24

What is conservative management for migraines?

Answer 24

1. Headache diary
2. Avoid triggers
3. Relaxation techniques (CBT, mindfulness)

Question 25

What is the acute treatment for migraine?

Answer 25

1) Simple analgesia (paracetamol, Ibuprofen)

2) Triptans – specific to migraines

Question 26

What is the preventative management for migraine?

Answer 26

1) Propanolol or topimarate

2) Amitryptiline