Migraine

Question 1

… is a form of primary headache disorder.

Answer 1

Migraine is a form of primary headache disorder.

Question 2

There are two major types of migraine:

Answer 2

Migraine without aura: characteristic migraine headache with associated symptoms.
Migraine with aura: a migraine headache that is preceded (and sometimes accompanied) by focal neurological symptoms.

There are two major types of migraine:

Question 3

Migraine describes a…

Answer 3

Migraine describes a recurrent moderate to severe headache commonly associated with nausea, vomiting, photophobia and phonophobia. The headache is typically unilateral and pulsating in nature lasting 4-72 hours.

Question 4

Migraine epidemiology

Answer 4

Migraine is estimated to have a global prevalence of 1 in 7 people.
Migraines most commonly occur between the ages of 25 - 55. Females (lifetime prevalence approximately 33%) are affected more than men (lifetime prevalence approximately 13%) though frequency is equal before puberty.

Question 5

Migraines may be episodic or chronic:

Answer 5

Chronic migraine: headache on more than 15 days of each month, 8 of which have features of migraine.
Episodic migraine: less frequency than described in the above definition.

Question 6

Auras that feature motor, brainstem or retinal symptoms are not typical. In particular NICE highlight the following symptoms that warrant consideration of urgent neurological review:

Answer 6

Motor weakness
Double vision
Visual symptoms affecting only one eye
Poor balance
Decreased level of consciousness

Question 7

Headache characteristics

Answer 7

Severe sudden onset: consider causes like SAH, venous sinus thrombosis, vertebral artery dissection
Progressive or persistent, acute change: consider space occupying lesions, subdural haematoma
Worse on standing: consider CSF leak
Worse on lying: consider causes of raised ICP; space occupying lesions, venous sinus thrombosis

Question 8

Precipitating factors - migraine

Answer 8

Recent trauma: consider subdural haematoma (subacute/chronic)
Triggered by Valsalva manoeuvre: consider posterior fossa lesion or Chiari 1 malformation

Question 9

Associated features

Headache

Answer 9

Fever, photophobia, neck stiffness: consider meningitis, encephalitis
Papilloedema: consider BIH, venous sinus thrombosis, space occupying lesions
Dizziness/vertigo: consider stroke
Visual changes: consider giant cell arteritis, glaucoma
Vomiting: consider space occupying lesions, carbon monoxide poisoning

Question 10

Patient factors and comorbidities - headache

Answer 10

Age > 50: consider sinister causes such as giant cell arteritis and space occupying lesions
Age < 10: consider evalutaion for secondary causes
Immunodeficiency: in particular increased risk of malignancy and infection
Active or previous cancer: consider metastatic spread, cancer therapy may increase risk of infection
Pregnancy: consider causes like pre-eclampsia and venous sinus thrombosis

Question 11

If multiple close contacts present with headache consider …

Answer 11

If multiple close contacts present with headache consider carbon monoxide poisoning

Question 12

Acute treatment - migraine

Answer 12

Treatment options include simple analgesia, triptans and anti-emetics.

Question 13

Migraine treatment - 3

Answer 13

Simple analgesia: paracetamol or NSAIDS (typically ibuprofen or aspirin) can be offered in the absence of contra-indications to be taken at the onset of a migraine headache. Diclofenac can be given as a suppository which may be preferable, particularly in the setting of nausea, for some patients.
Triptans: these are 5HT1-receptor agonist that can be taken at the onset of a migraine headache. It may be used alone or in combination with simple analgesia. Oral sumatriptan is considered first-line though alternative triptans and routes (e.g. nasal, subcutaneous) may be used if this is ineffective.
Anti-emetics: buccal prochlorperazine is often given and helps to relieve nausea. Suppositories (e.g. domperidone) can again be given depending on patient preference.

Question 14

Trigger avoidance

Migraine

Answer 14

Some patients have identifiable triggers and where possible patients should avoid these. Lifestyle factors are commonly implicated and advise should be given to maintain adequate hydration, get sufficient sleep and to stay healthy and active.

Where possible sources of stress should be avoided as well as other triggers (e.g. certain foods, smells, lights). A headache diary (maintained for at least 8 weeks) can make identification of triggers far easier.

Question 15

Preventative treatment

Migraine

Answer 15

Prophylactic medications may be given to suitable patients. It should be considered where the symptoms significantly impact quality of life and daily function, acute treatments are inappropriate or ineffective or if the patient is at risk of medication overuse headache (see below).

There are a number of medications that can be used and prior to initiation a full discussion of the possible benefits and side effects should be had. The options include:

Propranolol
Topiramate (contraindicated in pregnancy, the BNF states in women with childbearing potential ‘a highly effective’ contraception is required prior to commencement)
Amitriptyline

Question 16

Galcenezumab is a novel therapy recently made available on the NHS (NICE TA 659) for patients who:

Answer 16

have 4 or more migraine days a month
have tried at least 3 other medicines and they have not worked

It should only be continued if after 12 weeks:

episodic migraine (less than 15 headache days a month) reduced by at least 50%
chronic migraine (15 headache days a month or more) reduced by at least 30%

Question 17

Medication overuse headache

Answer 17

Medication ‘overuse’ itself has been shown to result in chronic headaches. As the name suggests this occurs when regular analgesia taken for symptomatic relief of headache causes or perpetuates the condition.

The International Headache Society defines it as ‘Headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped’.

Question 18

Patients with menstrual-related migraine may be commenced on specific therapies if standard measures fail.

Answer 18

Women who have pure menstrual or menstrual-related migraine can be initiated on the standard lifestyle and trigger avoidance advice as well as standard acute treatment.

If this is ineffective NICE CKS advise the consideration of the following medications (off-label) in the absence of contraindications:

Frovatriptan
Zolmitriptan

Question 19

There are a number of complications that may affect those with migraines.

Answer 19

Status migrainosus: a debilitating migraine that persists for longer than 72 hours.
Persistent aura without infarction: refers to symptoms of aura for one week or longer with no evidence of infarction of imaging.
Migrainous infarction: describes a cerebral infarction that occurs during an aura whose symptoms then persist, imaging demonstrates an ischaemic infarction.
Migraine aura-triggered seizure: migraine with aura that leads to a seizure.
Ischaemic stroke: migraines, in particular with aura, is a risk factor for ischaemic stoke. As such patients should be strongly advised to optimise other risk factors such as weight, diet, smoking and exercise. Use of the combined oral contraceptive is contraindicated in patients with migraine with aura and must be used in caution in those with migraine.