Migraine

Question 1

what is the most common cause of episodic headache?

Answer 1

migraine

Question 2

different types of migraines?

Answer 2

-Migraine without aura
-Migraine with aura
-Atypical :
* Acephalgic - no headache
* Basilar - very nauseating, vertigo
* Retinal, opthalmic
* Hemiplegic (familial/sporadic)
Abdominal - more common in young children

Question 3

examples of atypical migraines

Answer 3

• Acephalgic - no headache
• Basilar - very nauseating, vertigo
• Retinal, opthalmic
• Hemiplegic (familial/sporadic)
  Abdominal - more common in young children

Question 4

are migraines more common in males or females?

Answer 4

females

Question 5

what are some common triggers for migraines?

Answer 5

-sleep
-diet
-stress
-hormonal (e.g. oral contraception)
-physical exertion

Question 6

what may be useful in helping figure out specific migraine triggers?

Answer 6

-headache diary

Question 7

what criteria is used to determine if someone has a migraine without aura?

Answer 7

IHS criteria
* At least 5 attacks
* 4-72 hours
* 2 of: moderate/severe, unilateral, throbbing pain, worst movement
* 1 of: autonomic features, photophobia/phonophobia

Question 8

what is most common form of migraine?

Answer 8

migraine without aura (80%)
(migraine with aura is 20%)

Question 9

how long does aura in a migraine typically last?

Answer 9

20-60 mins

Question 10

when does a headache usually follow the aura in a migraine with aura?

Answer 10

the headache usually follows <1 hour later but the aura can occur simultaneously

Question 11

how does a migraine typically present?

Answer 11

-a unilateral pounding, throbbing headache which may be preceded by an aura, such as visual (e.g. lines, zigzags) or sensory (parasthesia) symptoms

-headache may last 4 to 72 hours and is associated with photophobia and phonophobia

Question 12

how long does a typical migraine last?

Answer 12

4-72 hours

Question 13

what is the non pharmacological management for migraines?

Answer 13

• Set realistic goals
• Education- avoid triggers
• Headache diary
  -Relaxation/ stress management

Question 14

what is acute pharmacological management for migraine?

Answer 14

-NSAID (aspirin, naproxen, ibuprofen) (+ an anti emetic if patient has gastroperesis)
-Triptans (5HT agonist) e.g. rizatriptan, eletriptan, sumatriptan

NSAIDs to be taken as early as possible

Triptans to be taken at the start of a headache

Question 15

when should prophylaxis medication be considered for migraine?

Answer 15

consider if patient is:
-experiencing more than 3 attacks per month

or

-very severe attacks

Question 16

what drugs may be taken for prophylaxis of a migraine?

Answer 16

-amitriptyline (1st line)
-propanolol (1st line)
-topiramate (2nd line)

go slow and keep low!
and trial each drug for minimum 3 months

Question 17

contra indication of propanolol?

Answer 17

asthma
PVD
heart failure

Question 18

SE and contraindication of topiramate?

Answer 18

CI: woman of child bearing age
SE: weight gain, paraesthesia, impaired concentration

Question 19

what are some non pharmacological methods of prophylaxis for migraines?

Answer 19

-acupuncture
-relaxation exercises

Question 20

pathophysiology behind a migraine without aura?

Answer 20

• Both vascular and neural influences cause migraines in susceptible individuals
• Stress triggers changes in the brain which cause serotonin release
• Blood vessels constrict and dilate
  -Chemicals including substance P irritate nerve and blood vessels causing pain

→ Increased sensitivity
* In both cases, the chemicals result in the sensitization of trigeminal neurones and brainstem pain pathways
-This makes otherwise innocuous sensory stimuli (such as CSF pulsation and head movement) painful, and light and sound are perceived as uncomfortable

Question 21

what is the pathophysiology behind a migraine with aura?

Answer 21

• Cortical spreading depolarisation in the migraine centre of the brain (dorsal raphe nucleus, locus coeruleus)
• Activation of the trigeminal vascular system causes dilation of blood vessels
  -Release of substance P, neurokinin A, CGRP

→ Increased sensitivity
* In both cases, the chemicals result in the sensitization of trigeminal neurones and brainstem pain pathways
-This makes otherwise innocuous sensory stimuli (such as CSF pulsation and head movement) painful, and light and sound are perceived as uncomfortable

Question 22

what are red flags for a headache?

Answer 22

!!RED FLAGS!!
* New onset headache > 55
* Known/ previous malignancy
* Immuno suppressed
* Early morning headache
-Exacerbating by valsalva

Question 23

amitriptyline common SE?

Answer 23

-dry mouth
-postural hypotension
-fatigue/ sedation