migraine

Question 1

what is the most common episodic headache?

Answer 1

a migraine

Question 2

migraine- more common in females or males?

Answer 2

females

Question 3

migraine- triggers?

Answer 3

sleep
diet
stress
hormonal
physical exertion

Question 4

migraine without aura- pathophysiology?

Answer 4

• Both vascular and neural influences cause migraines in susceptible individuals
• Stress triggers changes in the brain which cause serotonin to be released
• Blood vessels constrict and dilate
• Chemicals including substance P irritate nerves 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 5

migraine with aura- pathophysiology?

Answer 5

1. Cortical spreading depolarisation in the migraine centre of the brain (dorsal raphe nucleus, locus coeruleus)
2. Activation of the trigeminal vascular system causes dilation of blood vessels
3. 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 6

most common type of migraine?

Answer 6

migraine without aura (80%)

Question 7

migraine- presentation?

Answer 7

• Classically, a unilateral throbbing headache preceded by an aura, such as visual (eg. lines, zigzags) or sensory (paraesthesia spreading from fingers to face) symptoms
• The headache may last 4-72 hours and is associated with photophobia and phonophobia
• There may be identifiable triggers such as oral contraceptives or chocolat

Question 8

migraine- how long?

Answer 8

4-72 hours headache
Aura duration 20-60 mins

Question 9

aura in migraine- how long?

Answer 9

Aura duration 20-60 mins

Question 10

criteria for migraine without aura?

Answer 10

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 11

presentation- migraine with aura?

Answer 11

• Aura fully reversible visual, sensory, motor or language symptom
• Aura duration 20-60 mins
• Headache follows < 1 hour later but aura can occur simultaneously
• Visual aura most common, positive symptoms usually monochromatic

Question 12

atypical migraine examples

Answer 12

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

Question 13

acephalgic (atypical migraine) presentation?

Answer 13

no headache

Question 14

basilar (atypical migraine) presentation?

Answer 14

very nauseating, vertigo

Question 15

retinal (atypical migraine) presentation?

Answer 15

It causes brief attacks of blindness or visual problems like flashing lights in one eye

Question 16

hemiplegic (atypical migraine) presentation?

Answer 16

affected individuals experience a migraine headache along with weakness on one side of the body

this is familial/sporadic

Question 17

abdominal (atypical migraine) presentation?

Answer 17

recurrent episodes of moderate to severe stomach pain
-vomiting
-loss of appetite
more common in children

Question 18

migraine- investigations?

Answer 18

headache diary to help identify triggers

Question 19

non- pharmacological management- migraine?

Answer 19

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

Question 20

acute pharmacological management-migraine?

Answer 20

• NSAID (aspirin, naproxen, ibuprofen) taken as early as possible
• If gastroparesis consider antiemetic
• Triptans (5HT agonist) e.g. rizatriptan, eletriptan, sumatriptan - take at start of headache

Question 21

prophylaxis management-migraine?

Answer 21

Consider if patient is experiencing more than 3 attacks per month or very severe attacks
Drugs used include:
-Amitriptyline
-Propranalol (CI: asthma)
-Topiramate (CI: woman of childbearing age)

Also consider non-pharmacological methods: acupuncture, relaxation exercises

Question 22

A 65 year old woman with known hypertension and migraine presents with worsening almost daily headaches. These are in the same location as her normal migraine, but she denies her usual aura. She takes prophylactic amitriptyline 25mg regularly, as well as regular paracetamol QDS and is using codeine when the pain is worse (4x per week) for the last 4 months. There are no red flag features. Her BP today is 145/76mmHg. How should you manage her headache?

Answer 22

she has a medication overuse headache
best option: stop paracetamol and codeine for 1 month

Question 23

A 22 year old female presents to headache clinic complaining of headaches for the last few months. She describes these as occurring on one side only, throbbing and are preceded by tingling in her fingers. She usually has to hide under the covers in a quiet room whilst these attacks occur. Her past medical history includes asthma, type 2 diabetes and Raynaud’s. She is keen to be given something to stop these from happening. What would be the treatment of choice?

Answer 23

Amitryptiline

BB is CI in asthma

Question 24

can you take COC if you have migraine with aura?

Answer 24

No
-it increases risk of stroke

Question 25

when should sumatriptan be taken for a migraine?

Answer 25

Sumatriptan should be taken once the headache starts, but not during the aura phase

Question 26

SE amitriptyline?

Answer 26

dry mouth, postural hypotension, fatigue/ sedation

Question 27

CI topiramate?

Answer 27

women of childbearing age