migraine Flashcards
what is the most common episodic headache?
a migraine
migraine- more common in females or males?
females
migraine- triggers?
sleep
diet
stress
hormonal
physical exertion
migraine without aura- pathophysiology?
- 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
migraine with aura- pathophysiology?
- 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
most common type of migraine?
migraine without aura (80%)
migraine- presentation?
- 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
migraine- how long?
4-72 hours headache
Aura duration 20-60 mins
aura in migraine- how long?
Aura duration 20-60 mins
criteria for migraine without aura?
IHS criteria!
- At least 5 attacks
- 4-72 hours
- 2 of: moderate/severe, unilateral, throbbing pain, worst movement
- 1 of: autonomic features, photophobia/phonophobia
presentation- migraine with aura?
- 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
atypical migraine examples
- Acephalgic - no headache
- Basilar - very nauseating, vertigo
- Retinal, opthalmic
- Hemiplegic (familial/sporadic)
- Abdominal - more common in young children
acephalgic (atypical migraine) presentation?
no headache
basilar (atypical migraine) presentation?
very nauseating, vertigo
retinal (atypical migraine) presentation?
It causes brief attacks of blindness or visual problems like flashing lights in one eye
hemiplegic (atypical migraine) presentation?
affected individuals experience a migraine headache along with weakness on one side of the body
this is familial/sporadic
abdominal (atypical migraine) presentation?
recurrent episodes of moderate to severe stomach pain
-vomiting
-loss of appetite
more common in children
migraine- investigations?
headache diary to help identify triggers
non- pharmacological management- migraine?
- Set realistic goals
- Education - avoid triggers
- Headache diary
- Relaxation/stress management
acute pharmacological management-migraine?
- 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
prophylaxis management-migraine?
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
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?
she has a medication overuse headache
best option: stop paracetamol and codeine for 1 month
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?
Amitryptiline
BB is CI in asthma
can you take COC if you have migraine with aura?
No
-it increases risk of stroke
when should sumatriptan be taken for a migraine?
Sumatriptan should be taken once the headache starts, but not during the aura phase
SE amitriptyline?
dry mouth, postural hypotension, fatigue/ sedation
CI topiramate?
women of childbearing age
