Migraine

Question 1

What is a migraine?

Answer 1

Primary headache characterised by recurrent episodes of unilateral, localized pain a/w systemic disturbance.

Question 2

How can migraine be subclassified?

Answer 2

With aura (classic ~1/3)
Without aura (common migraine)
Migraine variants (familial hemiplegic, opthalmoplegic + basilar).

Question 3

Describe the epidemiology of migraine

Answer 3

F > M 3:1
Usual onset in adolescence/ early adulthood, but can occur in middle age.

Question 4

List 5 triggers/ risk factors for migraine

Answer 4

Tiredness, stress
Alcohol
COCP
Fasting / dehydration
Foods (e.g. caffeine, cheese, chocolate)
Menstruation
Bright lights

Question 5

Describe the headache in migraine

Answer 5

Severe
Pulsatile/ Throbbing
Unilateral
Duration 4-72h

Question 6

What occurs in aura precipitating migraines?

Answer 6

Typically visual, progressive
Last 5-60 mins
Characterised by transient hemianopic disturbance or a spreading scintillating scotoma
Flashing lights, Spots, Blurring, Zigzag lines, Blind spots

Question 7

List 3 symptoms of migraine

Answer 7

N+V
Photophobia
Phonophobia

Question 8

List signs of migraine

Answer 8

NO specific physical findings

Question 9

What mneumonic describes the headache in migraines?

Answer 9

POUND
Pulsatile
One-day duration
Unilateral
N+V
Disabling intensity

Question 10

Describe diagnosis of migraine

Answer 10

Clinical dx
R/O red flag causes of headache

Question 11

Describe criteria for diagnosis of migraine without aura

Answer 11

> ,5 attacks
4-72h duration
Headache that is >,2 of: unilateral, pulsating, mod-severe pain, worsened by activity
Concomitant Sx: N+V, Photophobia, Photophobia

Question 12

Describe criteria for migraine with aura

Answer 12

> ,2 attacks
,1 of visual, sensory, speech, motor, brainstem, retinal Sx of aura
≥ 3 characteristics of aura

Question 13

Describe investigations for migraine to rule out differential diagnoses

Answer 13

Neuro exam
Fundoscopy: r/o raised ICP
ESR: r/o temporal arteritis
CT/ MRI: r/o SOL, SAH
LP: r/o SAH, meningitis, low/ high CSF pressure

Question 14

Describe acute management of migraine

Answer 14

Combination therapy:
Oral Triptan (5-HT agonist) + NSAID
OR
Oral Triptan + Paracetamol
If ineffective: non-oral metoclopramide or prochlorperazine + non-oral triptan/ NSAID

Question 15

What is prescribed in preference to oral triptans in 12-17 year olds?

Answer 15

Nasal triptans

Question 16

When is migraine prophylaxis indicated?

Answer 16

If attacks are having significant impact on QoL + daily function, e.g. occur frequently (> once a week on average) or are prolonged + severe despite optimal acute Tx

Question 17

Which drugs can be used for prophylactic management of migraines?

Answer 17

Propanolol
Topiramate
Amitriptyline

Question 18

Which prophylactic migraine drug should be avoided in women of child bearing age?

Answer 18

Topiramate
Teratogenic + can reduce efficacy of hormonal contraceptives

Question 19

What can be offered if drug prophylaxis of migraines fails?

Answer 19

A course of up to 10 sessions of acupuncture over 5-8w

Question 20

What can be used for women with predictable menstrual migraine?

Answer 20

Frovatriptan (2.5mg BD)
Zolmitriptan (2.5mg BD-TDS)

Question 21

Which options may be considered by specialists for prophylaxis of migraine?
(outside NICE guidelines)

Answer 21

Candesartan
Monoclonal antibodies e.g. Erenumab

Question 22

What are the complications of migraine

Answer 22

Disruption of daily activities
Can lead to analgesia-overuse headaches in people who use analgesia regularly

Question 23

What is the prognosis for patients with migraine?

Answer 23

Usually CHRONIC
Most cases can be managed well with preventative/ early Tx measures