Migraine Flashcards
What is a migraine?
Migraine is a common type of primary headache characterized by a severe, unilateral, throbbing headache associated with nausea, photophobia, and phonophobia.
How long can migraine attacks last?
Attacks may last up to 72 hours.
What do patients typically do during a migraine attack?
Patients characteristically go to a darkened, quiet room during an attack.
What is a ‘classic’ migraine?
‘Classic’ migraine attacks are precipitated by an aura, which occurs in around one-third of migraine patients.
What are typical characteristics of a migraine aura?
Typical aura are visual, progressive, last 5-60 minutes, and are characterized by transient hemianopic disturbance or a spreading scintillating scotoma.
What is the prevalence of migraines in men and women?
Migraine is 3 times more common in women; prevalence in men is around 6%, in women 18%.
What are common triggers for a migraine attack?
Common triggers include tiredness, stress, alcohol, combined oral contraceptive pill, lack of food or dehydration, cheese, chocolate, red wines, citrus fruits, menstruation, and bright lights.
What are the diagnostic criteria for migraines?
A: At least 5 attacks fulfilling criteria B-D. B: Headache lasting 4-72 hours. C: At least two characteristics: unilateral location, pulsating quality, moderate/severe pain, aggravation by routine physical activity. D: At least one of the following: nausea/vomiting, photophobia, phonophobia. E: Not attributed to another disorder.
What is hemiplegic migraine?
Hemiplegic migraine is a variant of migraine in which motor weakness is a manifestation of aura in at least some attacks.
What is the estimated prevalence of hemiplegic migraine?
Hemiplegic migraine is very rare, with an estimated prevalence of 0.01% (around 1 in 1,000 migraine patients), more common in adolescent females.
Migraine Diagnostic Criteria
What are the diagnostic criteria for migraine without aura?
At least 5 attacks fulfilling criteria B-D.
What is the duration of headache attacks in migraine without aura?
Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated).
What are the characteristics of headache in migraine without aura?
Headache has at least two of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity.
What symptoms may occur during a migraine headache?
During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia.
What is the requirement for migraine diagnosis regarding other disorders?
Not attributed to another disorder.
How do migraine symptoms differ in children?
In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.
What is the typical aura in migraine with aura?
Typical aura includes a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’).
What percentage of migraine patients experience migraine with aura?
Migraine with aura is seen in around 25% of migraine patients.
What are the NICE criteria for migraines regarding aura?
NICE suggests migraines may be unilateral or bilateral and gives more detail about typical auras.
What are the characteristics of auras according to NICE?
Auras may occur with or without headache, are fully reversible, develop over at least 5 minutes, and last 5-60 minutes.
What are atypical aura symptoms that may prompt further investigation?
Atypical aura symptoms include:
1. motor weakness
2. double vision
3. visual symptoms affecting only one eye
4. poor balance
5. decreased level of consciousness.
What are the general rules for 5-HT receptor agonists and antagonists in migraine management?
5-HT receptor agonists are used in the acute treatment of migraine, while 5-HT receptor antagonists are used in prophylaxis.
What did NICE produce in 2012 regarding migraines?
NICE produced guidelines on the management of headache, including migraines.
What is the first-line acute treatment for migraines?
Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol.
What should be considered for young people aged 12-17 years in acute treatment?
Consider a nasal triptan in preference to an oral triptan.
What should be offered if first-line measures are not effective or tolerated?
Offer a non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan.
What caution should be taken when prescribing metoclopramide to young patients?
Caution should be exercised as acute dystonic reactions may develop.
When should prophylaxis be given for migraines?
Prophylaxis should be given if migraine attacks significantly impact quality of life and daily function.
What are some prophylaxis options for migraines?
Options include propranolol, topiramate, and amitriptyline.
What special consideration should be taken for topiramate in women?
Topiramate should be avoided in women of childbearing age as it may be teratogenic and can reduce the effectiveness of hormonal contraceptives.
What does NICE recommend if prophylaxis measures fail?
NICE recommends a course of up to 10 sessions of acupuncture over 5-8 weeks.
What does NICE advise regarding riboflavin for migraine?
Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people.
What treatment does NICE recommend for women with predictable menstrual migraine?
NICE recommends either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’.
What treatment options may be considered by specialists outside NICE guidelines?
Options include candesartan and monoclonal antibodies directed against the CGRP receptor, such as erenumab.
What is the status of pizotifen in migraine treatment?
Pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.
What is the first-line treatment for migraine during pregnancy?
Paracetamol 1g is first-line.
What can be used as a second-line treatment for migraine during pregnancy?
NSAIDs can be used second-line in the first and second trimester.
What medications should be avoided during pregnancy for migraine treatment?
Aspirin and opioids such as codeine should be avoided.
Is the combined oral contraceptive (COC) pill contraindicated for patients with migraine with aura?
Yes, the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72).
How do migraines relate to menstruation?
Many women find that the frequency and severity of migraines increase around the time of menstruation.
What treatments does SIGN recommend for migraines related to menstruation?
SIGN recommends mefanamic acid or a combination of aspirin, paracetamol, and caffeine. Triptans are also recommended in the acute situation.
Is hormone replacement therapy (HRT) safe for patients with a history of migraine?
It is safe to prescribe HRT, but it may make migraines worse.
