Migraine Flashcards
Define what migraine is [1]
What are the two types? [2]
Migraine describes a recurrent moderate to severe headache commonly associated with nausea, vomiting, photophobia and phonophobia. The headache is typically unilateral and pulsating in nature lasting 4-72 hours.
Migraine without aura:
- characteristic migraine headache with associated symptoms.
Migraine with aura:
- a migraine headache that is preceded (and sometimes accompanied) by focal neurological symptoms.
Migraines
Give a brief overview of the pathophysiology of migraine
Neurovascular Changes
- During the early phase of an attack, there may be a decrease in cerebral blood flow, followed by vasodilation and increased blood flow
Several neuropeptides and neurotransmitters have been implicated in migraine pathophysiology:
- Calcitonin gene-related peptide (CGRP): CGRP is a potent vasodilator and is involved in the activation of trigeminal nerve fibres,promoting inflammation and pain transmission.
Serotonin (5-HT):
- Serotonin is thought to play a role in migraine through its vasoactive properties and modulation of pain pathways.
Glutamate:
- Glutamate, an excitatory neurotransmitter, has been implicated in the initiation and maintenance of CSD and the sensitization of trigeminal nociceptive neurons.
Describe the feature of a migraine without aura [5+]
At least five attacks fulfilling criteria B-D:
B. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated)
C. Headache has at least two of the following four characteristics:
* unilateral location
* pulsating quality
* moderate or severe pain intensity
* aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following:
* nausea and/or vomiting
* photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis.
A headache meets the diagnostic criteria for migraine with aura if: [4+]
At least two attacks fulfilling criteria 2 and 3
B. One or more of the following fully reversible aura symptoms:
* visual
* sensory
* speech and/or language
* motor
* brainstem
* retinal
C. At least three of the following six characteristics:
* at least one aura symptom spreads gradually over ≥5 minutes
* two or more aura symptoms occur in succession
* each individual aura symptom lasts 5-60 minutes
* at least one aura symptom is unilateral
* at least one aura symptom is positive
* the aura is accompanied, or followed within 60 minutes, by headache
D. Not better accounted for by another ICHD-3 diagnosis.
Describe the typical symptoms of a migraine
There are five stages of migraine:
* Premonitory or prodromal stage (can begin several days before the headache)
* Aura (lasting up to 60 minutes)
* Headache stage (lasts 4 to 72 hours)
* Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
* Postdromal or recovery phase
Describe what aura symptoms are like [4]
Aura can affect vision, sensation or language. Visual symptoms are the most common. These may be:
Sparks in the vision
Blurred vision
Lines across the vision
Loss of visual fields (e.g., scotoma)
Migraine headaches last between 4 and 72 hours. Typical features are: [+]
Usually unilateral but can be bilateral
Moderate-severe intensity
Pounding or throbbing in nature
Photophobia (discomfort with lights)
Phonophobia (discomfort with loud noises)
Osmophobia (discomfort with strong smells)
Aura (visual changes)
Nausea and vomiting
Describe what is meant by a Hemiplegic Migraine [2]
The main feature of hemiplegic migraines is hemiplegia (unilateral limb weakness). Other symptoms may include ataxia (loss of coordination) and impaired consciousness.
NB Hemiplegic migraines can mimic a stroke or TIA It is essential to exclude a stroke with sudden-onset hemiplegia.
What are the three subtypes where migraines appear to directly cause neurological damage or other complications? [3]
Migrainous infarction:
An ischemic stroke that occurs during a typical attack of migraine with aura.
Migraine aura-triggered seizure:
- A seizure triggered by a migraine with aura.
Persistent aura without infarction:
- Aura symptoms that last for one week or more, without evidence of stroke on neuroimaging.
The neurological symptoms brought on by migraine with aura can be challenging to distinguish from a TIA/Stroke. Auras that feature motor, brainstem or retinal symptoms are not typical. In particular NICE highlights the following symptoms that warrant consideration of urgent neurological review: [4]
Motor weakness
Double vision
Visual symptoms affecting only one eye
Poor balance
Decreased level of consciousness
The NICE clinical practice guideline CG150 recommends further investigations (e.g. cerebral imaging) and/or referral for patients with new-onset headache and any of the following: [4]
- Immunosuppressed or compromised immunity
- < 20 years old and a history of malignancy
- History of malignancy known to metastasise to the brain
- Vomiting without other obvious cause.
Describe the acute treatment for migraine [+]
first-line: offer combination therapy with
* an oral triptan and an NSAID, or
* an oral triptan and paracetamol
* for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
* if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan
In the UK, new calcitonin gene-related peptide (CGRP) inhibitors may be used in acute migraine in patients who fail to respond to triptans or other standard treatments, or that these treatments are not tolerated or contraindicated.
- The main drug licensed for this indication is Rimegepant, which can be taken orally.
- These medications bind to the CGRP receptor and subsequently block attachment of CGRP which is a potent vasodilator that can amplify and perpetuate migraine headache pain.
caution should be exercised when prescribing metoclopramide to young patients as [] reactions may develop
caution should be exercised when prescribing metoclopramide to young patients as acute dystonic reactions may develop
Describe the prophylactic treatment for migraines [6+]
Usual:
* Propranolol
* Topiramate (contraindicated in pregnancy, the BNF states in women with childbearing potential ‘a highly effective’ contraception is required prior to commencement)
* Amitriptyline
More specialist options include:
* Pizotifen
* Candesartan
* Sodium valproate
Preventative treatment (newer agents)
* Erenumab (Aimovig): monoclonal antibody that blocks the CGRP receptor.
* Fremanezumab (Ajovy): monoclonal antibody that binds to the CGRP ligand preventing receptor activation
* Galcanezumab (Emgality): onoclonal antibody that binds to the CGRP ligand preventing receptor activation
When are newer preventative treatment agents indicated for use? [2]
When should they be considered for continued treatment? [2]
In general, these drugs have specific guidance around their prescribing as per NICE. They may be given to patients who:
* have 4 or more migraine days a month
* have tried at least 3 other medicines and they have not worked
In addition, they should only be continued if after 12 weeks:
* episodic migraine (less than 15 headache days a month) reduced by at least 50%
* chronic migraine (15 headache days a month or more) reduced by at least 30%
Migraine:
Anti-emetics: [] is often given and helps to relieve nausea.
Anti-emetics: buccal prochlorperazine is often given and helps to relieve nausea. Suppositories (e.g. domperidone) can again be given depending on patient preference.
What is status migrainosus? [1]
: a debilitating migraine that persists for longer than 72 hours.
Prophylactic [drug class] (e.g., [2]) are an option for menstrual migraines.
Symptoms tend to occur two days before until three days after the start of menstruation.
Prophylactic triptans (e.g., frovatriptan or zolmitriptan) are an option for menstrual migraines. Symptoms tend to occur two days before until three days after the start of menstruation. Regular triptans may be taken during this time.
triptan + NSAID or triptan + paracetamol
propranolol
topiramate or propranolol
Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Concurrent pizotifen use
Patients older than 55 years
A history of epilepsy
Previous intracranial tumour
A history of ischaemic heart disease
Which one of the following is a contraindication to the use of a triptan in the management of migraine?
A history of ischaemic heart disease
- They cause vasoconstriction of cranial blood vessels and inhibit the release of vasoactive peptides. However, they can also cause coronary artery vasospasm and are therefore contraindicated in patients with a history of ischaemic heart disease due to the increased risk of myocardial infarction.
