Migraine Flashcards
What are some key differences between a tension headache and a Migraine?
Tension: Bilateral, non-throbbing, rarely disabling, featureless
Migraine: Often throbbing, associated photo and phono phobia, nausea, disabling
Features of a tension headache
Common in the general population, RARE as a chief complaint
What is the prevalence of migraine amongst canadians and at what age does it peak?
- > 4 milion Canadians
2) 3:1 women:men
3) 25-55 years of age
Prevalence of primary headaches in school children
10-20% in school children (boys more than girls)
Prevalence of primary headaches in adolescents
~30% 1x/month
~90% 1x/year
Migraine headaches in children 7 years of age
1-3%
Migraine in 15 years of age
4-20%
Migraine is more common than what two diseases?
1) Asthma
2) Diabetes - combined
Migraine features
- Neurological, with strong genetic component
- Overal >10% global prevalence (more women)
- 2 subtypes (+/- aura)
- world’s 20 most disabling diseases (3 million women, and 1 million men)
Why is there a higher prevalence of migraines in women?
- Hormonal factors, including sudden increase in E2 at menstruation
- Gender difference after menopause suggests other factors involved
How do you define Migraine?
Episodic headache disorder
What might chronic headaches be a sign of?
Depression, anxiety, sleep disorders
Signs of a migraine without aura…
5 attacks of 1) lasting 4-72 hours 2) - unilateral location (although 40% are bilaterally), pulsating quality (50% are non pulsating), moderate or severe pain, aggravation by avoidance of physical activity >= 1 of the following 3) Nausea/vomiting or photo/phonophobia 4) not attributed to other disorder
Signs of a migraine WITH aura…
2 attacks of
1) Fully reversible visual/sensory/speech symptoms - no motor weakness
at least 2 of the following
1. unilateral symptoms that develop gradually over 5 min, at 2. least one symptom developing gradually over 5 mins
3. each symptom lasting >5 mins, <60 mins
3) migraine begins with aura or follows within 60 min
What is an aura?
1) at least 2 attacks
2) fully reversible symptoms
3) (2 of…)unilateral snesory, develops gradually, duration >5 min, s visual, must last at least 5 mins.. BLURRY VISION NOT AN AURA
International classification of headache disorders (2 + 1)
any 2 of
- unilateral
- throbbing
- worsened by activity
- moderate or severe
any 1 of
- nausea/vomiting or anorexia!
- photo phonophobia
4 phases of a migraine attack.
1) prodrome
2) headache
3) resolution (sensory hyper excitability)
4) postdrome
When does the prodrome phase occur?
12-24 hours before headache - can be fatigue, mood swings, excessive yawning, food cravings, driven by Dopamine!
What are common triggers of a migraine?
1) weather changes
2) poor sleep
3) weekends and holidays
4) menstrual cycle
5) strong smells
6) stress
7) fasting/skipping meals
8) certain foods - MSG, wine, caffeine
Vascular theory of migraine - suggests 2 things
1) AURA: caused by vasoconstriction (but vessels are normal)
2) THROBBING: due to vasodilation (but they are not dilated till later)
what is the primary cause of migraines?
- Genetic predisposition
- cortical neuronal hyper excitability and/or brainstem dysfunction
- Cortical spreading depression
- Activation and sensitization of trigeminal vascular system
- prolonged headache pain
What is migraine commonly misdiagnosed as?
(SECONDARY headache is sinus not primary) Sinus headache (face pain, worse lying down, associated nasal discharge)
What else is migraine commonly misdiagnosed as?
Tension type headache - In migraine neck pain (75-80%), more prevalent than nausea, stress is a trigger, 40% migraines are bilateral
Medication overuse headaches are common with what type and frequency of meds?
~2% prevalence
- Acetaminophen, Ibf, anything with caffeine - 2 days/week
- codeine narcotics - 5-8 doses/month
- triptans 10 days/month
What do patients want?
Complete relief (even with side effects) Oral tablet
Acute migraine medications
1) Triptans - 5HT B/D (serotonergic) receptor agonists (effective early, contraindicated with vascular risk factors)
2) Dihydroergotamine
3) nonspecific - NSAIDS, corticosteroids, antiemetics
Who gets a triptan?
1) Episodic and disabling migraine complaints
2) Absence of vascular contraindications
Safety of triptans, what are some problems?
1) Triptan sensations - chest pressure
2) CNS effects, dizziness, fatigue, somnolence
3) serotonin syndrome (very rare) - activates 5HT 2a not 1B/D/F
CV disease, uncontrolled HTN (CONTRAINDICATION)
What is serotonin syndrome?
Activation of the 5HT2a receptor (triptans activate BDF receptors)
Why do you treat migraines early?
The Central Trig vascular neurone become sensitized within 1 HOUR
central sensitization gives rise to cutaneous allodynia - pony tail painful, skin irritated/bothere - happens within one hour
Incomplete response once that develops!
How are headaches classified
- Primary - symptomatic based
2. Secondary - etiology based
Which is more prevalent a migraine with or without aura?
Without (75% vs 25% with)
which neurotransmitter may be involved in chronic headache/depression
lack of serotonin
WHat % of headaches go from episodic to chronic?
3%
What are the two most RELIABLE factors in diagnosing migraine without aura?
1) moderate to severe pain
2) difficulty to do physical activity
What is sensory hyper excitability?
Inherited component of a migraine, may have something to do with enhanced survivability
What are some co-existing disorders with Migraines?
- IRRITABLE BOWER SYn
- Anxiety
- depressed mood
- poor sleep
SEROTONIN PLAYS A KEY ROLE - large amount in gut
What are some childhood variants of migraines?
- cyclical vomiting
- sleep walking
- recurrent abdominal pain
- INFANT COLIC
- motion sickness
How is migraine caused?
- triggered in brainstem
- cortical spreading depression forward moving -
reduction in blood flow - migrates across cortex - doesn’t follow blood flow and cells are extracting less oxygen from blood (AURA) - this activates the trigeminal vascular system - messages go through trigeminal nucleus caudalis then sent cortically through thalamus
what is a true sinus headache?
- Face pain
- worse lying down
- associated with nasal discharge and fever
which molecular is important to think about with respect to inflammation?
CGRP
The trigeminal nerve description of migraines confuses diagnosis…..
- head and facial pain can be bilateral
- Neck pain (cervical nerve interactions)
- Sinus symptoms
when do you have an incomplete response to triptans?
Once cutaneous allodynia develops
What is the goal of preventative headache?
NOT TO BE HEADACHE FREE Reduce headache by 50% reduce acute med use increase effectiveness prevent chronicity
How does Botox work for migraine?
BLOCKs CGRP
