Migraine Flashcards by Elliot Jones

What is the definition of migraine?

A primary headache disorder characterised by recurrent headaches that are moderate to severe

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How many main types of migraine are there?

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What are the 3 main types of migraine?

Migraine with aura
Migraine without aura
Migraine aura without headache

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What are the two classifications of migraines?

Episodic and chronic

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What is chronic migraine?

When headache is present on at least 15 days a month with at least 8 days where headache and other symptoms meet diagnostic criteria for migraine

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What is thought to be the underlying pathology of migraines?

Neurovascular disorder staring in the brain and then affecting blood vessels

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What is thought to be the pathophysiology of migraines?

NMDA receptor activation causing cellular calcium influx and depolarisation. This causes a decreased blood flow to the cortex. Depolarisation spreads through pain receptors in the head and neck

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Is the actual mechanism of headache pain in migraines known?

No.

So probably don’t bother with the pathophysiology at all tbh

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What are the risk factors for migraines?

Female

- Family history

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What are the characteristic presenting symptoms of migraine?

Paroxysmal headaches
Premonitory phase
Resolution phase
Concentration and mood changes

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Describe a typical migraine headache

Severe and unilateral (mostly)

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What percentage of migraine headaches are bilateral?

30-60%

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What percentage of migraines have a premonitory phase?

20-60%

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What are the symptoms experienced in the premonitory phase of migraine?

Fatigue
Mood changes
GI symptoms
Nausea

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What happens in the resolution phase of migraine?

The headache gets gradually better

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How many attacks must a patient have had to be diagnosed with migraine without aura?

At least 5

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How long does the headache last in migraine without aura?

4-72 hours

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A headache in a migraine without aura has at least 2 of what features?

Unilateral
Pulsating
Moderate to severe
Aggravated by routine physical activity

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In addition to headache at least one of what other symptoms are present in migraine without aura?

Nausea and vomiting

- Photophobia and phonophobia

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What percentage of people with migraine without aura experience N&V?

At least 60%

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What proportion of migraine sufferers experience migraine with aura?

About 1/3

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What are the phase of migraine with aura?

Premonitory phase
Aura
Migraine

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When does the premonitory phase in migraine with aura occur?

Hours to days before

What are the common features of migraine with aura?

Depression
Tiredness
Difficulty concentrating
Irritability
Stiff neck
Food cravings

How does the nature of aura vary in migraine with aura?

Highly variable between individuals but is usually consistent for individuals

What is the timing of aura in migraine with aura?

Progress over minutes and last minutes to an hour before headache

What are some aura features in migraine with aura?

- Visual disturbances | - Sensory symptoms

What visual disturbance can occur in migraine with aura?

- Geometric patterns | - Hallucinations

How do visual disturbances onset in migraine with aura?

Usually start in one eye then may spread

What sensory symptoms can occur as part of an aura in migraine with aura?

Unilateral paraesthesia or numbness

What is the migraine in migraine with aura like?

Same as migraine without aura

What is a menstrual migraine?

A migraine without aura occurring regularly within two days before onset of menstruation and no other time

What may be seen on examination in a patient with a migraine?

- Localised oedema - Scalp tenderness - Prominence of temporal blood vessels - Neck stiffness and tenderness

When are investigations required in migraine?

Only to exclude an alternative diagnosis if one is suspected

When is referral to a neurologist required?

After failure of second-line management of acute symptoms or diagnosis is uncertain

What features are suggestive of a more serious pathology?

- New headache in over 50 or under 10s - Headache with long lasting aura - Systemic symptoms - 'Worst ever headache' - Change in features and timing - Scalp tenderness - Jaw claudication - Focal neurological symptoms

What are some differentials for migraine?

- Other forms of headache - Giant cell arteritis - Subarachnoid haemorrhage - Cerebral neoplasm - Systemic or CNS infection - Arterial dissection - Cerebral venous thrombosis - Ischaemic stroke

What other headaches could be differentials for migraine?

- Tension - Cluster - Medication-overuse - Post-traumatic

What are the aims of migraine management?

- Relieve symptoms - Reduce frequency - Reduce severity - Identify triggers

What is step 1 in managing the symptoms of an acute migraine?

Simple analgesic with/without anti-emetic

What simple analgesics can be tried to combat migraine?

Soluble aspirin 600-900mg OR | ibuprofen 400-600mg

What is step 2 in managing the symptoms of an acute migraine?

Rectal analgesia and rectal anti-emetic

What rectal therapies should be given for acute migraine symptoms?

100mg diclofenac with 30mg domperidone (if needed)

What is step 3 in managing the symptoms of an acute migraine?

Specific ant-migraine drugs

What are some examples of anti-migraine drugs?

- Triptans (5HT1 agonists) | - Ergotamine

When should patients be offered prophylaxis to reduce migraine frequency?

When they have 2 or more attacks per month

What are the first line prophylactic agents for migraine?

- Beta blockers | - Amitriptyline

What are the second line prophylactic agents for migraine?

- Topiramate | - Sodium valproate

What are the third line prophylactic agents for migraine?

- Pizotifen

What can help to identify triggers of migraine?

An 'attack and trigger' diary

What can an attack ad trigger diary help with?

Determining if certain avoidable behaviours are linked to migraine onset

What are some examples of possible avoidable migraine triggers?

- Stress - Bright lights - Loud noise - Anxiety - Dietary sensitivities - Sleep deprivation

What are the potential complications of migraine?

- Increased risk of psychiatric disorders - Status migrainosus - Migrainous infarction - Increased risk of ischaemic and haemorrhagic stroke

What psychiatric disorders is a person at increased risk of developing with migraines?

- Depression - Bipolar - GAD - Panic disorder

What is status migrainosus?

Debilitating migraine that lasts for more than 72 hours

What is a migrainous infarction?

When cerebral infarction occurs during the course of a typical attack of migraine with aura