Migraine Flashcards
What is the definition of migraine?
A primary headache disorder characterised by recurrent headaches that are moderate to severe
How many main types of migraine are there?
3
What are the 3 main types of migraine?
- Migraine with aura
- Migraine without aura
- Migraine aura without headache
What are the two classifications of migraines?
Episodic and chronic
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
What is thought to be the underlying pathology of migraines?
Neurovascular disorder staring in the brain and then affecting blood vessels
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
Is the actual mechanism of headache pain in migraines known?
No.
So probably don’t bother with the pathophysiology at all tbh
What are the risk factors for migraines?
- Female
- Family history
What are the characteristic presenting symptoms of migraine?
- Paroxysmal headaches
- Premonitory phase
- Resolution phase
- Concentration and mood changes
Describe a typical migraine headache
Severe and unilateral (mostly)
What percentage of migraine headaches are bilateral?
30-60%
What percentage of migraines have a premonitory phase?
20-60%
What are the symptoms experienced in the premonitory phase of migraine?
- Fatigue
- Mood changes
- GI symptoms
- Nausea
What happens in the resolution phase of migraine?
The headache gets gradually better
How many attacks must a patient have had to be diagnosed with migraine without aura?
At least 5
How long does the headache last in migraine without aura?
4-72 hours
A headache in a migraine without aura has at least 2 of what features?
- Unilateral
- Pulsating
- Moderate to severe
- Aggravated by routine physical activity
In addition to headache at least one of what other symptoms are present in migraine without aura?
- Nausea and vomiting
- Photophobia and phonophobia
What percentage of people with migraine without aura experience N&V?
At least 60%
What proportion of migraine sufferers experience migraine with aura?
About 1/3
What are the phase of migraine with aura?
- Premonitory phase
- Aura
- Migraine
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
