Migraine Flashcards
Are migraines with or without an aura more common?
Without aura
What causes a migraine?
Pathophysiology unknown, possibly:
- episodic cerebral oedema
- dilation of intracerebral vessels
- interruption of subcortical sensory pathways
- hormonal role - drop in oestrogen
- Triptans inhibit substance P and pro inflammatory neuropeptides
Describe features of the headache
On one side Typically at front or side of head Can start on one side and spread all over Throbbing or pulsating Moderate to severe pain Movement of head may make it worse Typically gradually gets worse Can last from 4 to 72 hours
Other than the headache itself, what are some other associated symptoms?
Nausea and vomiting Dislike of bright lights or loud noises Blurred vision Poor concentration Being off food or hungry Stuffy nose Diarrhoea Abdominal discomfort Polyuria Scalp tenderness Sweating Pale
What is the most common type of aura?
Visual aura
What symptoms can occur with a visual aura?
Scotoma or hemianopia
Lines, dots or zigzags
Bright shimmering light
Objects or letters on a page may seem to rotate, shake or boil
Other than visual aura, what other types are there?
Somatosensory - numbness and pins and needles. Usually starts in hands and travels up arm, then involves face
Speech - dysphasia paraphasia
Motor - ataxia, hemiparesis, opthalmoplegia
Feel fear or confusion
How long do auras last?
A few minutes to 1 hour
Does the aura usually go before the headache begins?
Yes
Can an aura occur with no following migraine?
Yes - silent migraine
What can trigger a migraine?
Diet - cheese, chocolate, red wine, citrus fruits, food containing tyramine, dehydration, missing meals
Environment- smoking, glaring light, flickering TV, loud noises, strong smells
Psychological- depression, anxiety, stress, relief of stress, anger
Too much or too little/ broken sleep
Medication - HRT, contraceptive pill
What are the four phases?
Prodrome
Aura phase
Headache
Resolution - may feel tired, irritable
What is the prodrome phase?
Precedes headache by days or hours - changes in mood, sleep pattern, food cravings
Are migraines more common in men or women?
Women 3x as common
What causes a visual aura?
Reduced blood flow to occipital cortex before an attack
How do you distinguish migraine from a TIA?
TIA has sudden onset, maximum deficit immediately and headache is rare.
In migraine, deficits occur gradually, almost always have headache
In both cases aura may be present
How do you diagnose a migraine?
From history
Headache lasting 4/72 hours with aura = classical
If no aura: more than or equal to 5 headaches lasting 4-72 hrs and N&V or phono/photophobia plus any 2 of:
Unilateral
Pulsating quality
Moderate or severe intense pain
Aggravation by or causing avoidance of routine physical activity e.g walking
What are some differentials?
Cluster headache Tension headache TIA Sinusitis or otitis media Intracranial pathology Cervical spondylosis HTN
How can migraines be managed?
Avoid triggers
Non pharmacological: rebreathing into paper bag, warm or cold pack to head
Ensure analgesic rebound headache is not a complicating matter
Triptan combined with either an NSAID or paracetamol
Mono therapy with above can be considered or with aspirin (900mg)
Antiemetics even in absence of N&V e.g non oral preparation of metaclopramide or prochlorperazine and consider adding non oral nsaid or triptan
How do triptans work?
5-HT agonist
Block transmission in trigeminal nerve to 2nd order neurons
When should triptans be avoided?
IHD, coronary spasm, uncontrolled HTN, recent lithium or SSRI use, liver/ kidney impairment, Reynaud’s
Rare SEs: arrhythmias, or angina+/-MI even if no pre existing risk
What can be used for prophylaxis?
Propranolol or topiramate
Amitriptyline can be used but is off licence
Last resort: botulinum toxin type A injections
If you have a migraine with aura, how many times as likely are you to have an ischaemic stroke compared to those without a migraine?
2x
Taking the COCP increases the risk of stroke in women who have a migraine with aura. True or false?
True
Women with aura + migraine should not be given COCP
Use progesterone only or non hormonal contraception
Though a low dose COCP can be used in women with migraine without aura
