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
Do migraines often run in families?
Yes
What percentage of people have migraine with aura?
30 %
Migraine without aura is more common
What is a migraine with brainstem aura?
A rare type previously called basilar type
Experience 2 or more before migraine: visual disturbance, speaking difficulties, hearing problems, tingling in hands and feet, dizziness, vertigo
What is hemiplegic migraine?
Migraine with weakness or paralysis on one side of body is a key symptom occurring before headache
What is allodynia?
All stimuli produce pain
Why should topiramate be used cautiously?
Teratogenic
Can interfere with pill efficacy
If perimenstrual migraine uncontrolled with standard treatment, what can be given?
Consider frovatriptan or zolmitriptan on the days migraine expected
Worsening headaches during pregnancy are associated with…
Greater risk of pre eclampsia and cardiovascular complications
What are the most common side effects of triptans?
Dizziness Nausea Drowsiness Warm, hot sensation Feeling of heaviness or pressure in areas e.g arm, face, chest
Why is it best not to take codeine or medication containing codeine for migraines?
Can cause nausea and vomiting - this can also make migraine worse
Medication overuse headaches if used frequently
How do you take a triptan?
Take first dose when headache just beginning to develop, not before. They do not work as well if taken too early.
If one triptan doesn’t work, the same in a higher dose or a different type may work.
Should triptans be taken during pregnancy?
No
If trying to reduce frequency of migraine attacks, should propranolol or topiramate be used in women of childbearing age?
Propranolol
When should prophylaxis be given?
If experiencing 2 or more attacks per month
If the normal prophylactic measures are not working, what does NICE advise?
A course of up to 10 sessions of acupuncture over 5 to 8 weeks
Is propranolol cardioselective?
No has systemic effect - can cause bronchoconstriction (avoid in asthma)
Prophylactic treatment can achieve what percentage reduction in attack frequency?
50%
What is the first choice of triptan?
Sumatriptan 50-100mg
Offer other triptan if sumatriptan fails
If vomiting - can consider inta nasal or subcutaneous preparations
If the patient has an aura, should triptans be taken at start of aura or start of headache?
Start of headache
How should follow up appointment be arranged in adults with migraine?
Within 2-8 weeks of starting treatment
- discuss frequency of attacks, effectiveness of treatment, adverse effects
What aura symptoms are atypical and may prompt further investigation/ referral?
Motor weakness Double vision Vision symptoms affecting one eye Poor balance Decreased level of consciousness
How are migraines managed during pregnancy?
Paracetamol 1g is first line
NSAIDS can be used second line in first and second trimester
Avoid aspirin and opioids
Is it safe to prescribe HRT for patients with a history of migraine?
Yes but may make migraine worse
