Migraine Flashcards
Define migraine.
Migraine is a chronic, genetically determined, episodic, neurological disorder that usually presents in early-to-mid life and presents with nausea, photophobia and reduced ability to function with a headache.
What is the International Headache Society criteria for migraine?
At least 5 headache attacks lasting 4-72 hours (when untreated) and having 2 of the following characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity
And one of the following:
- Nausea and/or vomiting
- Photophobia/phonophobia
What are the risk factors for migraine?
- FH
- Female
- Menstruation
- Obese
- Stress
- Overuse of headache medication
- Sleep disorders
Other:
- Low socio-economic background
- Allergies or asthma
- Hypothyroidism
What classifies as chronic migraines ?
Chronic migraines = >15 days of headache a month
How common are migraines?
- Affects 1 in 6
- Before puberty, migraine prevalence is higher in boys than in girls
- 3:1 M:F in adults
- Prevalence declines with age in both sexes
What is the pathophysiology of migraine?
- Those with migraines have a brain which is hyperexcitable to a variety of stimuli
- Neurogenic inflammation of first division of trigeminal sensory neurons causes a change in how pain is processed by the brain.
- Activated trigeminal neurons → dilation of meningeal blood vessels → leakage of plasma proteins into tissues and platelet activation → nociceptive input → headache
S: Where is the pain in migraines?
O: What is the onset of migraines like?
S: Occurs unilaterally, sometimes bilateral and spreads to face or neck
O: 1 in 3 experience an aura of both… This may last 5mins to an hour.
- positive phenomena (visual sparkles, flashing lights)
- negative phenomena (visual loss or scotoma)
- Sensory aura (numbness, tingling), and aura with aphasia/dysphagia may occur.
C: How is the pain of a migraine characterised?
R: Does the pain spread anywhere?
S: How severe is it?
C: throbbing, pulsating headache
R: Can spread to face and neck
S: moderate to severe pain
A: What other symptoms are associated with migraine?
T: How long do migraines last?
Associated symptoms:
- Photophobia/phonophobia
- Nausea
- Vomiting
- Aura
T: Can last 4-72 hours if left untreated.
What is pathognomic of a migraine?
Aura ,which occurs during or precedes headache, is pathognomonic of migraine but only occurs in 15% to 30% of patients.
Define aura.
a complex of reversible visual, sensory, or speech symptoms
E: What makes migraine symptoms worse? What makes them better?
Worse: movement, light, noise
Better: lying still in a dark room
What symptom is most common in migraine?
Nausea
What investigations should be done for migraine?
Clinical diagnosis - testing is only used to rule out plausible alternative diagnoses. Must fulfil Classification of Headache Disorders (ICHD)-IIIb criteria for migraine.
Investigations to consider:
ESR/CRP- rule out temporal arteritis.
LP +/- CSF culture - may be abnormal in SAH, meningitis, high/low CSF pressure; recommended in most patients with abrupt-onset headache.
CT/MRI/angiography - rule out SOLs, ischaemic lesions, subarachnoid haemorrhage
What features should increase suspicion of dangerous underlying headache/migraine mimic? (SNOOP4)
- Systemic symptoms: fever, weight loss
- Neurological symptoms or abnormal signs: confusion, impaired alertness or consciousness
- Onset: sudden, abrupt, or split-second
- Older: new-onset and progressive headache, especially in patient over 50 years of age
- 4 ‘P’
- Pattern change (increased frequency)
- Papilloedema
- Precipitating factors (valsalva, etc)
- Positional aggravation.
How do you treat migraines?
Trigger avoidance/behavioural modification
Preventative measures for ongoing migraines:
- Symptoms linked to menstrual cycle - cycle control (hormonal therapy to suppress menses) AND magnesium AND triptans (frovatriptan)
- Aura and hemiplegic/basilar features - anticonvulsants (topiramate) AND TCA (amitriptyline) AND beta-blocker (propanolol)
- Frequent /troublesome auras - CCB (verapamil)
- Hemiplegic/basilar-type migraine - CCB (verapamil)
- With depression - antidepressants (venlafaxine)
How do you treat an acute migraine presenting in A&E with persistent symptoms?
- IV metoclopramide/prochlorperazine AND diphenhydramine - once
- Hydration
- O2- 15L
- IV dexamethasone 8-16mg - once
What are the complications of migraine?
- Status migranosus - >72 hours (look for medication overuse)
- Migrainous infarction
- Migraine-triggered seizure
- Depression
- Chronic migraine
- Persistent aura without infarction
What is the prognosis with migraine?
Frequency decreases with age
Good with medication
The patient describes seeing zig zags before the headache starts and she draws this. Which 2 of the following are true?
- The patient is describing an aura
- For the diagnosis of migraine to be made an aura must have been present on one or more occasions
- Aura is always followed by headache
- The above represents central scotoma
- The above makes the diagnosis of migraine very likely
Which 3 medications are used in the prophylaxis of migraine?
- Propranolol
- Diclofenac
- Amitriptyline
- Rizatriptan
- Pizotifen
Propanolol, amitriptyline and pizotifen
Rizatriptan and other triptans are used only in acute attacks. Diclofenac may also be used in acute attacks
Granisetron is a powerful anti-emetic that is generally reserved for nausea and vomiting post chemotherapy. Soluble aspirin is commonly used as an analgesic in the treatment of migraine.
Which of the following is NOT a contraindication to using 5HT agonists?
- Ischaemic heart disease
- Uncontrolled hypertension
- Adults over 65
- Children below 12
- Asthma
Contraindications for the use of sumatriptan include:
- Ischaemic heart disease
- Prinzmetal’s angina
- Uncontrolled hypertension
Sumatriptan is not to be used:
- In children below 12
- In adults over 65
- With ergotamine preparations or vasoconstrictor drugs in general
- When methysergide has been prescribed for prevention of migraine because methysergide also has vasoconstrictor properties
- 5-HT agonists are associated with return of symptoms within 48 hours in 20-50% of patients who have initially responded.
This is a troublesome aspect of their use.
Which drugs are used for acute migraine and prevention of migraine?
The patient says she gets a funny moving zigzag shape in her field of vision before her headache starts, which then subsequently disappears. What is the medical term for this?
scintillating scotoma - pathognomonic of migraine
