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.
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
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.
- 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?
