Migraine

Question 1

Define Migraine

Answer 1

Chronic, genetically determined, episodic neurological disorder that presents as a severe episodic headache that may have a prodrome of focal neurological symptoms (aura)

Question 2

Risk factors for Migraine

Answer 2

FMHx of migraine
High caffeine intake
Exposure to change in barometric pressure
Females
Obesity 
Stressful life events
Overuse of headache medication
Sleep disorders

Question 3

Symptoms of Migraine

Answer 3

Headache (unilateral (60%) | Paroxysmal | pulsating/throbbing | 4-72hr | worse on exertion/physical activity/stress)

± aura - 30% (visual change | aphasia | tingling | numbness | flashing lights | visual loss, scotoma | sensory aura)
=> typical aura = transient hemianopic disturbance of Migra (jagged crescent)

Nausea and vomiting
Photophobia
Phonophobia
DISABILITY (unable to carry out ADLs, distinguish from tension)

May be triggered by stress | exercise | lack of sleep | OCP | caffeine | alcohol | cheese | chocolate | analgesia use

Question 4

Investigations for Migraine

Answer 4

Clinical diagnosis

ESR: rule out GCA

MRI brain/CT head: exclude SOL

LP and CSFL exclude SAH and meningitis

Question 5

Management for an acute Migraine episode

Answer 5

Rescue therapy = Metoclopramide IV + Diphenhydramine IV

High flow oxygen

IV corticosteroid

Question 6

Management for Migraine

Answer 6

Conservative: headache diary | avoid precipitating factors (regular meals, sleep hygiene, hydration) | avoid triggers (cheese, OCP, caffeine, alcohol, stress)

Sumitriptan oral
+ analgesia (NSAIDs, aspirin, paracetamol)
+ Anti-emetic (metoclopramide PO)
± hydration
± magnesium
± Ergot alkaloids (Dihydroergotamine) + corticosteroids

Triptans are CI in pregnancy -> give paracetamol ± anti-emetics

Question 7

Prophylactic management for Migraine

Answer 7

Propanolol or Topiramirate

Amitriptryline

Question 8

Complications of Migraine

Answer 8

Status migrainosus (>72h) - use IV fluids, steroids, Mg sulfate, anticonvulsants, NSAIDs, anti-emetics

Migrainous infarction
Migraine-triggered seizures
Depression
Chronic migraine
Persistent aura without infarction

Question 9

Prognosis for Migraine

Answer 9

Most patients do well with treatment
Frequency decreases with age
Development of complications or those with co-morbidities or a long-standing history of medication overuse - expectations for improvement should be modest, and the goals of treatment should shift from elimination of pain to improvement in function