Migraine (N) Flashcards
Define migraine.
Chronic, episodic neurological disorder that has a strong genetic component and usually presents in early-to-mid life
What are primary headaches characterised by?
Recurrent episodes of unilateral, localised pain
What are the three types of migraines?
- migraine with aura (classical migraine)
- migraine without aura (common migraine)
- migraine variants (e.g. familial hemiplegic, opthalmoplegic)
Describe the aetiology of migraines?
Poorly understood
- early aura of cortical spreading depression (associated with intracranial vasoconstriction –> localised ischaemia)
- –> meningeal and extracranial vasodilation (mediated by serotonin, bradykinin and trigeminovascular system)
What demographics are affected most by migraines? (3)
- F>M (3:1)
- adolescence
- early adulthood
What are some triggers for migraines? (9)
- chocolate
- hangovers
- orgasms
- cheese/caffeine
- oral contraceptives
- lie ins
- alcohol
- travel
- exercise
What are the risk factors for migraine? (7 + 3)
- female sex
- family history
- obesity
- stressful life events
- medication overuse
- sleep disorders
- menstruation
- (low socio-economic status)
- (allergies / asthma)
- (hypothyroidism)
What are the clinical features of migraine?
- prolonged unilateral headache (4-72h, recurrent episodes)
- throbbing/pulsatile pain
- nausea/vomiting
- decreased ability to function
- headache worse with activity
- photophobia & phonophobia
- aura beforehand (15-30min before - flashing lights, tingling, spots, zigzags)
- abdominal pain in children
What examinations do we do for migraine to exclude secondary causes?
- MMSE
- neurological examination
- fundoscopy
How is a diagnosis of migraine usually made?
Clinical diagnosis based on history and examination
What other investigations can be considered for migraine (alongside clinical diagnosis)? (4)
- bloods - ESR
- CT / MRI
- lumbar puncture - CSF
- angiography
What are some differential diagnoses for migraines?
- tension headache (bilateral pressure-like and non-throbbing pain)
- cluster headache (severe pain around one eye with ipsilateral symptoms, up to 3h 8times per day)
- medication overuse headache
- headache after head/neck trauma
- subarachnoid haemorrhage
- cerebral neoplasm
- low-pressure headache
- high-pressure headache
- CNS infection
- temporal arteritis
- arterial dissection
- central venous thrombosis
- ischaemic stroke
- reversible cerebral vasoconstriction syndrome
What are the diagnostic criteria for migraine without aura?
At least 5 attacks with:
- Headache attacks lasting 4 to 72 hours (when untreated or unsuccessfully treated)
- Headache has at least 2 of the following 4 characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
- During headache at least one of the following:
- nausea and/or vomiting
- photophobia
- phonophobia
What is the diagnostic criteria for migraine with aura?
At least 2 attacks with:
- One or more of the following fully reversible aura symptoms:
- visual
- sensory
- speech and/or language
- motor
- brainstem
- retinal
- At least 3 of the following 6 characteristics:
- At least one aura symptom spreads gradually over 5 minutes
- Two or more aura symptoms occur in succession
- Each individual aura symptom lasts 5 to 60 minutes
- At least one aura symptom is unilateral
- At least one aura symptom is positive
- The aura is accompanied, or followed within 60 minutes, by headache
What initial management should be provided to all patients with migraine? (2)
- limit stimuli
- treat nausea with IV fluids and metoclopramide (anti-emetics)
What is the 1st line treatment for a patient presenting to the ED with persistent migraine?
- rescue therapy - metoclopramide 10-20mg IV (anti-emetic)
- CONSIDER hydration
- CONSIDER high-flow oxygen
- CONSIDER corticosteroid
What is the 1st line treatment for a patient with mild to moderate migraine (non-pregnant)?
- NSAID (e.g. aspirin, diclofenac potassium, ibuprofen, naproxen)
- CONSIDER anti-emetic
- CONSIDER hydration
- 2nd line: paracetamol monotherapy
- 3rd line: paracetamol/aspirin/caffeine
What is the 1st line treatment for a patient with severe migraine (non-pregnant)?
- triptan (e.g. sumatriptan PO)
- CONSIDER anti-emetic
- CONSIDER hydration
- CONSIDER NSAID/paracetamol/aspirin/caffeine
- 2nd line: ergot alkaloid
- 3rd line: corticosteroid
- 4th line: butalbital-containing compounds
What is the 1st line treatment for a pregnant patient with migraine?
- paracetamol
- CONSIDER anti-emetic +/- diphenhydramine
- CONSIDER hydration
- CONSIDER magnesium
- avoid aspirin and opioids during pregnancy
What is the 1st line treatment for frequent recurring severe/disabling migraines?
- trigger avoidance and non-pharmacological therapies
- consider preventative treatment: specialist referral for pharmacological treatment
Generally, what is the 1st-line treatment for migraines (and how does this differ in 12-17 year olds)?
- oral triptan (sumatriptan) + NSAIDs (+ metoclopramide)
- 12-17: nasal triptans rather than oral
In which groups of patients are triptans contraindicated in?
Those with coronary artery disease as this may cause vasospasm
What is the main prophylactic treatment for migraine?
- beta blockers (propranolol) or topiramate
- propranolol should be avoided in asthmatics - can cause bronchoconstriction
- propranolol preferred in pregnant women and women of child-bearing age - topiramate can cause cleft lip in infants
What is the main concern with giving medications for migraines, and how do we treat this?
- can trigger medication overuse headaches
- if this is due to simple analgesics + triptans - stop immediately
- if this is due to opioid analgesics - withdraw gradually
What should happen to individuals with migraine with aura regarding the COC pill?
COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)
What are some complications of migraines? (3)
- pre-eclampsia risk
- depression risk
- medication overuse headache
Describe the prognosis of migraine.
Most patients do well with treatment
