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Year 3 > Migraine (N) > Flashcards

Migraine (N) Flashcards

1
Q

Define migraine.

A

Chronic, episodic neurological disorder that has a strong genetic component and usually presents in early-to-mid life

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2
Q

What are primary headaches characterised by?

A

Recurrent episodes of unilateral, localised pain

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3
Q

What are the three types of migraines?

A
  • migraine with aura (classical migraine)
  • migraine without aura (common migraine)
  • migraine variants (e.g. familial hemiplegic, opthalmoplegic)
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4
Q

Describe the aetiology of migraines?

A

Poorly understood

  1. early aura of cortical spreading depression (associated with intracranial vasoconstriction –> localised ischaemia)
  2. –> meningeal and extracranial vasodilation (mediated by serotonin, bradykinin and trigeminovascular system)
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5
Q

What demographics are affected most by migraines? (3)

A
  • F>M (3:1)
  • adolescence
  • early adulthood
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6
Q

What are some triggers for migraines? (9)

A
  • chocolate
  • hangovers
  • orgasms
  • cheese/caffeine
  • oral contraceptives
  • lie ins
  • alcohol
  • travel
  • exercise
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7
Q

What are the risk factors for migraine? (7 + 3)

A
  • female sex
  • family history
  • obesity
  • stressful life events
  • medication overuse
  • sleep disorders
  • menstruation
  • (low socio-economic status)
  • (allergies / asthma)
  • (hypothyroidism)
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8
Q

What are the clinical features of migraine?

A
  • 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
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9
Q

What examinations do we do for migraine to exclude secondary causes?

A
  • MMSE
  • neurological examination
  • fundoscopy
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10
Q

How is a diagnosis of migraine usually made?

A

Clinical diagnosis based on history and examination

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11
Q

What other investigations can be considered for migraine (alongside clinical diagnosis)? (4)

A
  • bloods - ESR
  • CT / MRI
  • lumbar puncture - CSF
  • angiography
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12
Q

What are some differential diagnoses for migraines?

A
  • 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
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13
Q

What are the diagnostic criteria for migraine without aura?

A

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
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14
Q

What is the diagnostic criteria for migraine with aura?

A

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
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15
Q

What initial management should be provided to all patients with migraine? (2)

A
  • limit stimuli
  • treat nausea with IV fluids and metoclopramide (anti-emetics)
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16
Q

What is the 1st line treatment for a patient presenting to the ED with persistent migraine?

A
  • rescue therapy - metoclopramide 10-20mg IV (anti-emetic)
  • CONSIDER hydration
  • CONSIDER high-flow oxygen
  • CONSIDER corticosteroid
17
Q

What is the 1st line treatment for a patient with mild to moderate migraine (non-pregnant)?

A
  • NSAID (e.g. aspirin, diclofenac potassium, ibuprofen, naproxen)
  • CONSIDER anti-emetic
  • CONSIDER hydration
  • 2nd line: paracetamol monotherapy
  • 3rd line: paracetamol/aspirin/caffeine
18
Q

What is the 1st line treatment for a patient with severe migraine (non-pregnant)?

A
  • 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
19
Q

What is the 1st line treatment for a pregnant patient with migraine?

A
  • paracetamol
  • CONSIDER anti-emetic +/- diphenhydramine
  • CONSIDER hydration
  • CONSIDER magnesium
  • avoid aspirin and opioids during pregnancy
20
Q

What is the 1st line treatment for frequent recurring severe/disabling migraines?

A
  • trigger avoidance and non-pharmacological therapies
  • consider preventative treatment: specialist referral for pharmacological treatment
21
Q

Generally, what is the 1st-line treatment for migraines (and how does this differ in 12-17 year olds)?

A
  • oral triptan (sumatriptan) + NSAIDs (+ metoclopramide)
  • 12-17: nasal triptans rather than oral
22
Q

In which groups of patients are triptans contraindicated in?

A

Those with coronary artery disease as this may cause vasospasm

23
Q

What is the main prophylactic treatment for migraine?

A
  • 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
24
Q

What is the main concern with giving medications for migraines, and how do we treat this?

A
  • can trigger medication overuse headaches
  • if this is due to simple analgesics + triptans - stop immediately
  • if this is due to opioid analgesics - withdraw gradually
25
Q

What should happen to individuals with migraine with aura regarding the COC pill?

A

COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)

26
Q

What are some complications of migraines? (3)

A
  • pre-eclampsia risk
  • depression risk
  • medication overuse headache
27
Q

Describe the prognosis of migraine.

A

Most patients do well with treatment

Year 3 (22 decks)

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