Migraines Flashcards
What are migraines?
They are defined as a chronic disorder in which patients experience episodic attacks of a headache and other associated clinical features
What is the pathophysiology of migraines?
There is no simple explanation for why migraines occur, and it may be a combination of structural, functional, chemical, vascular and inflammatory factors
What are the four classifications of migraines?
Migraines Without Aura
Migraines With Aura
Silent Migraines
Hemiplegic Migraines
What are migraines without aura?
They are defined as migraines which occurs without specific warning signs just before the headache begins
What are migraines with aura?
They are defined as migraines which occurs with specific warning signs just before the headache begins
What are silent migraines?
They are defined as migraines that result in aura clinical features; however, no headache is experienced
What are hemiplegic migraines?
They are a rare type of migraine in which individuals experience a temporary weakness on one side of their body (hemiplegia) as part of their migraine attack
What do hemiplegic migraines mimic? What do we do as a result?
Strokes
It is important to act fast and thoroughly investigate these patients
What are the ten migraine triggers?
Chocolate
Hormonal Changes
Orgasms
Cheese/Caffeine
combined Oral contraceptives
Lights
Alcohol
Tiredness
Exercise
Stress
Which gender is at a greater risk of migraines?
Females
What should we consider when female patients present with migraines?
We should look at their medication list and check whether they are being prescribed the combined oral contraceptive pill
This should then be changed to a progesterone only or non-hormonal contraceptive method
What is an absolute contraindication of the COCP?
Migraines with aura
Why is the combined oral contraceptive pill contraindicated in migraine with aura?
There is an increased risk of ischaemic stroke
What are the five clinical features of migraines?
Severe Unilateral Throbbing Headache
Headache Worsening Due To Exercise
Photophobia
Phonophobia
Nausea & Vomiting
What is photophobia?
It is defined as a sensitivity to light
What is phonophobia?
It is defined as a sensitivity to sound
How long do migraine attacks usually last?
4 – 72 hours
What is a prodrome?
It refers to subtle changes that warn of an upcoming migraine, usually occurring three days before the headache
What are the six clinical features of a predrome?
Constipation
Urinary Frequency
Neck Stiffness
Mood Changes
Food Cravings
Yawning
What is a migraine aura?
It refers to transient neurological symptoms which may occur hours before or during an attack
What are the six clinical features of a migraine aura?
Blurry Vision
Hemianopia Disturbances
Spreading Scintillating Scotoma
Paraesthesia
Ataxia
Dysarthria
What is hemianopia?
It is defined as vision loss affection half the visual field
What is scotoma?
It is defined as a spot in the visual field in which vision is absent or deficient
What is ataxia?
It is defined as a group of symptoms including slurred speech, stumbling, falling and incoordination
What is dysarthria?
It is a motor speech disorder in which the muscles that are used to produced are damaged, paralysed or weakened
How long do the clinical features of a migraine aura tend to last?
15 - 60 minutes
What do migraine auras commonly get mistaken for?
A transient ischaemic attack (TIA)
This is due to the fact that it similarly causes a sudden loss of function
Which five aura features are deemed as atypical, requiring further investigation/referral?
Motor weakness
Double vision
Unilateral visual disutrbances
Poor balance
Decreased level of consciousness
What is a post-drone?
It is a phase that can occur after a migraine attack
What are the three clinical features of a pro-drome?
Fatigue
Confusion
Elation
What investigations can be conducted to diagnose a migraine?
There are no specific investigations that can be conducted
However, a diagnosis can be aided by the conduction of a migraine diary
How long should we advise individuals to keep note of a migraine diary for?
A few weeks
What information should be noted in a migraine diary?
Date
Time
Duration of attack
Clinical features experienced
Medications administered
How are migraine diaries used to diagnose/investigate migraines?
They allow recognition of overuse headaches, which are caused by administration of painkillers on a long-term basis
It also allows identification of potential triggers for an individual’s migraine, which can allow individuals to take prophylactic measures
What would indicate that individuals have a medication overuse migraine?
If they take painkillers on more than 10 days every month and experience migraine features
What feature would provide a definitive diagnosis of migraine medication overuse headaches?
The clinicla features resolve, or revert to their original pattern, within 2 months of stopping the medication
What is the migraine diagnostic criteria from ‘The International Headache Society’?
There should be at least five migraine attacks, which fulfil the following criteria…
- Headache duration 4 -72 hours
- Headache needs to meet two of the following criteria (unilateral, pulsating quality, moderate to severe intensity, aggravated by exercise)
- During headache there is either nausea and vomiting OR photophobia and photophobia
- The headache is not attributed to another disorder
In what way do we conservatively manage a migraine attack?
This involves advising patients to go into
a quiet, dark room to sleep
In some cases, individuals feel better once they have vomited
In what three ways do we pharmacologically manage migraine attacks?
Basic Analgesia
Triptans
Antiemetics
What four basic analgesia drugs can be used to manage migraine attacks?
Paracetamol
Ibuprofen
Naproxen
Aspirin
When should patients take basic analgesia drugs when managing migraine attacks? Why?
It is advised that individuals take these at the first signs of a migraine attack
This gives them time to absorb into the bloodstream and ease symptoms
What basic analgesia is not advised for patients to take during a migraine attack?
Co-codamol
What drug classification do triptans belong to?
5HT receptor (serotonin receptor) agonists
What two triptans can be administered to manage a migraine attack?
Sumatriptan
Rizatriptan
What are the three mechanisms of actions of triptans?
Vasoconstriction of arteries
Inhibition of peripheral pain receptors
Reduced neuronal activity in the CNS
Which administration route of triptans is recommended in adults?
Oral
Which administration route of triptans is recommended in patients aged 12 - 17?
Intranasal
What is a side effect of triptans?
Chest tightness
What are the two contraindications of triptan administration?
Cardiovascular Disease
SSRIs
What three anti-emetics are used to manage migraines attacks?
Chlorpromazine
Metoclopramide
Prochlorperazine
What is the first line anti-emetic used to manage migraines?
Metoclopramide
When are anti-emetics used to manage migraine attacks?
If the patient’s migraine with aura is accompanied by nausea and vomiting
What is a side effect of metoclopramide, in young patients?
Acute dystonia reaction
What are the three acute pharmacological management options that can be used to manage predictable menstrual migraines?
Mefanamic acid
OR
A combination of aspirin, paracetamol and caffeine
OR
Triptans
How do we prevent the development of medication overuse migraines when pharmacologically managing them?
We limit the prescription of these drugs to ten per month, which is equivalent to two per week
In cases where medication overuse migraines develop, what is the most appropriate management?
We stop simple analgesia and triptans abruptly
We withdraw opioid analgesia gradually
When is prophylactic management of migraines recommended?
> 2 attacks/month
In what two ways do we conservatively prevent migraines?
We can advise patients about acupuncture therapy. This is usually not conducted by the GP practice and patients would have to explore this privately. It is suggested that individuals trial a course of up to 10 sessions over a 5-8 week period.
We can ask patients to complete a migraine diary to allow identification of potential triggers for an individual’s migraine. This can allow individuals to take prophylactic measures to avoid these triggers.
When is acupuncture recommended to prophylactically manage migraines?
Third line management option
Following hypertensive and anti-convulsant failure
In what four ways can we pharmacologically prevent migraines?
Hypertensives
Anti-Convulsants
Tricyclic Antidepressants
Botulin A Injections
When do we administer hypertensives to prevent migraines?
They are the first line prophylactic medications advised
What three hypertensives are used to prevent migraines?
Propranolol
Metoprolol
Verapamil
When do we administer anti-convulsants to prevent migraines?
They are the second line prophylactic medications advised
What anti-convulsant do we use to prevent migraines?
Topiramate
What should we remember when we administer topiramate?
It is a teratogenic drug and therefore it should not be administered to pregnant patients and those of child bearing age
What are the two teratogenic effects of topiramate?
Cleft lip
Cleft palate
When are tricyclic antidepressants used to prevent migraines?
They are the third line prophylactic medications advised
What tricyclic antidepressant is used to prevent migraines?
Amitriptyline
When should we administer botulin A injections to prevent migraines?
They should be considered in individuals who suffer from chronic migraines and as a last resort
How often should botulin A injections be administered to prevent migraines?
Every 12 weeks
What are the two prophylactic pharmacological management options that can be used to manage predictable menstrual migraines? What doses?
Frovatriptan (2.5 mg twice a day)
OR
Zolmitriptan (2.5 mg twice or three times a day)
How should we generally manage pregnant/breastfeeding patients with migraines?
Pharmacological migraine treatment should be limited as much as possible in these patients
Instead, these patients should identify and avoid potential migraine triggers
When pharmacological management is essential, what is the first line pharmacological management option in pregnant/breastfeeding patients with migraines?
Paracetamol 1g
When pharmacological management is essential, what is the second line pharmacological management option in pregnant/breastfeeding patients with migraines? In which two trimesters can this be administered in?
NSAIDs
First & second
Which two opioids should be avoided during pregnancy to manage migraines?
Aspirin
Codeine
Is HRT safe to administer in a patient with a history of migraine?
Yes, however it can make the migraines worse
