Migraines

Question 1

What are migraines?

Answer 1

Migraines are a complex neurological condition that cause headache and other associated symptoms. They occur in “attacks” that often follow a typical pattern.

Question 2

There are several types of migraine:

Answer 2

Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine

Question 3

Migraine is a common type of primary headache. It is characterised typically by:

Answer 3

a severe, unilateral, throbbing headache

associated with nausea, photophobia and phonophobia

attacks may last up to 72 hours

patients characteristically go to a darkened, quiet room during an attack

‘classic’ migraine attacks are precipitated by an aura. These occur in around one-third of migraine patients

typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma

formal diagnostic criteria are produced by the International Headache Society (see below)

Question 4

Epidemiology of migraines?

Answer 4

3 times more common in women
prevalence in men is around 6%, in women 18%

Question 5

Common triggers for a migraine attack

Answer 5

tiredness, stress
alcohol
combined oral contraceptive pill
lack of food or dehydration
cheese, chocolate, red wines, citrus fruits
menstruation
bright lights

Question 6

Aura is the term used to describe?

Answer 6

the visual changes associated with migraines. There can be multiple different types of aura:

Sparks in vision
Blurring vision
Lines across vision
Loss of different visual fields

Question 7

Hemiplegic migraines?

Answer 7

can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine.

Symptoms of a hemiplegic migraine can vary significantly. They can include:

Typical migraine symptoms
Sudden or gradual onset
Hemiplegia (unilateral weakness of the limbs)
Ataxia
Changes in consciousness

Question 8

The course of a migraine can be broken down into 5 stages, including:

Answer 8

Premonitory or prodromal stage (can begin 3 days before the headache)

Aura (lasting up to 60 minutes)

Headache stage (lasts 4-72 hours)

Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)

Postdromal or recovery phase

These stages are not typical of everyone and they will vary between patients. Some patients may only experience one or two of the stages. The prodromal stage can involve several days of subtle symptoms such as yawning, fatigue or mood changes prior to the onset of the migraine.

Question 9

Acute Management

Answer 9

Patients often develop their own patterns for helping to relieve their symptoms. Often patients will go to a dark quiet room and sleep. Options for medical management are:

Paracetamol
Triptans (e.g. sumatriptan 50mg as the migraine starts)
NSAIDs (e.g ibuprofen or naproxen)
Antiemetics if vomiting occurs (e.g. metoclopramide)

Question 10

Triptans

Answer 10

Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists). They have various mechanisms of action and it is not clear which mechanisms are responsible for their effects on migraines. They act on:

Smooth muscle in arteries to cause vasoconstriction

Peripheral pain receptors to inhibit activation of pain receptors

Reduce neuronal activity in the central nervous system

Question 11

Migraine Prophylaxis

Answer 11

Keeping a headache diary can be helpful in identifying the triggers. Avoiding triggers can reduce the frequency of the migraine. A headache diary is also useful in demonstrating the response to treatment.

Certain medications can be used long term to reduce the frequency and severity of attacks:

Propranolol
Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
Amitriptyline

Acupuncture is an option recommended by NICE recommend for the treatment of migraines. It is reported to be as effective as prophylactic medications.

Supplementation with vitamin B2 (riboflavin) may reduce frequency and severity.

In migraine specifically triggered around menstruation, prophylaxis with NSAIDs (e.g. mefanamic acid) or triptans (frovatriptan or zolmitriptan) can be used as a preventative measure.

Migraines tend to get better over time and people often go into remission from their symptoms.