Migraine
Background
Pathophysiology
- Severe headaches, usually episodic but can be chronic.
- Neurogenic inflammation leads to vasodilation and altered pain sensation.
- Often improves with age.
Triggers
- CHeese
- Oral contraception.
- Caffeine or its withdrawal.
- AlcohOL
- Anxiety
- Travel
- Exercise
- Sleep deprivation.
50% have no trigger.
Signs and symptoms
- Photo- or phonophobia.
- Lasts 4-72 hOurs.
- Unilateral. However, can be bilateral.
- Nausea and vomiting.
- Debilitating. Worse with activity and patient will want to be still.
25% experience aura:
- 15-30 minutes pre ± during headache.
- Visual: sparkles, flashing lights, scotoma
- Sensory: numbness and tingling (e.g. moving up arm) may also occur.
- Motor symptoms: dysarthria, ataxia, ophthalmoplegia, hemiparesis.
- Others: dysphasia, ANS symptoms (lacrimation, conjunctival injection).
- Some experience aura alone.
- Some experience a prodrome over hours to days, in which they may feel sleepy, moody, or hungry.
Neck pain or stiffness can occur, though may also suggest meningism.
Risk factors
- Female gender. Often premenstrual.
- Combined contraceptive pill.
- Obesity
- Patent foramen ovale.
- A small number are part of a familial syndrome, including familial hemiplegic migraine, which presents with fever, severe auras, and reduced consciousness.
Diagnosis
- ≥2 headaches with aura.
- Or ≥5 headaches lasting 4-72 hours AND any 1 of {nausea/vomiting or phono/photophobia} AND any 2 of {unilateral location, pulsating quality, moderate or severe intensity, worse on moving, or limiting activity}.
Management
Acute treatment
- {NSAID or paracetamol PO} and/or {triptan PO, or IN if age 12-17}.
- Adding metoclopromide PO to NSAID or paracetamol may help even in absence of nausea and vomiting.
- Non-oral options if vomiting: triptan SQ/IN, diclofenac PR, domperidone PR.
Emergency department treatment of severe migraines:
- Parenteral options: triptan SQ, antiemetic IV (metoclopromide, prochlorperazine), or ketorolac IV.
- Add dexamethasone IV to reduce headache recurrence within 72h.
Prevention
- Migraine diary may help identify.
- Regular meals, good sleep, avoid dehydration.
- Stress reduction: CBT, relaxation therapy.
Indications for medical prophylaxis:
- Frequent disability e.g. ≥2 episodes per month causing 3 days disability.
- Standard acute treatment not effective.
Therapeutic options:
- 1st line options: propranolol, amitriptyline, or topiramate. All similarly effective in adults, while in kids propranolol has the best evidence.
- Acupuncture may be effective.
- Botulinum toxin type A for refractory, chronic migraine.
- Verapamil for hemiplegic migraine.
Complications
- Chronic migraine: ≥15 headache days per month, of which ≥8 are migrainous, for ≥3 months.
- Status migrainosus: >72 hour migraine.
- Migrainous infarction: infarct during migraine. Higher risk if on combined pill and has migraine with aura, so use POP instead.
- Depression, anxiety.
Triptans
Drugs
Mechanism
Contraindications and interactions
- CVD: IHD, HTN, coronary spasm.
- Drugs: lithium, SSRIs, ergot.
Side effects
- Arrhythmias
- Angina or MI.
Altered sensations:
- Tingling, chest or throat tightness, pressure.
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