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

    Triggers include CHOCOLATES and:

    • CHeese
    • Oral contraception.
    • Caffeine or its withdrawal.
    • AlcohOL
    • Anxiety
    • Travel
    • Exercise
    • Sleep deprivation.

    50% have no trigger.

  • Signs and symptoms

    POUNDing headache:

    • 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

    Clinical diagnosis. International Headache Society criteria:

    • ≥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

    Home 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

    Avoid triggers:

    • 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

    Sumatriptan, almotriptan, eletriptan, rizatriptan.

    Mechanism

    5-HT1 agonist vasoconstrictors.

    Contraindications and interactions

    • CVD: IHD, HTN, coronary spasm.
    • Drugs: lithium, SSRIs, ergot.

    Side effects

    Rare but serious:

    • Arrhythmias
    • Angina or MI.

    Altered sensations:

    • Tingling, chest or throat tightness, pressure.

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