Migraine

Migraine

• Usually starts in adolescence or early adult life
• Family history often positive
• More common in females

Characteristics:

1. Usually unilateral (may be generalized also)
2. Throbbing (may be continuous dull ache also)
3. Each episode lasts for 4-72 hours
4. Pain aggravated with physical activity
5. Often accompanied with nausea, vomiting, photophobia, phonophobia, visual blurring
6. In some patients, “AURA” may occur just before the headache

Aura

Clinical features which occur 30 to 60 min. before the headache, warning the person that the headache is coming.

• Visual features: like visual field defects (scotomas), flickering lights, zig-zag lines, colored spots before the eyes etc.
• Neurological features: like Numbness, paresthesias, aphasia, weakness, dysarthria

Some Points about Aura

• Occurs only in about 30% of the migraine patients
• Some people get Aura but no headache (aura without headache). Can be confused with stroke/TIA
• Aura is not dangerous by itself

Pathogenesis of MigraineZ

Dysfunction of the neurons in the brain ⇒ leads to release of chemicals (neuropeptides) ⇒ act on the intracranial blood vessels ⇒ vasodilation ⇒ produces headache

Remember 1 important neuropeptide: Calcitonin Gene-Related Peptide (a peptide which is related to the calcitonin gene) CGRP

Things which can trigger a migraine attack

• Sleep disturbances: (less sleep, disturbed sleep pattern)
• Emotional & excess physical stress
• Menstruation
• Dehydration
• Excess exposure to TV / computer screens (so, no PS4)
• Foods: (Chocolate, Cheese, Coffee, alcohol, MSG found in Chinese foods)
• Bright & flickering lights
• Strong smells: (perfumes, benzene, chemicals, food smells)
• Oral contraceptives

Work up in a Migraine Patient

• Migraine is a clinical diagnosis, based on the history
• There is no blood test or imaging to “diagnose”
• Imaging like CT or MRI brain is done to rule out other intracranial pathology

Management of Migraine

1. Avoid the triggering factors
2. Healthy lifestyle (good sleep, no alcohol, exercise, no stress, avoid TV or mobile phone screens for long periods)
3. Medicines to treat the acute attack
4. Maintenance treatment (ALAATOOL) in some patients

Management of Acute Attack

1. Lie down in a dark quiet room
2. Avoid light and loud sounds
3. Medicines (any of the following). Take at the start of the aura or headache.

A) Simple Analgesics (Panadol with caffeine, Panadol extra, NSAIDs). Don’t overuse (can lead to “medication overuse headache”)

B) Ergotamine Containing Meds e.g. Cafergot (ergotamine + caffeine). Avoid in pregnancy, CAD, HTN.

C) Triptans (expensive) ++ Cluster headaches not tension e.g. sumatriptan, zolmitriptan etc.

• Oral tabs, nasal sprays, subcutaneous injections
• Quick relief
• They are “serotonin receptor agonists”, & prevent the release of “migraine causing neuropeptides”
• Contraindicated in pregnancy, uncontrolled HTN, CAD, history of stroke

D) Blockers of (CGRP inhibitors) “Calcitonin Gene Related Peptides”

E) Antiemetics

• Metoclopramide, chlorpromazine, prochlorperazine
• Used along with analgesics to help the nausea/vomiting; symptomatic treatment

Narcotic analgesics are not used (why?) Risk of addiction, tolerance ++ Respiratory depression sedation constipation

Chronic Management of Migraine

Long term treatment given to people who have very frequent acute attacks (more than 3 times a month)

1. Some antihypertension meds like propranolol, verapamil, & candesartan.
2. Anti-epileptic meds like Topiramate, valproic acid
3. Antidepressants like Amitryptyline; great for long run
4. Some monoclonal antibodies (injections)
5. Acupuncture

Rapid Fire Questions on Migraine

1. Is it a primary or secondary headache? Primary
2. Name some secondary headache syndromes? HTN, Eye disease, Intracranial hemorrhage, SOLs ; secondary(face diseases + HTN)
3. Name 3 primary headaches? Migriane, tension, Cluster
4. Usual location of migraine? Unilateral usually could be both sides
5. Nature of migraine pain, throbbing or continuous? Throbbing
6. Other symptoms associated with the attack? Neusea/Vomitting, Photophobia, Phonophobia, blurred vision
7. What is an aura? before migraine attack
8. Name some visual features of an aura? zig zag line, colored spots vision; numbness, hemiplegia
9. Name some neurological features of an aura? 30%
10. Is aura LAAZIM in all migraine patients? no
11. Aura is dangerous, right or wrong? **
12. Aura can occur without any headache, right or wrong? **
13. Aura can be confused with what?
14. Which chemicals are released in the brain to cause migraine? Name any 1? neuropeptides
15. Which foods can trigger an attack? CCC ; C4, Chocolate, CaffieneCC
16. Name some more triggering factors? sleep disturbance, menstural irregularities, perfumes, oral contraceptives, stress
17. Diagnosis of migraine is based on what, CT or MRI? clinical diagnosis
18. During an acute attack, what should the patient do, besides taking meds? sit in darkroom, avoid sound bright
19. Name the 3 commonly used meds to treat an acute attack? panadol extra, analgesics, triptans
20. Why not to use pain killers for a long time? Overuse results in headache
21. Name any triptan? **
22. Mode of action of triptans? serotonin receptors
23. Name 3 contraindications to use triptans and ergotamine? pregnancy… constriction
24. Name a newer drug to treat the acute attack? CGRP + Monoclonal
25. What other symptomatic treatment along with analgesics? antimetics
26. When to give chronic treatment? proponolol
27. Name 3 meds used as chronic management? propanolol, amitriptyline, INR