Makindo Medical Notes.com

Related Subjects:Migraine |Basilar Migraine |Cluster Headaches |Sumatriptan |Tension Headache |Analgesic Overuse Headache |Headaches in General |CADASIL

About

• Chronic episodic recurrent headache often + additional symptoms
• Affects 1 in 10. Commoner in women( 14%) > Men (4%)
• Onset in childhood or early adult years but onset can be in older patients
• There are two main types: 1)Migraine with aura 2) Migraine without aura
• International Headache Classification (ICHD-2)

Diagnostic criteria Migraine without Aura

• At least 5 attacks fulfilling following 4 criteria
• Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

Headache has at least two of the following characteristics

• Symptoms
  • 1) unilateral location
  • 2)pulsating quality
  • 3)moderate or severe pain intensity
  • 4) aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
• During headache at least one of the following: nausea and/or vomiting, photophobia and phonophobia
• Not attributed to another disorder

Diagnostic criteria Migraine with Aura: At least 2 attacks fulfilling following four criteria

• Aura consisting of at least one of the following, but no motor weakness: fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision), fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness), fully reversible dysphasic speech disturbance
• At least two of the following: homonymous visual symptoms, and/or unilateral sensory symptoms, at least one aura symptom develops gradually over = 5 minutes and/or different aura symptoms occur in succession over =5 minutes each symptom lasts > 5 and < 60 minutes
• Migraine without aura begins during the aura or follows aura within 60 minutes
• Not attributed to another disorder

Aetiology

• Serotonin and calcitonin gene-related peptide (CGRP) are possibly involved in the pathophysiology
• A phenomenon called Cortical Spreading Depression is a self-propagating wave of neuronal and glial depolarization that spreads across the cerebral cortex.
• There are associations with right-to-left cardiac shunts

Notes

• No single theory or hypothesis can explain all of the phenomena that occur with migraine
• The vascular theory has been refuted but there is still some thought that there is a role for the trigeminal nerve and related regional blood

Associations

• CADASIL
• PFOs - controversial - some patients especially in those with aura get benefit from PFO closure
• Mitochondrial diseases - MELAS syndrome have migraine-like headaches
• Migraine like syndrome may be seen with stroke and high levels of antiphospholipid antibodies

Clinical

• Headaches can last from 4 hours to 72 hours
• Episodic sometimes pulsating headache with nausea and vomiting and photophobia and malaise - patients feel awful
• Migraine with aura: Headache preceded by an aura - may be visual e.g. flashing lights of fortification spectra, scotoma. There can be associated weakness e.g. hemiparesis and also sensory abnormalities
• Common migraine: Headache may be associated with nausea, sickness and even diarrhoea or colic
• In 60% the headache is unilateral and for the rest is bilateral
• Often there are triggers - stress, sudden reduction of stress - Saturday mornings, red wine, alcohol, cheese, lack of sleep or lying in, heat, dehydration, exercise

Investigations

• Rarely any are needed in typical migraine. In cases where the diagnosis is in doubt or the presentation is very acute then a SAH may need exclusion with CT/LP
• If temporal arteritis suspected then urgent ESR
• Bubble echo tests if PFO suspected in those with aura

Variants

• Vertebrobasilar migraine - diplopia, vertigo, dysarthria affects posterior circulation. There can even be a come which can persist for days and stupor.
• Ophthalmoplegic migraine associated 3rd nerve palsy which can persist for days and the obvious differential is a SAH with PCA aneurysm
• Retinal migraine Headache and constricted vision
• Benign recurrent vertigo Episodic vertigo and dizziness. responds to migraine therapy
• Menstrual migraine - at or around menstruation. Mefenamic acid should be started and continued during menstruation.

Acute Management

• Patient typically prefer to lie down in a dark quiet room undisturbed. Sleep if possible can often help and the headache is often self-limiting. Movement and agitation make it worse.
• NSAIDS:Ibuprofen 400-600 mg stat is useful. Another is Naproxen 500mg. Patients should carry and use early. Paracetamol 1 g may also be given in addition or instead but many find it ineffective. Metoclopramide may be combined to manage sickness and improve gastric motility. For those vomiting then PR Diclofenac 100 mg can be tried or Diclofenac 75 mg im. Ibuprofen can be used in pregnancy until 28 weeks and is the NSAID of choice in pregnancy. Repeated use should be avoided after 28 weeks of gestation
• Aspirin 900mg is effective for 2-hour pain relief and is recommended as a first-line treatment option. High dose aspirin is a potential gastric irritant, however, single doses usually only have mild transient adverse effects. It is contraindicated in under 16s due to the risk of Reyes syndrome and in the third trimester of pregnancy
• 5HT agonists: Triptans e.g. Sumatriptan 50-100 mg PO is the first line triptan. Usually given when the headache starts. Sumatriptan can also be given as nasal spray 20 mg or 6 mg s/c injection. They are not to be used in those with coexisting ischaemic heart disease or peripheral vascular disease or pregnant or hemiplegic migraine or age over 65. For menstrual migraine, frovatriptan is the triptan of choice. If early vomiting is an issue nasal or subcutaneous triptans may be recommended by a specialist.

Prevention

• Beta blockers e.g. Propranolol 80-160 mg per day. Atenolol 50-100 mg od. Not for use in asthmatics.
• Candesartan can be prescribed but is unlicensed and is given at a dose of 16mg daily for episodic or chronic migraine
• Amitriptyline 25-150mg at night – this can be started at 10mg and titrated up according to response and tolerance. Can cause drowsiness and a dry mouth.
• Topiramate is effective at reducing monthly migraine frequency and monthly migraine days in trials. It is associated with a number of side effects including nausea, paraesthesia, anorexia and weight loss.
• Botulinum toxin type A Is commissioned as per NICE TA for chronic migraine. Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine): that has not responded to at least three prior pharmacological prophylaxis therapies and whose condition is appropriately managed for medication overuse.
• Fremanezumab is commissioned as per NICE TA631. It is prescribed by the headache specialist team via homecare for self-injection.
• Menstrual migraine: A drop in oestrogen prior to menstruation is a known trigger for migraine. Triptans reduce the occurrence of migraine both menstrually related and pure menstrual migraine from 2 days before the start of bleeding and 3 days after. Frovatriptan2.5mg twice a day is the triptan of choice (low NNT/high patient numbers). It is also effective at reducing migraine severity and need for rescue medication.

References

• SIGN guidance on Migraine
• Migraine management