Migraine

Question 1

Definition

Answer 1

Severe episodic headache that may have a prodrome of focal neurological symptoms (aura) and is associated with systemic disturbance.

Question 2

Classification

Answer 2

Can be classified as:

o Migraine with aura (classical migraine)
o Migraine without aura (common migraine)
o Migraine variants (e.g. familial hemiplegic, ophthalmoplegic)

Question 3

Aetiology

Answer 3

• Poorly understood
• Early aura of cortical spreading depression is associated with intracranial
vasoconstriction leading to localised ischaemia
• This is then followed by meningeal and extracranial vasodilation mediated by
serotonin, bradykinin and the trigeminovascular system

Question 4

Epidemiology

Answer 4

• Prevalence:
o Males - 6%
o Females - 15-20%

• Usually occurs in adolescence and early adulthood

Question 5

Presenting symptoms (headache)

Answer 5

o Pulsatile
o Duration 4-72 hrs
o Episodic

o NOTE: chronic daily headaches lasting weeks would suggest a different aetiology

Question 6

Presenting symptoms (associated symptoms)

Answer 6

o Nausea
o Vomiting
o Photophobia/Phonophobia

o Aura:
• Flashing lights
• Spots
• Blurring
• Zigzag lines
• Blind spots (scotomas)
• Tingling/numbness in the limbs

Question 7

Triggers/Risk factors

Answer 7

o Stress
o Exercise
o Lack of sleep
o Oral contraceptive pill
o Foods (e.g. caffeine, alcohol, cheese, chocolate)

Question 8

Signs on physical examination

Answer 8

• NO specific physical findings

* Exclude secondary causes with MMSE, neurological examination, fundoscopy etc.

Question 9

Investigations

Answer 9

• Diagnosis is usually based on HISTORY
• Investigations may be useful for excluding other diagnoses
• Bloods, CT/MRI, lumbar puncture

Question 10

Management plan (acute)

Answer 10

o NSAIDs
o Paracetamol
o Codeine
o Antiemetics
o Triptans (5-HT agonists) - e.g. sumatriptan

NOTE: analgesia overuse can cause headaches

Question 11

Management plan (prophylaxis)

Answer 11

o beta-blockers
o Amitriptyline
o Topiramate
o Sodium valproate
o Menstrual migraines can be controlled with the oral contraceptive pill

Question 12

Management plan (advice)

Answer 12

o Avoid triggers

o Rest in a quiet dark room during episodes

Question 13

Possible complications

Answer 13

• Disruption of daily activities

* Can lead to analgesia-overuse headaches in people who use analgesia regularly

Question 14

Prognosis

Answer 14

• Usually CHRONIC

* Most cases can be managed well with preventative/early treatment measures