FN: Migraine Flashcards Preview

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Flashcards in FN: Migraine Deck (32):
1

Epi

8% prev
F:M = 2:1

2

Risk factors

Obesity
PFO

3

Pathophysiology

1. Vascular: cerebrovascular constriction - aura, dilatation - headache
2. brain: spreading cortical depression
3. Inflammation: activation of CN V nerve terminals in meninges and cerebral vessels

4

Triggers

CHOCOLATE
Cheese
OCP
Caffeine
alcohOL
Anxiety
Travel
Excercise

5

Symptoms

Headaces
Prodrome
Aura

6

Headache types

1. Aura lasting 15-30min then unilateral throbbing headache
2. Phono/photophobia
3. n/v
4. Allodynia
5. Often premenstrual

7

Prodrome (50%): preced migraine by hrs - days

1. yawning
2. Food cravings
3. Changes in sleep, appetite or mood

8

Aura (20%): precedes migraine by mins and my persist

1. visual: distortion, lines, dots, zig-zags, scotom, hemianopia
2. Sensory: parasthesia (fingers - face)
3. Motor: dysarthria, ataxia, ophthalmoplegia, hemiparesis (hemiplegic migraine)
4. Speech: dysphasia, paraphasia

9

Classification

1. Migraine with aura (classical migraine)
2. Migraine w/o aura (common migraine)

10

Diagnostic criteria

1. Typical aura + headache, or
2. >5 headaches lasting 4-72h with either n/v or photo/phonophobia + >2 of:
1. Unilateral
2. Pulsating
3. Interferes with normal life
4. Worsened by routine activity

11

Differential

1. cluster/tension headache
2. Cervical spondylosis
3. HTN
4. Intracranal pathology
5. Epilepsy

12

Treatment acute episode

1st: paracetamol + metoclopramide/doperidone
2nd: NSAID (e.g. ketoprofen) + M/D
3rd: rizatriptan - CI: IHD, uncontrolled HTN, SSRIs
4th: ergotamine

13

Prophylaxis

Avoid triggers
1st: propanolol, topiramate
2nd: Valporate, pizotifen (increased wt), gabapentin

14

Rule out diagnosis – Red flags

Onset after 50 (migraine does not usually come on at this age)
Sudden onset (SAH)
Hx of cancer metastesis
Progressivaly worsening over days (abcess/tumour?)
Waking patient at night (tumour)
Early morning vomiting (Raised ICP)
Unilateral loss of power (stroke)
Seizure (tumour)
Weight loss (tumour or cerebral TB)
Altered consciousness (meningitis)
Fever (meningitis)
Immunodeficiency

15

Exam

Pulse and BP
Optic fundi (papiloedema warrants urgent admission)
Test for neck stiffness
Palpate scalpe for tenderness
Examine cranial nerves
Neuro exam on limbs

16

Management

• Reassure and relieve anxiety
• Avoid precipitating dietary factors
• Trial a different contraceptive
• Simple analgesia (overuse can lead to rebound)
• Anti-emetics (domperidone or metaclopramiede)
• Triptans
Accupuncture

17

• Reassure and relieve anxiety
• Avoid precipitating dietary factors
• Trial a different contraceptive
• Simple analgesia (overuse can lead to rebound)
• Anti-emetics (domperidone or metaclopramiede)
• Triptans
Accupuncture

1. Reassure
2. Avoid dietary factors
3. Try different COP
4. NSAIDS
5. Anti-emetics
6. Triptans
7. Acupuncture?

18

Triptans advise

Sumitriptan is available over the counter 50 mg dosage

19

when to consider prophylaxis

Prophylaxis is considered if >2 attacks per month or if attacks are particularly severe/prolonged

20

Prophylaxis
firstline

Propranolol

21

Prophylaxis second line

: Tricyclic or anti-epileptic drugs (sodium valproate or topiramate) are second line.

22

Propranolol for the use

Proven efficacy
Also treats hypertension and anxiety

23

Propranolol against the use

Contra-indicated by asthma and peripheral vascular disease

24

Amitriptyliine for the use

Also treats insomnia and depression

25

Amitriptyline against the use

Lack of evidence
Not licensed

26

Sodium valproate S.E.

S.E: Nausea, tremor, dizziness and birth defects

27

Topiramte for the use

Recent licence
Proven efficacy

28

Topiramate against the use

S.E: paraesthesia, impaired concentration and sleep, weight loss
Affects efficacy of COP, progesterone only pill
Interacts with some other drugs

29

Pizotifen against the use

S.E.: weight gain and sedation
Evidence limited

30

Feverfew (Herbal remedy) for and against

Safe
Lack of evidence

31

Botulinum toxin Type A

is recommended by NICE for the prevention of heads in adults with chronic migraine (experiencing headaches for at lest 15 days each month with migraine on at least 8 of these days) who have tried at least 3 other drugs to prevent migraine. It is given by im injection at multiple sites around the head and back of the neck every 12 weeks

32

Foramen ovale closure?

At present NIE does not recommended routine percutaneous closure of patent foramen ovale for the prevention of migraine, because of the risks associated with this procedure

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