Headaches: Migraine Flashcards
Definition
Migraine is a primary headache which is usually episodic. Episodes of recurrent throbbing. ‘Classic’ migraines are preceded by an aura often with visual changes, however, these only occur in one-third of patients.
Types of migraines
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
Epidemiology
Female
Less than 40
Risk factors
Family history
Obesity
Triggers
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie ins
Alcohol/Anxiety
Travel/Tumult
Exercise
Other important triggers include tiredness, lack of food, dehydration, menstruation, red wine and bright lights
Aetiology
Stress
Bright lights
Strong smells
Certain foods
Dehydration
Menstruation
Abnormal sleeping patterns
Trauma
Pathophysiology
Migraines are due to neuronal hyper-excitability. This leads to trigeminal nerves initiating an inflammatory response with subsequent dilation of meningeal blood vessels, and sensitisation of surrounding nerve fibres leading to pain.
The aura is thought to occur due to cortical spreading depression, which is a propagating wave of depolarisation across the cerebral cortex.
5 stages of migraines
- Premonitory/prodromal stage = can involve several days of subtle symptoms such as:
- yawning
- fatigue
- mood changes
Prior to onset of migraine - Aura = lasts up to 60 minutes, part of the attack before headache = visual phenomenon (2 zigzag lines)
- Headaches = throbbing headache lasts 4-72 hours
- Resolution = headache can fade away or be relieved completely by vomiting or sleeping
- Postdrome or recovery phase = symptoms can often premonitory symptoms
Signs and symptoms
Severe, unilateral, pulsating headache lasting up to 72 hours*
At least 2 of:
- Unilateral pain
- Throbbing
- Motion sickness
- Mod- severely intense
+ 1 or more of:
Nausea and vomiting
Photophobia and phonophobia: patients may go to a dark and quiet room to help with symptoms
WTH NORMAL NEURO EXAM
Typical aura
Develops over 5 minutes, lasts 5-60 minutes and is fully reversible
- Visual symptoms e.g. zigzag lines
- Paresthesia
- Speech disturbance
Atypical Aura
May last more than 60 minutes
- Motor weakness (e.g. hemiplegic migraine)
- Diplopia
- Visual symptoms affecting one eye
- Poor balance (e.g. vestibular migraine)
- Decreased level of consciousness
How may migraines present in children
More commonly bilateral, shorter-lasting and associated with gastrointestinal symptoms such as abdominal pain.
Diagnostic criteria for migraine with aura
At least 2 headaches fulfilling criteria B and C
B: One or more of the following reversible aura symptoms:
- Visual
- Sensory
- Speech and/or language
- Motor
- Brainstem
- Retinal
C: At least 3 of the following:
≥1 aura symptom spreads gradually over ≥5 minutes
≥2 aura symptoms occur in succession
Each aura symptom lasts 5-60 minutes
≥1 aura symptom is unilateral
≥1 aura symptom is positive
The aura is accompanied, or followed within 60 minutes, by headache
D: No other likely diagnosis
Diagnostic criteria for migraine without aura
A: At least 5 headaches fulfilling criteria B-D
B: Duration: 4-72 hours (untreated or not successfully treated)
C: At least 2 of the following:
- Unilateral
- Pulsating
- Moderate to severe in intensity
- Aggravated by, or causing avoidance of, routine activity
D: At least 1 the following during the headache:
- Nausea and/or vomiting
- Photophobia and phonophobia
E: No other likely diagnosis
Diagnosis
Migraine is a clinical diagnosis but investigations may be performed to rule out other pathology.
Investigations to consider:
CT or MRI head: rule out the cause of a secondary headache, such as a subarachnoid haemorrhage
ESR: exclude giant cell arteritis
Lumbar puncture indications:
- Thunderclap headache
- Severe, rapid onset headache/ progressive headache/ unresponsive headaches
