Migraine Flashcards
Define migraine
Chronic, genetically determined, episodic neurological disorder that presents as a severe episodic headache that may have a prodrome of focal neurological symptoms (aura)
Classifications of migraine
Migraine with aura = classical (10%)
Migraine without aura = common (90%)
Migraine variants = familial hemiplegic, ophthalmoplegic, basilar
Episodic = <15 days/month, chronic >15 days/month
Risk factors for migraine
Family history of migraine
High caffeine intake
Exposure to change in barometric pressure
Females
Obesity
Stressful life events
Overuse of headache medications
Sleep disorders
Symptoms of migraine
Headache
- Unilateral (60%)
- Paroxysmal
- Pulsating/throbbing sensation
- 4-72hr, may recur
- Exacerbated bye exertion (physical activity, stress) - distinguishes from tension-type
- Moderate to severe
Aura (premonitory phase) in 30% - reversible preceding
- Positive phenomena - flashing lights, fortification of spectral/zigzag
- Negative phenomena. -visual loss, scotoma, sensory or motor aura
- Visual changes
- Aphasia
- Tingling
- Numbness
- Sensory aura
- Typical = transient hemianopic disturbance or a Migra (‘jagged crescent’)
Nausea and vomiting
Photophobia
Phonophobia
Disability - UNABLE to carry out ADLs (distinguishes from tension-type)
Triggers: stress | exercise | lack of sleep | OCP | caffeine | alcohol | cheese | chocolate | analgesia use
Management for acute episodes of migraine
- Simple analgesia e.g. paracetamol, ibuprofen
- Oral sumitriptan 25-100mg (Nasal <18yo)
- Combination nasal triptan + NSAID/paracetamol
- Consider anti-emetics (metoclopramide 5-10mg PO, cyclizine, prochlorperazine)
Rescue therapy: Metoclopramide (10-20mg IV single dose) AND Diphenhydramine (50mg IV single dose)
+ High flow oxygen
+ IV corticosteroid e.g. dexamethasone 8-16 IV as a single dose
Follow up in 1 month of earlier if symptoms worsen
Management for migraine between episodes
Conservative: headache diary, avoid precipitating factors (cheese, OCP, caffeine, alcohol, stress), optician referral, regular meals and drink, sleep hygiene, regular exercise
Medical:
First line: propranolol, topiramate
second line: amitryptiline
Complications of migraine
Status migrainosus (>72h) - use IV fluids, steroids, Mg sulfate, anticonvulsants, NSAIDs, anti-emetics
Migrainous infarction
Migraine-triggered seizures
Depression
Chronic migraine
Persistent aura without infarction
Prognosis of migraine
Most patients do well with treatment
Frequency decreases with age
The prognosis is guarded for patients who have developed complications of migraine or who have co-morbidities or a long-standing history of medication overuse.
- In these cases, expectations for improvement should be modest, and the goals of treatment should shift from elimination of pain to improvement in function
