Migraine

Question 1

What are some key differences between a tension headache and a Migraine?

Answer 1

Tension: Bilateral, non-throbbing, rarely disabling, featureless

Migraine: Often throbbing, associated photo and phono phobia, nausea, disabling

Question 2

Features of a tension headache

Answer 2

Common in the general population, RARE as a chief complaint

Question 3

What is the prevalence of migraine amongst canadians and at what age does it peak?

Answer 3

1. > 4 milion Canadians
   2) 3:1 women:men
   3) 25-55 years of age

Question 4

Prevalence of primary headaches in school children

Answer 4

10-20% in school children (boys more than girls)

Question 5

Prevalence of primary headaches in adolescents

Answer 5

~30% 1x/month

~90% 1x/year

Question 6

Migraine headaches in children 7 years of age

Answer 6

1-3%

Question 7

Migraine in 15 years of age

Answer 7

4-20%

Question 8

Migraine is more common than what two diseases?

Answer 8

1) Asthma

2) Diabetes - combined

Question 9

Migraine features

Answer 9

1. Neurological, with strong genetic component
2. Overal >10% global prevalence (more women)
3. 2 subtypes (+/- aura)
4. world’s 20 most disabling diseases (3 million women, and 1 million men)

Question 10

Why is there a higher prevalence of migraines in women?

Answer 10

1. Hormonal factors, including sudden increase in E2 at menstruation
2. Gender difference after menopause suggests other factors involved

Question 11

How do you define Migraine?

Answer 11

Episodic headache disorder

Question 12

What might chronic headaches be a sign of?

Answer 12

Depression, anxiety, sleep disorders

Question 13

Signs of a migraine without aura…

Answer 13

5 attacks of 
1) lasting 4-72 hours
2) - unilateral location (although 40% are bilaterally), pulsating quality (50% are non pulsating), moderate or severe pain, aggravation by avoidance of physical activity
>= 1 of the following
3) Nausea/vomiting or photo/phonophobia
4) not attributed to other disorder

Question 14

Signs of a migraine WITH aura…

Answer 14

2 attacks of
1) Fully reversible visual/sensory/speech symptoms - no motor weakness
at least 2 of the following
1. unilateral symptoms that develop gradually over 5 min, at 2. least one symptom developing gradually over 5 mins
3. each symptom lasting >5 mins, <60 mins
3) migraine begins with aura or follows within 60 min

Question 15

What is an aura?

Answer 15

1) at least 2 attacks
2) fully reversible symptoms
3) (2 of…)unilateral snesory, develops gradually, duration >5 min, s visual, must last at least 5 mins.. BLURRY VISION NOT AN AURA

Question 16

International classification of headache disorders (2 + 1)

Answer 16

any 2 of

• unilateral
• throbbing
• worsened by activity
• moderate or severe

any 1 of

• nausea/vomiting or anorexia!
• photo phonophobia

Question 17

4 phases of a migraine attack.

Answer 17

1) prodrome
2) headache
3) resolution (sensory hyper excitability)
4) postdrome

Question 18

When does the prodrome phase occur?

Answer 18

12-24 hours before headache - can be fatigue, mood swings, excessive yawning, food cravings, driven by Dopamine!

Question 19

What are common triggers of a migraine?

Answer 19

1) weather changes
2) poor sleep
3) weekends and holidays
4) menstrual cycle
5) strong smells
6) stress
7) fasting/skipping meals
8) certain foods - MSG, wine, caffeine

Question 20

Vascular theory of migraine - suggests 2 things

Answer 20

1) AURA: caused by vasoconstriction (but vessels are normal)

2) THROBBING: due to vasodilation (but they are not dilated till later)

Question 21

what is the primary cause of migraines?

Answer 21

1. Genetic predisposition
2. cortical neuronal hyper excitability and/or brainstem dysfunction
3. Cortical spreading depression
4. Activation and sensitization of trigeminal vascular system
5. prolonged headache pain

Question 22

What is migraine commonly misdiagnosed as?

Answer 22

(SECONDARY headache is sinus not primary) 
Sinus headache (face pain, worse lying down, associated nasal discharge)

Question 23

What else is migraine commonly misdiagnosed as?

Answer 23

Tension type headache - 
In migraine 
neck pain (75-80%), more prevalent than nausea, stress is a trigger, 40% migraines are bilateral

Question 24

Medication overuse headaches are common with what type and frequency of meds?

Answer 24

~2% prevalence

1. Acetaminophen, Ibf, anything with caffeine - 2 days/week
2. codeine narcotics - 5-8 doses/month
3. triptans 10 days/month

Question 25

What do patients want?

Answer 25

``` Complete relief (even with side effects) Oral tablet ```

Question 26

Acute migraine medications

Answer 26

1) Triptans - 5HT B/D (serotonergic) receptor agonists (effective early, contraindicated with vascular risk factors) 2) Dihydroergotamine 3) nonspecific - NSAIDS, corticosteroids, antiemetics

Question 27

Who gets a triptan?

Answer 27

1) Episodic and disabling migraine complaints | 2) Absence of vascular contraindications

Question 28

Safety of triptans, what are some problems?

Answer 28

1) Triptan sensations - chest pressure 2) CNS effects, dizziness, fatigue, somnolence 3) serotonin syndrome (very rare) - activates 5HT 2a not 1B/D/F CV disease, uncontrolled HTN (CONTRAINDICATION)

Question 29

What is serotonin syndrome?

Answer 29

Activation of the 5HT2a receptor (triptans activate BDF receptors)

Question 30

Why do you treat migraines early?

Answer 30

The Central Trig vascular neurone become sensitized within 1 HOUR central sensitization gives rise to cutaneous allodynia - pony tail painful, skin irritated/bothere - happens within one hour Incomplete response once that develops!

Question 31

How are headaches classified

Answer 31

1. Primary - symptomatic based | 2. Secondary - etiology based

Question 32

Which is more prevalent a migraine with or without aura?

Answer 32

Without (75% vs 25% with)

Question 33

which neurotransmitter may be involved in chronic headache/depression

Answer 33

lack of serotonin

Question 34

WHat % of headaches go from episodic to chronic?

Answer 34

3%

Question 35

What are the two most RELIABLE factors in diagnosing migraine without aura?

Answer 35

1) moderate to severe pain | 2) difficulty to do physical activity

Question 36

What is sensory hyper excitability?

Answer 36

Inherited component of a migraine, may have something to do with enhanced survivability

Question 37

What are some co-existing disorders with Migraines?

Answer 37

1. IRRITABLE BOWER SYn 2. Anxiety 3. depressed mood 4. poor sleep SEROTONIN PLAYS A KEY ROLE - large amount in gut

Question 38

What are some childhood variants of migraines?

Answer 38

1. cyclical vomiting 2. sleep walking 3. recurrent abdominal pain 4. INFANT COLIC 5. motion sickness

Question 39

How is migraine caused?

Answer 39

- triggered in brainstem - cortical spreading depression forward moving - reduction in blood flow - migrates across cortex - doesn't follow blood flow and cells are extracting less oxygen from blood (AURA) - this activates the trigeminal vascular system - messages go through trigeminal nucleus caudalis then sent cortically through thalamus

Question 40

what is a true sinus headache?

Answer 40

1. Face pain 2. worse lying down 3. associated with nasal discharge and fever

Question 41

which molecular is important to think about with respect to inflammation?

Answer 41

CGRP

Question 42

The trigeminal nerve description of migraines confuses diagnosis.....

Answer 42

1. head and facial pain can be bilateral 2. Neck pain (cervical nerve interactions) 3. Sinus symptoms

Question 43

when do you have an incomplete response to triptans?

Answer 43

Once cutaneous allodynia develops

Question 44

What is the goal of preventative headache?

Answer 44

``` NOT TO BE HEADACHE FREE Reduce headache by 50% reduce acute med use increase effectiveness prevent chronicity ```

Question 45

How does Botox work for migraine?

Answer 45

BLOCKs CGRP