Migraine

Question 0

Types of migraine

Answer 0

CLASSIC
aura dots/shapes 10-30mins before onset
Nausea and vomiting
COMMON
no preceding neurological disturbances
RARE
Opthalmoplegic, hemiplegic and basilar migraine with severe motor distubances

Question 1

What is a migraine?

Answer 1

Extremely painful headache
Visual disturbances
Nausea and vomiting
Photphobia
Phonophobia

Question 2

What causes migraine?

Answer 2

Activation of trigeminovasculature system and pain sensitive meniges account for pain.
Aura due to cortical spreading depression
Two theories vascular or neurogenic.

Question 3

What is cortical spreading depression?

Answer 3

• wave of neuronal depolarisation followed by neuronal inactivity that spreads across the cortex
• may be clinically silent in common migraine
• caused by stimulation of visual cortex, hormonal changes (progesterone in menstrual cycle), genetic disposition

Question 4

Neurogenic migraine hypothesis

Answer 4

• Csd activates trigeminovascular system causes vasodilation (by released calcitonin gene-regulated peptide)
• BBB becomes leaky leading to neurogenic inflammation and pain

-evidence=block csd with gluatamte antagonist, blocks vascular changes

Question 5

What is the vascular hypothesis?

Answer 5

Vascular changes cause changes in blood flow, producing ischaemia and csd
Evidence= not always an aura with migraine.

Question 6

Role of beta-adrenergic antagoinists

Answer 6

Block vasodilation
PROPANOLOL
TIMOLOL

Prevention of migraine.

Question 7

Role of antiepileptic drugs

Answer 7

Blocks neuroexcitation
Prevents migraine

TOPIRAMATE
CARBAMAZEPINE

Question 8

Role of tri-cyclic antidepressants

Answer 8

Prevent migraine

AMITRIPTYLINE

Question 9

Role of l-type calcium channel blocker

Answer 9

Decrease headache frequency
Prevent migraine, maybe by preventing CSD

VERAPAMIL

Question 10

Role of botulinum toxin?!

Answer 10

Prevents release of CGRP

Question 11

Treatment during migraine?

Answer 11

Asprin, acetominophen, NSAIDs,

5HT1 receptor agonists “triptans”

Question 12

What are triptans?

Answer 12

5HT1 receptor agonists

• effective if given in first 30 mins
• reduces nausea and vomiting
• SUMATRIPTAN, ZOLMINTRIPTAM, NARATRIPTAN, RIZATRIPTAN, ELETRIPTAN
• taken alone or with NSAIDs

Question 13

What is the MOA of triptans?

Answer 13

5HT1R is an inhibitory autoreceptor on presynaptic serotonergic neurones and blood vessels.
Neurones:
- may counteract neurogenic inflamation blocking CGRP release from trigeminal nerve terminals, dont know mechanism

Blood vessels:
- vasoconstriction, prevents stretching of meninges

Question 14

Importance of GCRP.

Answer 14

Novel treatment target

Antagonist=OLCEGPANT shows promising results in early trials