Migranes

Question 1

Pathophysiology of migraines?

Answer 1

Vascular theory : aura may results from vasoconstriction, unlike headache which follows vasodilation.

Neurogenic theory : involves neuronal hyper excitability and cortical spreading depression which causes transient neuronal swelling.

Neurovascular theory : focuses on CGRP and PACAP peptide that activate neurons and cause vasodilation.

Inflammatory theory : transition from aura to headache may be driving by sterile inflammation, interleukins and possible injury

Question 2

Treatment for migraines?

Answer 2

NSAIDS such as ibuprofen.

Ergot alkaloids : dihydroergotamine is the most common

Triptans : induce vasoconstriction but do not cause nausea and vomiting. Sumatriptan is the most common.

Novel drugs : small molecules like Telcagepant, anti CGRP Mab like Erenumab.

Question 3

Classification of headaches ?

Answer 3

• Primary headaches refer to all the conditions with different manifestations which result in pain in the
  head.
• Secondary headaches refer to headaches caused by trauma, tumor, or increase in intracranial pressure. The headache is not a primary condition but there is an underlying cause responsible for the headache.

Question 4

Types of migraines?

Answer 4

Migraine without aura : most common with a prevalence of 80%. At least 5 attacks lasting 4 to 72 hours untreated. Features include unilateral location, pulsating quality, moderate or severe pain, aggravated by physical activity, nausea, vomiting and photophobia.

Migraines with aura : prevalence of 20%. Typically lasts between 5 to 60 min.

Question 5

What is an aura?

Answer 5

Aura refers to a reversible neurological symptom. It is important to define the features of these reversible
neurological symptoms.
If a patient presents with a neurological deicit, a differential diagnosis must be made.
Aura symptoms are usually visual, but they also include sensory and speech/language disturbances, motor
symptoms, and brainstem symptoms.

Question 6

DDX between aura and stroke?

Answer 6

Red flags that may indicate stroke include : occurs first time after age 40, symptoms are exclusively negative, when the aura is very short or very long and when it changes frequency, pattern and characteristics.

Question 7

Preventative treatment of migraines?

Answer 7

Preventative treatments include : beta blockers, antidepressants, calcium channel blockers, anti epileptic drugs.
They are considered successful if they decrease attack rate by 50%.