Migraines

Question 1

What are the 4 main types of migraine?

Answer 1

Migraine without aura
Migraine with aura
Silent migraine (aura but no headache)
Hemiplegic migraine

Question 2

What features of a migraine headache can differentiate it from other types of headaches?

Answer 2

Lasts 4-72 hrs 
Moderate-severe intensity 
Pounding/throbbing 
Better when lying down-> differentiates from ICP associated headache 
Normally unilateral 
Photophobia 
Phonophobia 
\+/- aura 
N+V

Question 3

What is aura in the context of a migraine?

Answer 3

Visual changes

• sparks in vision
• blurring
• lines across vision
• loss of visual fields

Question 4

How would someone suffering from hemiplegic migraine present? What is important to rule out in these patients?

Answer 4

Migraine symptoms 
Sudden or gradual onset 
Hemiplegia 
Ataxia 
Changes in consciousness

Question 5

What are the potential migraine triggers?

Answer 5

Stress
Bright lights 
Strong smells 
Chocolate, cheese or caffeine 
Dehydration 
Menstruation 
Abnormal sleep patterns 
Trauma

Question 6

What are the typical 5 stages of migraine?

Answer 6

Premonitory/prodromal=
-subtle symptoms over several days prior to migraine i.e. yawning, fatigue, changes in mood

Aura= up to 60 mins

• can be induced by flickering lights due to inducing the occipital lobe to fire signals at the same freq
• Fortication spectral= jagged lights across visual field
• Scotoma= blind spot in vision i.e. spreading black cloud due to nerve cells switching off after increased activity with light flickering

Headache= 4-72 hrs

Resolution= headache resolves

Postdromal/recovery

Question 7

How can a migraine episode be managed acutely?

Answer 7

Sleep in dark room 
Paracetamol 
Triptans 
NSAIDs
Antiemetics (metoclopramide)

Question 8

What is the role of triptans in migraine management? What is their MOA?

Answer 8

5HT receptor agonists used to abort migraine as it develops

MOA:

• vasoconstriction of SM in arteries
• inhibit activation of peripheral pain receptors
• reduce neuronal activity in CNS

Question 9

What can be done as part of migraine prophylaxis?

Answer 9

Keep headache diary so can identify possible triggers
Long term meds to reduce freq and severity:
-betablocker= propranolol
-topiramate (teratogenic)
-candesartan
-valproate
-amitriptyline (TCA)
Acupuncture
Botox into scalp
Riboflavin (B12 supplementation)
NSAIDs prophylaxis when migraines associated with menstruation

Question 10

What are common non-headache manifestations of chronic migraine?

Answer 10

Chronic fatigue
Mood and cognitive disturbance i.e. insomnia/irritability 
Stuttering 
Stimulus sensitivity 
Migraine related dysequilibrium 
Migraine vertigo 
Reflex syncope 
Restless legs 
Sensory disturbance 
Back pain 
Diffuse muscle tenderness

Question 11

What new treatment has been developed that might help with treatment of refractory migranes?
What forms is the treatment currently available?

Answer 11

CGRP blockade:

• CGRP is released from c-fibres and increases the sensitivity of A-alpha fibres which increases the risk of migraines
• by blocking CGRP release you are blocking sensitisation of A-alpha fibres

Options:
-antagonists= acute 
I.e. Antogepant/Rimegenant 
-MAb= prophylaxis
-Fremaezumab= used for those with chronic migraines which have failed 1 treatment