Migrane

Question 1

What is Migrane?

Answer 1

Migraine is a primary headache characterized by recurrent episodes of unilateral, throbbing localized pain that are frequently accompanied by nausea, vomiting, and sensitivity to light and sound

• lasting 4-72 hours

Question 2

What is the epidemiology of migrane?

Answer 2

• around 1 in 7 people (common)
• 2-3x more likely in women
• occurs at any age, more common between 25-55
  *

Question 3

What are risk factors for the development of migrane?

Answer 3

• High frequency episodic migraine.
• Overuse of acute migraine medications.
• Excessive caffeine intake.
• Obesity.
• Snoring and sleep disorders.
• Co-morbid conditions such as head injury, pain disorders, anxiety and depression.
• Major life events such as divorce, marriage, or loss of a job.

Question 4

What is the underlying pathophysiology of migrane

Answer 4

Unknown

• often associated with triggers (e.g. stress, disturbed sleep, lack of exercise)
• Generally: Neurovascular disorder
  
  • neurogenic inflammation and vasoldilation (throbbin) has been observed

Question 5

What are the presenting symptoms of migrane?

Answer 5

• • Throbbin, unilateral moderate to severe pain
    
    • pain causes avoidance of routine activities of daily life
• Lasting 4-72 hours
• At least one of:
  • Nausea and/or vomiting.
  • Photophobia (sensitivity to light) and
  • phonophobia (sensitivity to sound).
• Auras might be present

Question 6

How might an aura in migrane present?

Answer 6

Aura is not necessary for diagnosis of migrane to be made

Might present as

• visual aura (most common)
  
  • zigzag lines and/or scotoma
• sensation aura
  
  • pins an needles, numbness
• loss of speech, dysphasia
• Other types of aura possible but uncommon

Question 7

What are predromal/postdromal symptoms of migrane?

Answer 7

1. Predromal
   
   1. often 1-2 days before other symptoms,
   2. such as fatigue, poor concentration, neck stiffness, and yawning
2. Postdromal
   
   1. up to 48hr after symptoms, such as fatigue and elated or depressed mood

Question 8

What are the presenting signs of migranes on exmination?

Answer 8

Normally none - clinical diagnosis based on history of headache

Question 9

Which investigations should be done in a patient with suspected migrane?

Answer 9

Check red flags to exclude severe causes that might mimmic migrane

• if unclear: MRI head
  *

Question 10

What would be conservative treatment for a patient with migranes?

Answer 10

1. Give advise and information
2. Encourage to find out possible triggers (e.g. headache diary)
3. Avoid known triggers + lifestyle change
   
   • e.g. stress management, good sleep hygiene, adequate hydration, regular meals, exercise, and maintenance of a healthy weight
4. Stop conbined oral contraveptive pill in women with

Depending on severity of attacks

• consider medication

Question 11

What medical treatment would you consider in a patient with migranes?

Answer 11

1. Analgesia
   
   1. ibuprofen/paracetamol, aspirin
2. Triptan (alone or with analgesia above)
   
   1. sumatriptan (50–100 mg)
3. If N&V
   
   • offer anti-emetic (e.g. metoclopramide 10mg)
4. Acute medication should be taken early while pain is mild.

If they have aura, triptans should be taken at the start of the headache and not at the start of the aura (unless the aura and headache start simultaneously).

Arrange review in 2-8 Weeks

Question 12

What is the MOA of Triptans?

Answer 12

Triptans (e.g. Sumatriptan) = medication used in migrane

• 5HT receptor agonist
  
  • (serotonin) on blood vessels leading to vasoconstriction and decrease the release of pro-inflammatory neuropeptide release
  • On trigeminal neurons: reduces pain transmission

Question 13

What is the prognosis of a patient with migranes?

Answer 13

Varies in different people

• increases with age
• in women: often improves after menopause
• might change in pregnancy (most peopel will not change)
  
  • inprove in 2nd and 3rd trimester (not necessarily)
  • deteriorates, first presents in 1st trimester

Question 14

What are the complications of migrane?

Answer 14

• Reduced function and quality of life
• Medication overuse headache
• Progression to chronic migrane (more than 15 days/month migrane)
• status migrainosus — debilitating migraine attack lasting for more than 72 hours.
• Persistent aura
  • without infarction — aura symptoms lasting for more than 1 week, with no radiographic evidence of infarction.
  • with infarction - symptoms of aura lasting for more than 60 minutes with evidence of an ischaemic brain lesion on neuroimaging
• Migraine aura-triggered seizure
• Increased risk of ischaemic stroke
  
  • may also be risk factor for haemorrhagic stroke

Question 15

What is medication overuse headache?

Answer 15

• Headache occuring more than 15 days/week
• due to overuse of headache medication

Question 16

What are possible preventative treatments of migranes?

When do you offer preventative treatment?

Answer 16

Consider preventative treatment if:

1. Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment.
2. Acute treatments are either contraindicated or ineffective.

Offer

• propranolol
• amitriptyline
• topiramate.