Migraine

• Clinical Manifestations, Differential Diagnosis & Classification

• Pathophysiology

• Treatment of Acute Attack

• Preventive Therapy• Non Pharmacological• Pharmacological

• Migraine is a common,chronic,incapacitating neurovascular disorder characterized by recurrent attacks of throbbing headache

• May or may not be associated with aura• Headache without aura (common migraine) is

associated with nausea ,vomiting ,photophobia , phonophobia , visual disturbances

• Aggravated by emotional,physical stress,lack or excess sleep, missed meal ,alcohol ,food, menstruation and OCP.

FOOD ITEMS

• If not treated, attack last 4-72 hours• May start at any age• Common early to middle adolescence• One year prevalence 11%• 6% among men• 15-18% among women• 10% have weekly attacks• 20% attacks lasting 2-3 days.

• Differential Diagnosis• Cluster headache

– Middle age men, unilateral– Occur at night, at same time, days, weeks or

months– Associated with red eye, tearing ,nasal

congestion and Horner's syndrome.

• Tension headache– Constant daily headache– Aggravated by stress, fatigue,noise – No aura

• Classification

– Common migraine (without aura) 65%– Classical migraine (with aura) 15%

• Lateralized throbbing headache• Often give a family history of migraine

– Combined type 15%– Only aura without pain 5%

• Basilar artery migraine:Uncommon variant with

* Blindness or visual disturbance* Dysarthria* Tinnitus* Vertigo* Distal paraesthesia* Transient loss or impairment of consciousness or confusion

• It is followed by throbbing occipital headache often with nausea and vomiting

• Ophthalmoplegic migraine:* It is rare* Lateralized pain in the orbit* Ophthalmoplegia due to 3rd and 6th nerve palsy* Ophthalmic division of 5th nerve may also be involved* Symptoms outlast days or

weeks

Modified Diagnostic criteriaModified Diagnostic criteriaFor common migraine (Without aura)For common migraine (Without aura)

• Migraine is defined as episodic attack of headache lasting 4-72hrs

• With 2 0f the following symptoms• Unilateral pain• Throbbing • Aggravation on movement• Pain of moderate or severe intensity

• And one of the following symptoms– Nausea or vomiting– Photophobia or phonophobia

PathophysiologyPathophysiology• Pain sensitive structures in the

cranium– Extracranial vessels– Proximal intracranial vessels– Dura matter

• Pain mechanism– Cranial blood vessels– Trigeminal innervations of cranial vessels

• Calcitonin gene related peptide/ neurogenic inflammation in the dura

– Connection between trigeminal system and cranial parasympathetic outflow

– Neural events results in dilatation of blood vessels

– Dysfunction of ion channels in the brainstem nuclei that modulate cranio-vascualar afferent

– Cranial parasympathetic out flow - vasodilatation - pain

PathophysiologyPathophysiology

– Dilatation of intracranial vessels -Short phase of hyperemia causes flashing of lights

– Trigeminal nerve (sensory input)

– Trigeminal ganglion - trigeminocervical complex

– Thalamus – parasympathetic out flow– Constriction of intracranial blood vessles -

Oligemia that pass across the cortex, resulting in depressed neuronal function aura

Trigemino vascular inputTrigemino vascular input

PathophysiologyPathophysiology

PathophysiologyPathophysiology• Genetic factors

• Familial hemiplegic migraine– Mutation in voltage gated Ca channels have

been identified– Other ion channels may be involved in

migraine without aura

TreatmentTreatment

Acute attack

Preventive therapy

TreatmentTreatment

• Acute attack–Analgesics and NSAIDS–Metochlopramide / Sedatives

–Ergot derivatives

–Triptans

–methysergide

Analgesics and NSAIDSAnalgesics and NSAIDS

– Most respond well to simple Rx – Should take at the onset of headache– Adequate doses (Aspirin 900mg, Ibuprofen

400-800mg)– Anti emetics: facilitate the absorption of 1ry

drug– Overuse of drug to be avoided– Maintaining headache diary – Severity and the response may vary with each

attack

Ergot derivativesErgot derivatives

• Ergot derivatives– Long experience – Disadvantages

• Complex pharmacology• Erratic

pharmacokinetics

• Lack of evidence on effective dose

• Adverse vascular events• High risk of overuse

syndrome • Rebound headache

• Dose– 1 to 2 mg at the onset

of headache, followed by 1mg every 30 minutes

– Up to 6mg per attack– Upton 10mg per weekContridicationspregnancy, PVD, IHD

TriptansTriptans

• 5HT1B/1D receptor agonist• Expensive/Restriction on presence of

Cardiovascular disease• Advantages

– Selective pharmacology– Simple and consistent pharmacokinetics– Evidence based prescription instructions– Efficacy based on well controlled trials– Moderate side effects– Well established safety records

Triptans - actionsTriptans - actions

• Cranial vasoconstriction• Peripheral neuronal inhibition • Inhibition of transmission of the 2nd order

neurons of trigeminal cervical complex• Via 5Ht 1B / D receptors

These actions inhibit the effects of nociceptive trigerminal afferents and control the acute attack of migraine

Triptan - actionsTriptan - actions

TriptansTriptans

• Sumatriptan 50-100mg

• Rizatriptan 10mg More effe

• Eletriptan 80mg

• Naraptriptan 2.5mg

• Zolmitryptan

• Almotriptan

TriptansTriptans

• Sumatriptan– Improvement in headache in 2hrs – 55-65%

– Headache free at 2hrs - 25-35%– sc, intra nasal,rectal and oral

Side effects

Tingling paresthesia ,sensation of warmth

Dizziness ,flushing, neck pain, stiffness

Contraindicated in IHD,CVA ,HT (uncontrolled)

Preventive therapyPreventive therapy

• Non pharmacological• Keeping a diary. Time/ duration/activity/food• Regular meals / type of food• Extremes of temperature• Sleep• Gentle massage-pressing temporal artery• Hot or cold compresses• Relaxation• meditation


• Pharmacological – when to start– Patient’s selection– Consider if >2attacks/month

– If >5 attacks consider seriously

– Frequency – increasing frequency

– Duration– Severity: Migraine severity assessment score

(MIDAS)– Nonspecific, moderate efficacy, substantial side

effects


Proven or well accepted

• Propranolol 40-120mg BD

• Amitryptiline 25-75mg/D

• Valproate 400-600mg BD

• Flunarizine 5-15mg/d

• Serotonin antagonist: Pizotifen 0.5-3mg/d


Widely used with poor evidence of benefit

• Verapamil 160 -320 mg/d

• SSRI


Promising results

• Gabapentine 900-2400mg/d

• Topiramate 25-200mg/d

• Chinese restaurant syndrome

• Caused by monosodium glutamate /a food additive

• Pain in the forehead, temple, tightness around the face

• Hot dog headache

• Bacon ,ham- as a result of eating cured meat.

• Frontal headache / throbbing /after ½ hour

• Flushing and redness of face

• People with migraine are more prone

• Ice cream headache

• Sharp pain after eating cold food/ cool drink

• Local pain in palate/throat/face/head

• People who are more prone to migraine are three times more likely to suffer from this.

Career

Migraine