migraine

Dr. asha varier

definition

“Migraine is a familial disorder characterized by

recurrent attacks of headache widely variable in

intensity, frequency and duration. Attacks are

commonly unilateral and are usually associated

with anorexia, nausea and vomiting”

-World Federation of Neurology

SinusSinus

TreatmentTreatment

TensionTension

MigraineMigraine

The Headache Dilemma…The Headache Dilemma…

Migraine burden• 99% of women and 93% of men have had headache

during their lifetime• Headache is the commonest presenting complaint in

both GP and Speciality clinic• Prevalence is highest between age 25 – 55 years• In India 15-20%, suffer from migraine• Adults – male female ratio is 1:2• Childhood – equal incidence

facts• Migraine is one of the common causes of recurrent

headaches• According to IHS, migraine constitutes 16% of primary

headaches• Migraine afflicts 10-20% of the general population• More than 2/3 of migraine sufferers either have never

consulted a doctor or have stopped doing so• Migraine is underdiagnosed and undertreated • Migraine greatly affects quality of life. The WHO ranks

migraine among the world’s most disabling medical illnesses

history• Headache attacks

– How it begins• Precipitating event, illness, injury

• Headache attack descriptions– Frequency and patterns

• Any significant changes– Location– Time to peak intensity– Duration– Quality and intensity– Warning symptoms and aura– Associated symptoms and level of disability– Triggers and aggravating or relieving factors

triggers

– Relaxation after stress: weekends/holidays– Change in habit: sleep, travel etc.– Bright lights/loud noise– Diet: alcohol, cheese, citrus fruits, possibly chocolate (but

evidence is inconclusive); missed or delayed meals– Strenuous unaccustomed exercise– Menstruation– Auditory/visual/olfactory stimuli

• A trigger diary kept by patients can be useful

Predisposing factors

• Predisposing factors are different from precipitating/trigger factors

• Five main predisposing factors are recognized– Stress– Depression/anxiety– Menstruation– Menopause– Head or neck trauma

Phases of acute migraine

• Prodrome

• Aura

• Headache

• Postdrome

prodrome

• Vague premonitory symptoms that begin from 12 to 36 hours before the aura and headache

• Symptoms include– Yawning– Excitation– Depression– Lethargy– Craving or distaste for various foods

Duration – 15 to 20 min

aura

Aura is a warning or signal before

onset of headache

Symptoms

• Flashing of lights

• Zig-zag lines

• Difficulty in focussing

Duration : 15-30 min

headache

• Headache is generally unilateral and is associated with symptoms like: Anorexia NauseaVomiting PhotophobiaPhonophobiaTinnitus

• Duration is 4-72 hrs

Postdrome- resolution phase

Following headache, patient complains of

• Fatigue

• Depression

• Severe exhaustion

• Some patients feel unusually fresh

Duration: Few hours or up to 2 days

IHS classification

Migraine – Without aura– With Aura

Tension-type Headache– Episodic– Chronic

Cluster Headache and other trigeminal autonomic cephalalgias

Secondary headaches

Migraine without aura

A. Headache lasting from 4 to 72 hoursB. At least 2 of the following

• Unilateral location• Pulsating quality• Moderate or severe intensity• Aggravation by routine physical activity

C. At least 1 of the following:• Nausea and/or vomiting• Photophobia and phonophobia

D. At least five attacks fulfilling these criteriaE. No evidence of organic disease

Migraine with aura• Positive Neurological Symptoms

– Reversible brain/neurological symptoms• Visual flashes, spots, or zig-zag lines• Traveling tingling sensations

– transient hemianopic disturbances

– Resolves within 1 hour

• Negative Neurological Symptoms– Reversible brain/neurological symptoms

• Visual blind spots• Numbness• Speech or word finding problems• Trouble thinking

– Resolves within 1 hour

Tension Headache or Migraine?

Tension type- episodic• A. Number of days with such headache < 180/year (<15/month)• B. Headache lasting from 30 minutes to 7 days• C. At least 2 of the following:

• Pressing/tightening (non-pulsating) quality• Mild or moderate intensity (may » inhibit, but does not prohibit activities)• Bilateral location• No aggravation by walking stairs » or similar routine physical activity

• D. Both of the following:• No nausea or vomiting (anorexia may occur)• Photophobia and phonophobia are absent

• E. At least 10 previous headache episodes fulfilling these criteria• F. No evidence of organic disease

Sinus vs migraine

· Fact::· Up to 50% of migraine patients report their headaches are influenced

by weather1

· 45% of migraine patients report sinus symptoms including2

– Lacrimation

– Nasal congestion

– Rhinorrhea

Headaches that are triggered by weather or are associated with sinus

symptoms are not migraines.

Myth

Medication overuse headache (MOH)

• Affects an estimated 1 in 50 people• First noted with phenacetin and ergotamine• Typically results from overuse of OTC

analgesics• A related syndrome occurs with ‘triptans’• Accurate diagnosis is difficult in the presence

of MOH • A detailed medication history is essential

Cluster headache

• Formerly known as migrainous neuralgia• Generally affects men (ratio 6:1), often smokers, in

their 20s or older• Typically occurs in bouts for 6-12 weeks every one or

two years• Attacks typically occur at night, waking the patient 1

to 2 hours after falling asleep, lasting 30 to 60 minutes

• Pain is intense, probably as severe as renal colic, and strictly unilateral

Neckpain during migraine

• Prevalence – 75% of subjects

• Descriptions – 69% - tightness– 17% - stiffness– 5% - throbbing– 5% - other

61%

92%

41%

0%

20%

40%

60%

80%

100%

Prodrome Postdrome

Migraine Phase

Disability & pain intensity

0

10

20

30

40

50

Mild ModeratelySevere

Severe ExtremelySevere

52% severe impairment

39% moderate

9% normal

pathophysiology

VASCULAR THEORY

Intracerebral blood vessel vasoconstriction – aura

Intracranial/Extracranial blood vessel vasodilation – headache

SEROTONIN THEORY Decreased serotonin levels linked to migraine

Specific serotonin receptors found in blood vessels of brain

PRESENT UNDERSTANDINGNeurovascular process, in which neural events result in activation

of blood vessels, which in turn results in pain and further nerve activation

1 pathway, multiple symptoms

Physical examination

• Physical examination can reassure patients • Optic fundi should always be examined • Blood pressure measurement is recommended• Examine head and neck for muscle tenderness,

especially in tension-type headache• Examine jaw and bite • Some paediatricians recommend head circumference

measurement for children, plotted on a centile chart

Longterm goals

• Reducing the attack frequency and severity

• Avoiding escalation of headache medication

• Educating and enabling the patient to manage the disorder

• Improving the patient’s quality of life

management• Non-pharmacological treatment

– Identification of triggers– Meditation– Relaxation training– Psychotherapy

• Pharmacotherapy non-specific

– Abortive therapy specific– Preventive therapy

Abortive- nonspecific

• Aspirin• Paracetamol• Ibuprofen• Diclofenac• Tolfenamic• naproxen

With antiemetic

Oral / parenteral

Abortive- specific

• Ergot alkaloids• ergotamine – 1-2mg/d, max 6mg/d- oral• dihydroergotamine- 0.75- 1mg – sc• 5 HT receptor agonists• sumatriptan – 25- 300mg oral• 6 mg sc• rizatriptan - 10mg oral

Why prophylaxis ?

• Abortive drugs should not be used more than 2-3 times a week

• Long-term prophylaxis improves quality of life by reducing frequency and severity of attacks

• 80% of migraineurs may require prophylaxis

When prophylaxis ?According to the US Headache Consortium Guidelines,indications for preventive treatment include:• Patients who have very frequent headaches (more than 2 per week)• Attack duration is > 48 hours• Headache severity is extreme• Migraine attacks are accompanied by prolonged aura• Unacceptable adverse effects occur with acute migraine treatment• Contraindication to acute treatment• Migraine substantially interferes with the patient’s daily routine,

despite acute treatment• Special circumstances such as hemiplegic migraine or attacks with a

risk of permanent neurologic injury• Patient preference

Prophylaxis- drugs

• Betablockers – propranolol – 40-320mg/d – 1st line in adults• Calcium channel blockers • flunarazine – 10-20mg - paed• verapamil - 120- 480mg• TCA – Amitryptiline -10 -20mg – CTTH, ass. Depression, c/c

pain, sleep• SSRI –Fluoxetine - 20-60mg• Anticonvulsant –valproate-600-1200mg - ETTH• Antihist – cyproheptadine – 4- 8mg

summary• Tension-type headaches are very common in the

general population• Migraine headaches are also common but are more

common than tension-type headaches in medical clinics because of greater severity and disability

• True “sinus headaches” are uncommon• Sinus symptoms and neck pain are very common

symptoms of migraine• Most cases of recurrent “sinus headaches” are

migraine especially if there is a family history of recurrent or chronic headaches

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