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

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 worlds 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

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 Nausea Vomiting Photophobia Phonophobia Tinnitus 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 hours B. At least 2 of the following
Unilateral location Pulsating quality Moderate or severe intensity Aggravation by routine physical activity Nausea and/or vomiting Photophobia and phonophobia

C.

At least 1 of the following:

D. At least five attacks fulfilling these criteria E. 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
Myth
Headaches that are triggered by weather or are associated with sinus symptoms are not migraines.

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

Fact::

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

100% 80% 60% 40% 20% 0%

Prodrome

92% 61% 41%

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

Postdrome Migraine Phase

Disability & pain intensity

9% normal
50

52% severe impair ment

40 30

39% mod erat e

20 10 0

Mild

Moderately Severe

Severe

Extremely Severe

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 UNDERSTANDING
Neurovascular 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 patients quality of life

management
Non-pharmacological treatment Identification of triggers Meditation Relaxation training Psychotherapy non-specific specific

Pharmacotherapy

Abortive therapy
Preventive therapy

Abortive- nonspecific
Aspirin Paracetamol Ibuprofen Diclofenac Tolfenamic naproxen
Oral / parenteral

With antiemetic

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 patients 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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