migraine

• related: Neurology, Headache2

Demographics

People that suffer migraines are often 10-30 years of age; females are more commonly affected than males.

The pathophysiology of migraines is poorly understood, but it is thought to be due to neuronal dysfunction.

Factors that can precipitate migraines include:

• Stress
• Oral contraceptives
• Menstruation
• Exertion
• Foods containing tyramine or nitrates (chocolate, cheese, processed meats)

Symptoms

Migraine without aura (a.k.a. common migraine) are severe headaches that are not preceded by an aura. Most cases of migraines do not involve an aura. Need to meet following criteria:

• duration 4-72 hours
• at least 2 of following:
  • unilateral pain
  • pulsating pain, moderate or severe pain
  • aggravation or causing avoidance of physical activity
• at least one of following during headache:
  • nausea
  • vomiting
  • photophobia and phonophobia

Migraine with aura (a.k.a. classic migraine) are severe headaches preceded by a visual change such as bright or flashing lights, dark spots occluding areas of vision (scotomas), visual field changes, and even reversible focal neurological deficits such as hemiparesis lasting 5-30 min. Auras typically last for 10-20 minutes.

Migraines in children are often bifrontal and shorter in duration.

Basilar migraines occur due to cerebral vasospasm involving the brainstem. Patients typically have basilar aura symptoms (eg, vertigo, dysarthria, tinnitus, diplopia) without motor weakness, followed by a migraine-type headache.

• tension headache can also present similar like migraine but does not cause nausea, and have at least 2 of following:
  • bilateral
  • nonpulsating
  • mild to moderate
  • do not interfere with daily activities

Imaging

• not warranted with sx and normal physical exam

• considered for following:

  • not classic headache
  • change in pattern
  • focal neurologic signs/sx
  • red flags:
    • onset after 50
    • persistent neurologic changes
    • systemic sx
    • immunosuppression
    • sudden onset
    • progressive pain
    • positional nature
    • headache precipitated by valsalva
    • papilledema

• Urgent secondary causes:

  • SAH, thunderclap onset
  • SDH: prior trauma, altered level of consciousness, neurologic deficits
  • meningitis: fever, confusion
  • HTN emergency: blurry vision
  • temporal arteritis
  • CVA
  • neoplasm: weight loss, age > 50, wakes from sleep, progressive
  • pseudotumor cerebri

Treatment

Treatment is based on severity.

• Mild to moderate severity with infrequency (<8 per month), use abortive therapy:
  • NSAIDS, tylenol
  • Ergotamine, dihydroergotamine
  • triptans: avoid in HTN and CV disease
    • SQ sumitriptan 6mg NNT 2.3, much quicker, $500 / 6 syringes
    • Oral rizatriptan 10mg NNT 3
  • antiemetics: metoclopramide, domeperidone

• ppx considered when:

  • 3 days/month headache, not responding to abortive

  • 8 days/month headaches

  • significant interference with activity despite abortive therapy

• expect 30-50% decrease in sx after 3-4 weeks

• Beta blockers: propranolol, metoprolol, nadolol

• TCA: nortriptyline, amitriptyline

• anti-epilepticcs: topiramate, gabapentin, divalproex

• Botox injection

• Aimovig injections

• natural supplements shown to decrased frequency, duration, severity:

  • oral mag: 400-600 mg QD
  • Coenzyme Q10: 300mg QD
  • Butterbur: 50-150mg QD, hepatotoxicity
  • Oral riboflavin 400mg QD: decrease frequency but not severity or duration

• lifestyle modifications:

  • avoid dietary triggers (1 in 5 pts)
    • caffeine withdrawal
    • nitrites/nitrates in preserved meats
    • tyramines, xanthines, aged cheese, red wine, beer, chocolate, champagne
    • MSG
    • dairy
    • fatty food

Migraine prophylaxis includes the use of:

• Tricyclic antidepressant (e.g. amitriptyline)
• Beta blockers (e.g. metoprolol, propranolol, timolol)
• Calcium channel blockers (e.g. nifedipine, verapamil)
• Anticonvulsants (e.g. valproate, topiramate)

Complications

• women with active migraine with aura has increased ischemic CV disease and stroke. People without aura do not have increased events.
• Men with migraine have higher risk for CV events