Migraine

Introduction

Migraine is headache resulting from changes in the calibre of certain blood vessels in the brain with resulting physical, autonomic and emotional disturbance.
It can be very incapacitating.
Each headache attack lasts for a few hours to a maximum of 3 days but can be aborted with appropriate intervention
It affects more females than males, usually between the ages of 15 and 50 years

Clinical features of migraine

1. Vascular Headaches

  • Common migraine (or migraine without aura)
  • Throbbing pain usually affecting one side of the head around the temples, associated nausea and vomiting
  • Dislike of light and noise

2. Classical migraine (or migraine with aura):

  • Attacks of pain preceded by seeing flashes of light
  • Disturbances in the field of vision (scotomas)
  • Visual hallucinations

3. Childhood periodic syndromes:

  • Abdominal pain and vomiting
  • Alternating hemiplegia
  • Benign positional vertigo

4. Basilary artery migraine

  • predominantly brain stem symptoms
  • Dysarthria
  • Vertigo
  • Tinnitus
  • Decreased hearing
  • Diplopia
  • Ataxia
  • It may coexist with tension-type headache.
  • It may present without headache (migraine equivalent) usually seen in psychiatry.
  • It may present with complications:
  • stroke-like manifestations
  • ophthalmoplegia
  • status attacks: unrelieved, persistent headaches

Differential diagnoses

Complications of migraine

Investigations

  • Neuro-imaging
  • Computerized tomographic scan
  • MRI
  • Electroencephalography

Treatment for migraine

Treatment objectives

  • Prevent recurrence
  • Eliminate pain

Non-drug treatment

  • Manage in a quiet (and dark) room
  • Physiotherapy/biofeedback
  • Psychotherapy

Drug treatment

1. Acute attack

A. Aspirin (acetylsalicylic acid) tablets

  • Adult: 300-900 mg every 4 – 6 hours when necessary maximum 4g daily.
  • Child and adolescent – not recommend (risk of Reye’s syndrome)
    • Treat with an anti-emetic agent (e.g. metoclopramide), or other non-steroidal anti-inflammatory agents plus metoclopramide

B. Ergotamine preparations (useful only during the aura phase)

  • Adult: 1 – 2 mg orally at first sign of attack; maximum 4 mg in 24 hours. Do not repeat at intervals of less than 4 days; maximum 8 mg in any one week. Not to be used more than twice in any one month
  • Child: not recommended

C. Narcotic analgesics

  • Pethidine,
  • Codeine

D. Triptans

  • Sumatriptan.

Oral: initial dose: 25mg, 50mg, or 100mg orally, once.
Dose may be repeated after at least two hours if migraine recurs, (maximum of 300mg in 24 hours)

Prophylaxis for migraine

Consider prophylactic migraine treatment for patients who:

  1. Suffer at least 2 attacks a month
  2. Suffer an increasing frequency of headaches
  3. Suffer significant disability in spite of suitable treatment for acute attacks
  4. Cannot take suitable treatment for acute attacks

Prophylactic options are:

  • Propranolol: 40 mg orally every 8-12 hours
  • Tricyclic antidepressants, notably amitriptyline 10 mg orally at night, increased to a maintenance dose of 50-75 mg at night
  • Sodium valproate: Initially 300 mg orally every 12 hours, increased if necessary to 1.2 g daily in 2 divided doses

In refractory cases:

  • Cyproheptadine, An antihistamine with serotonin antagonist and calcium channel-blocking properties
    • 4 mg orally; a further 4 mg if necessary; maintenance 4 mg every 4-6 hours

Contraindications on some drugs used in migraine treatment

  • Aspirin and other NSAIDs: use with┬ácaution in patients with history of dyspepsia and in asthmatics
  • Tricyclic antidepressants: use with caution in patients with cardiac symptoms
  • Ergotamine:
    • use should not exceed 4 – 6 mg per attack
    • Caution in patients with vascular and renal disorders
    • Not recommended for children
  • Opiates: risk of addiction
  • B-blockers: slow down cardiovascular function; reduce sensitivity to hypoglycaemiabin diabetics.

Prevention of migraine

The following are ways to prevent migraine attacks:

  1. Avoid precipitants: These must be identified for effective prevention
  2. Reduce stress levels as much as possible
  3. Give prophylactic medicines if attacks last more than 15 days a month, or are severely incapacitating (in the absence of other causes)