Migraine Headache: Introduction,Clinical Features, Trigger factors,Diagnosis,management and Prophylaxis
Migraine is the 2nd most common cause of headache affecting 15% of women and 6 % of men worldwide. It is an episodic headache associated with certain features like sensitivity to light light, sound or movement . Nausea vomiting often accompany the headache.
Triggers for Migraine Headache:
Hormonal Changes:- Changes during menses, pregnancy, menopause, and effect of OCP
Changes in daily schedule:- over sleeping, inadequate sleep, skipping meal and a rest after a hectic schedule.
Weather:- Rapidly rising barometric pressure, rise in pressure, temperature and humidity
Foods:- food rich in tyramin like aged cheese, chocolate,banana, soya sauce and citrus fruits
Environmental triggers like cigarette smoke, perfumes, petrol and fresh paint
Pathogenesis of Migraine ( PDF format)
Variants Of Migraine:
- Hemiplegic migraine- weakness which is usually reversible
- Basilar Migraine- dizziness,ataxia,tinnitus, vomiting
- Retinal Migraine- recurrent attack of unilateral visual disturbances
- Complicated Migraine- chronic migraine and status migraines.
- Ophthalmoplegic Migraine- Associated with periorbital pain, diplopia sec to cranial neuropathies.
- Scalp tenderness
- Visual disturbances
Diagnosis is Clinical, No investigations are mandatory.
Diagnostic Criteria for Migraine:-
Repeated attacks of Headache lasting 4-72 hours in patient with normal physical examination and no other reasonable cause for headache, and
Atleast 2 of the following features:
- Unilateral pain
- Throbbing pain
- Aggravated by movements
- Moderate to severe intensity
Plus Atleast 1 of the following features:
- Nausea/ Vomiting
- Photophobia or Phonophobia
Management Of Migraine Headache:-
MIDAS ( Migraine Disability Assessment Score) is a well validated tool , on the basis of which Migraine is Graded from I to IV
General Measures Against Migraine:
- Identify and Avoid Trigger factors
- Regular exercise and healthy diet
- Regular sleep pattern, avoid alcohol
- Yoga .
Judicious use of 1 or more drug is the mainstay of treatment:
- Mild cases- Oral agents
- Sever cases- Parental therapy
- NSAIDS- decrease both severity + Duration. Naproxen, Ibuprofen are good enough
- 5 HT1 agonists- Sumatriptan, Naratriptan,
- Parental Inj Dihydroergotamine + Sumatriptan is FDA approved therapy
- Dopamine Antagonists:- Metoclopramide, Prochlorperazine are used as adjunctive therapy
Other Agents are:
- Nasal BUTHORPHANOL
- Oral Acetaminophen + Dichloralphenazone+ Isomethaptene
- Parental Meperidine ( 50-100 mg )
Prophylaxis therapy In Migraine headache:
According to the British Assocaiation for Study of Headache, Prophylaxis are required when any of:-
- Frequent disabling attacks > 2 per month inspite of Acute therapy
- Failure of acute Therapy
- Hemiplegic migraine, Basilar Migraine
- Very high attack frequency( >2/week)
- Progressively worsening attack.
- Patients Request
Calcium Channel Blocker – FLUNARIZINE 5-10 mg reduces the frequency by 50-75%. Women require lower doses.
Beta Blockers- PROPONALOL
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SOURCE: Lecture notes from Harrison, Davidson and ache.org