Migraine
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Migraine in general practice, clinical view
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Migraine
- 1. Prepared by : Dr. Ahmed Ibrahim Eldesouky Abouelela Family Medicine Registrar MBBch Alexandria university Family Medicine Master degree MRCGP.int
- 2. 35 years old female patient coming to your clinic complaining of recurrent attacks of severe headache over the last 4 months. She describes the headache like unilateral, pulsating pain that last more than 6 hours. The attacks are accompanied by nausea and some times vomiting. During the attacks she like to site in a dark room and can’t make any activity.
- 3. If a patient coming to your clinic with a complain of a headache, what will make you suspect that it could be a migraine
- 4. The patient: female, between 20 and 50 years. The headache: recurrent, unilateral, pulsating, long lasting, inhibiting or prohibiting daily activities. Association: aura symptoms (visual, sensory, speech or motor), nausea, vomiting, photophobia and phonophobia.
- 5. Migraine is not only a headache Sometimes migraine present with other symptoms Unilateral weakness, vertigo, impaired visual symptoms, confusion and even abdominal pain could be symptoms of a migraine.
- 6. Migraine is a primary headache disorder characterized by a recurrent headache that is moderate to severe felt as a throbbing pain on one side of the head. Migraine is derived from the Greek word meaning ‘pain involving half the head’. Affects at least 1 person in 10. It is more common in females (18% of women, 6% men). It’s peaks between 20 and 50 years. The frequency of headaches reduces after the age of 50.
- 7. Some people have migraine attacks frequently, that reach up to several times a week. Other people only have a migraine occasionally possible years to pass between migraine attacks.
- 8. There are several types of migraine, including: Classic migraine (migraine with aura). Common migraine (migraine without aura). Unusual forms of migraine.
- 9. A complex of neurological symptoms that occurs before, during the headache or in isolation. Appears gradually over few minutes and generally last less than 60 minutes. Can be visual, sensory, motor or combination of these. Visual occur in up to 99% of cases (scotoma, hemianopia) Sensory (unilateral paraesthesia)
- 12. The exact cause of migraine is unknown, but thought to be a result of abnormal brain activity temporarily affecting nerve signals, chemicals and blood vessels in the brain due to genetic causes. Many possible migraine triggers have been suggested, including hormonal, emotional, physical, dietary, environmental and drugs.
- 13. Some women trigger migraines during their period. Some women only experience migraines during the period, which is known as pure Menstrual migraine. Many women find their migraines improve after the menopause Menopause can trigger migraines in some women.
- 14. Emotional triggers: stress, anxiety, tension, shock, depression and excitement. Physical triggers: tiredness, poor quality sleep, poor posture, neck or shoulder tension, jet lag, low blood sugar (fasting) and exercise. Dietary triggers: missed, delayed or irregular meals, dehydration, alcohol, food contain tyramine, caffeine products, such as tea and coffee, specific foods such as chocolate, citrus fruit and cheese. Environmental triggers: bright lights, flickering screens, such as a television or computer screen, smoking (or smoky rooms), loud noises, changes in climate, such as changes in humidity or very cold temperatures, strong smells and a stuffy atmosphere. Medications: oral contraceptive pills, HRT and some types of sleeping tablets.
- 15. There's no specific test to diagnose migraine. Diagnosis depends on the criteria of the headache and history given by the patient. International Headache Society (IHS) criteria and guideline consider to be the cornerstone of diagnosis of migraine with it’s different types.
- 16. A. At least two attacks fulfilling criteria B and C. B. One or more of the following fully reversible aura symptoms: visual, sensory, speech and/or language, motor, brainstem, retinal. C. At least two of: 1 - at least one aura symptom spreads gradually over at least 5 minutes. 2 - each aura symptom lasts 5–60 minutes. 3 - at least one symptom is unilateral. 4 - headache follows aura within 60 minutes. D. Not attributable to another disorder including TIA.
- 17. A. The patient should have had at least five attacks fulfilling criteria B and D. B. The headaches last 4–72 hours. C. The headache must have at least two of the following: 1 - unilateral location. 2 - pulsing quality. 3 - moderate or severe intensity, inhibiting or prohibiting daily activities. 4 - headache worsened by routine physical activity. D. The headache must have at least two of the following: 1 - nausea and/or vomiting. 2 - photophobia and phonophobia. E. Not attributable to another disorder.
- 18. Hemiplegic migraine. Basilar migraine. Retinal migraine. Migrainous (vestibular) vertigo. Migrainous stupor. Ophthalmoplegic migraine. Migraine equivalents. Menstrual migraine. Status migrainosus.
- 19. Hemiplegic migraine is referred to as a “migraine variant”. Hemiplegic simply means paralysis on one side of the body. A person with hemiplegic migraine will experience a temporary weakness on one side of their body as part of their migraine attack. This can involve the face, arm or leg and be accompanied by numbness, or pins and needles. The patient may experience speech difficulties, vision problems or confusion. Symptoms are similar to those of a stroke and TIA and need a careful differential diagnosis.
- 20. This weakness may last from one hour to several days but usually, it goes within 24 hours. The head pain associated with migraine typically follows the weakness, but a headache may precede it or be absent. There are two types of hemiplegic migraine: 1 - Familial hemiplegic migraine (FHM). 2 - Sporadic hemiplegic migraine (SHM). It is vital to refer the patient to confirm the diagnosis by a specialist. Some guidelines consider hemiplegic migraine as a subtype of classic migraine.
- 21. Basilar migraine is recognized as a type of classic migraine. Caused by vasoconstriction, or narrowing of the blood vessels. Attacks are a described as episodes of dizziness, vertigo or vision changes like lack of coordination and double vision with migraine. The symptoms may last just a few minutes to an hour. Unlike most other types of migraine, the pain is often in the occipital region. Also, basilar migraine pain might not be a throbbing pain.
- 22. Migraine may present with symptoms of visual loss. Associated headache and nausea may not be present. Clinical features 1 - Zigzag lines or lights 2 - Multicolored flashing lights 3 - Unilateral or bilateral field deficit 4 - Resolution within a few hours
- 23. Migraine is a relatively common cause of vertigo and often unrecognized because of its many styles. It should be suspected if there is: 1) History and/or family history of migraine. 2) History of recurrent bouts of spontaneous vertigo or ataxia that persist for hours or days in the absence of aural symptoms. Vertigo takes the place of the aura that precedes the headache or may be a migraine equivalent whereby vertigo replaces the symptoms of headache. Nausea and vomiting may be present. Pizotifen or propranolol are recommended for prophylaxis.
- 24. Confusion is the key, which may precede or follow a headache. During the confused period, the patient is inattentive and distracted and has difficulty maintaining speech and other motor activities.
- 25. Ophthalmoplegic migraine is a very rare type of a migraine occurs mainly in young people. Symptoms will be due to the weakness of one or more of the muscles that move the eye. Symptoms include dilation of the pupils, inability to move the eye upward, downward or across, as well as a drooping of the upper eyelid together with a headache.
- 26. Migraine that presents in a form other than head pain. A diagnosis of migraine equivalent is determined by: 1 - A previous history or family history of migraine attacks. 2 - No evidence of organic or physical lesions. 3 - Replacement of normal headaches by an equivalent group of symptoms. Although not common, most of migraine equivalent is “abdominal migraine”, which is characterized by recurrent episodes of vomiting and abdominal pain without a headache mainly in female children.
- 27. A migraine equivalent may be characterized by visual symptoms such as blind spots, partial vision, neurologic deficits, or psychic disturbances without a headache. It is easier to diagnose if these symptoms had previously accompanied attacks associated with headaches, but often the elderly develop the visual symptoms for the first time without head pain.
- 28. A specific condition where the timing of attacks is limited to the menstrual cycle. There is no aura and it can last longer than other types. Affect fewer than 10% of women. The two most accepted theories on the cause are: 1 - Withdrawal of estrogen as part of the normal menstrual cycle. 2 - Release of prostaglandin during the first 48 hours of menstruation.
- 29. A migraine that lasts for more than 72 hours. Often need admission at least in 24 - hour admission sitting to relieve the pain and dehydrate the patient. More common with a classic migraine
- 30. Treatment of acute attack. Health education. Provide action plan. Prophylaxis life style and medication.
- 31. Commence treatment at the earliest impending sign. Mild headaches may require no more than conventional treatment and a good lie down in a quiet dark room. Rest in a quiet, darkened, cool room. Place cold packs on the forehead or neck. Avoid drinking coffee, tea or orange juice. Avoid moving around too much. Do not read or watch television. For patients who find relief from simply ‘sleeping off’ an attack, consider prescribing temazepam or diazepam in addition to the medication. For moderate attacks use oral ergotamine or sumatriptan and for severe attacks use injection therapy.
- 32. Aspirin or paracetamol. Paracetamol or ibuprofen (for children). Consider NSAIDs (e.g. ibuprofen, naproxen, diclofenac rapid). Triptan preparation: tablet, nasal spray or SC injection used in moderate to severe attacks. Ergotamine in case of severe attacks. If nausea and vomiting is a feature: metoclopramide or prochlorperazine should be added to the treatment.
- 33. Avoid triptans in patients with coronary artery disease, Prinzmetal angina, uncontrolled hypertension or during pregnancy. Stop triptans if chest pain develops. Use triptans with caution in patients taking SSRIs, MAOIs and lithium. Do not use ergotamine preparations if sumatriptan used in previous 6 hours, and do not use sumatriptan if ergotamine preparations used in previous 24-hours.
- 34. Personal action plan http://www.fvfiles.com/521060.pdf School action plan https://www.spx.org/upload/Clinic/Migraine_Action_Pl an_15.pdf
- 35. Non-drug self-management with avoidance of any known trigger factors is the key. Consider prophylactic therapy for frequent attacks that cause disruption to the patient’s lifestyle and well- being. Certainly, consider it for weekly attacks and a poor response to therapy for the acute attack.
- 36. The most commonly used drugs include: Beta-blockers: propranolol 40 mg (o) bd or tds (max. 320 mg/day), metoprolol, atenolol Tricyclic antidepressants: amitriptyline Sodium valproate Pizotifen 0.5–2.0 mg at night Cyproheptadine (ideal for children) Clonidine
- 37. Methysergide (reserve for unresponsive severe migraine) 1 mg tds after food—up to 4 months only Calcium-channel blockers: nifedipine, verapamil NSAIDs: naproxen, indomethacin, ibuprofen MAOIs: phenelzine, moclobemide Sumatriptan Gabapentin Topiramate Botulinum toxin
- 38. Naproxen 550 mg (o) bd, 48 hours before expected attack for 4–10 days or Estradiol gel 1.5 mg transdermally, once daily for 7 days.
- 39. Select the initial drug according to the patient’s medical profile: Low or normal weight / Food-sensitive migraine: Pizotifen. Hypertensive or looks tension: Beta blocker. Depressed or anxious: Amitriptyline. Cervical spondylosis: Naproxen. Menstrual migraine: Naproxen or Mefenamic acid or Ibuprofen or Estradiol transdermal gel.
- 40. Each drug should be tried for 2 months before it is judged to be ineffective. Amitriptyline can be added to propranolol, pizotifen or methysergide and may convert a relatively poor response to very good control.
- 42. Migraine can be classified to: A. Common, uncommon. B. Classic, non classic. C. Common, classical and unusual. D. Common, classical, unusual and complicated.
- 43. Triggers of Migraine include which of these: A. Poor quality sleep. B. Foods contain tyramine. C. Changes in humidity or very cold temperatures. D. All of the above.
- 44. Migraine variant is referred to: A. Migrainous (vestibular) vertigo. B. Basilar migraine. C. Hemiplegic migraine. D. Ophthalmoplegic migraine.
- 45. Episodes of dizziness, vertigo or vision changes like lack of coordination and double vision with migraine describe which types of unusual migraine: A. Migrainous (vestibular) vertigo. B. Basilar migraine. C. Hemiplegic migraine. D. Ophthalmoplegic migraine.
- 46. In Migrainous stupor: A. Confusion is the key symptom. B. Vertigo is the key symptom. C. Visual impairment is the key symptom. D. Unilateral weakness is the key symptom.
- 47. In treatment of acute migraine: A. Ergotamine and sumatriptan can be combined together. B. Ergotamine and sumatriptan can’t be combined together. C. Ergotamine and sumatriptan can be used together with some time space. D. Ergotamine and sumatriptan can be combined together just if metoclopramide is added.
- 48. One of the best medication for Menstrual migraine prophylaxis: A. Estradiol gel 1.5 mg transdermally, once daily for 7 days. B. Methysergide 1 mg tds after food. C. Beta-blockers: propranolol 40 mg (o) bd or tds. D. Pizotifen 0.5–2.0 mg at night.
- 49. If Migraine prophylaxis medications was recommended: A. It should be tried for 1 month. B. It should be tried for 2 months. C. It should be tried for 3 months. D. It should be tried for 4 months.