Migraine is a common cause of headache affecting about 15% of individuals. Headaches are typically recurrent, and last anywhere up o 72 hours.
They are typically associated with nausea and photophobia, and rarely can present with neurological signs and symptoms mimicking a stroke.
- Times of relaxation (e.g. often at weekends)
- Chocolate – due to high phenylethylamine content
- Cheese – due to high tryamine content
- Noise / lights
- Oral contraceptive pill
- Common around puberty
- Common around menstruation / pregnancy / menopause
- In pregnancy, cases often resolve as the pregnancy progresses, and are uncommon in the second and third trimesters. Don’t use aspirin after 30 weeks and when breatfeeding.
- Sometimes occurs after minor blow to the head
- Patent foramen ovale
- Ch – chocolate
- O – Oral contraceptive
- C – caffeine (or withdrawal)
- Ol – alcohol
- T – travel
- E – exercise
- Visual Aura – a perceived visual disturbace (e.g. zig-zag lines, bright lights, distorted objects, scotomo (dark patches), techopsia (flashes)). These often occur before an attack and last 15-60 minutes. They are caused by reduced blood flow to the occipital cortex before an attack.
- They also often occur before an epileptic seizure in epileptic patients.
- Patients may also have a sensory aura – e.g. pins/needles spreading up limbs, or a speech aura – whereby they may suffer temporary dysarthria
- Throbbing sensation
- Unilateral – the pain often begins locally and then spreads.
- Heightened sensitivity to pain – all stimuli (e.g. wearing glasses, brushing hair) cause pain
- There are no clinical / neurological signs.
- Headaches lasting 4/72h with aura – classical Migraine
- Headaches lasting 4/72 hours with no aura, (sometimes called Common migraine)but with:
- Nausea / vomiting OR photophobia AND at least 2 of:
- Interferes with normal life
- Worsened by normal activities (e.g. walking / bending / climbing stairs)
- Basilar migraine – includes symptoms such as tongue tingling, vertigo, diplopia, visual disturbance (perhaps even blindness), dysarthria, ataxia
- Facioplegic Migraine – unilateral face weakness
- Initial Oligaemia – which causes the aura, is then following by
- Hyperaemia / blood vessel dilation / oedema – which stimulates nerve endings and causes pain.
- NB – overuse of analgesics predisposes to attacks
- Ergotamine – 1mg orally as headache begins. Repeat at ½ hour intervals up to 3mg/day or 6mg/week. Do not use with contraceptive pill, peripheral vascular disease, pregnancy, liver/kidney impairment, Raynaud’s Phenomenon, hemiplegic migraine.
- Pizotifen – this is an antihistamine and 5-HT antagonist – it causes vasoconstriction of cranial arteries.Give 0.5mg at night (increase to 1mg). Side effects include weight gain, drowsyness, ↑effects of alcohol, ↑glaucoma risk. Rarely can cause arrhythmias and angina.
- Propanol – beta-blocker – give 10mg 3x/day, increasing to 40mg 3x/day if necessary.
- Amytriptiline –TCA – 10mg+ at night. Side effects include drowysness, dry mouth and blurred vision