Migraine

Migraine
Migraine is an episodic unilateral headache accompanied by visual disturbances and vomiting. The episodic nature of the headache is most characteristic. Initially during aura, there is a decrease in cerebral blood flow, particularly in the occipital and parietal lobes. Later, during the phase of headache there is a dilatation of the extracranial arteries related to the variations in 5-HT blood levels.Types of Migraine1. Classical migraine: The headache is preceded by visual or sensory aura.2. Common migraine: This is without aura. Headache, nausea, vomiting and photophobia are the classical symptoms.3. Hemiplegic migraine: In this type, hemiplegia lasting for a few days follows the headache.

4. Basilar migraine:  Vertigo, diplopia, dysarthria with or without visual symptoms precede occipital headache.

5. Cluster headache: Bouts of severe pain around one eye with associated epiphora and nasal congestion is the hallmark and this type, mostly affects males.

Treatment

Treatment of migraine involves managing acute attacks with analgesics and prevention of further attacks. Precipitating causes have to be taken care of and family and work related stress should be managed by various methods of coping with stress and relaxation and keeping regular hours of sleep and meals habits.

Simple analgesics like asprin, acetoaminophen and also ibuprofen and diclofenac are used to alleviate pain. Ergotamine is used when analgesics give less relief. It acts by causing vasoconstriction of extracranial vessels and reduction of platelets aggregation. Sumatriptan is a highly selective 5-HT1 receptor agonist which are mainly located in cerebral arteries. It constricts cerebral blood vessels.

Dopamine antagonists, metoclopramide, chlorpromazine, prochlorperazine have been used for severe attacks.

Narcotics and short course of corticosteroids and antipsychotics can be used when severe migraine does not respond to conventional measures.

Precipitating Factors

Although investigation have not conclusively proved that any factor causes migraine headache, some patients do recognize certain factors that precipitate an attach. Certain dietary factors like Tyramine, monosodium glutamate, excessive alcohol, excessive analgesics, ergotamine, and oral contraceptives act as trigger to cause migraine.
Stress, menses, heat, noise, caffeine etc. can also cause migraine.

Diagnosis: Careful history is important.

Diagnostic criteria

Migraine without aura

A. At least 5 attacks fulfilling criteria B-D

B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

C. Headache has at least 2 of the following characteristics:

  1. Unilateral location
  2. Pulsating quality
  3. Moderate or severe pain intensity
  4. Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

D. During headache at least 1 of the following:

  1. Nausea and/or vomiting
  2. Photophobia and phonophobia

E. Not attributed to another disorder

Migraine with aura

A. At least 2 attacks fulfilling criterion B

B. Migraine aura fulfilling criteria B-C for one of the subforms (typical aura with migraine headache, typical aura with non-migraine headache, typical aura without headache, familial hemiplegic migraine, sporadic hemiplegic migraine, or basilar-type migraine)

C. Not attributed to another disorder

Typical aura with migraine headache

A. At least 2 attacks fulfilling criteria B-D

B. Aura consisting of at least 1 of the following, but no motor weakness:

  1. Fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)
  2. Fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)
  3. Fully reversible dysphasic speech disturbance

C. At least two of the following:

  1. Homonymous visual symptoms and/or unilateral sensory symptoms
  2. At least one aura symptom develops gradually over >/=5 minutes and/or different aura symptoms occur in succession over >/=5 minutes
  3. Each symptom lasts >/=5 and </=60 minutes

D. Headache fulfilling criteria B-D for “Migraine without aura” begins during the aura or follows aura within 60 minutes

E. Not attributed to another disorder

Typical aura without headache

As “Typical aura with migraine headache” except:

B. Aura consisting of at least 1 of the following, with or without speech disturbance but no motor weakness:

  1. Fully reversible visual symptoms including positive features (eg, flickering lights, spots or lines) and/or negative features (ie, loss of vision)
  2. Fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)

D. Headache does not occur during aura nor follow aura within 60 minutes

Prevention of Migraine

Preventive measures are to be considered when migraine attacks occur more than two or three times a month and disturb normal activity. Preventive medication is continued for 6 months and gradually withdrawn. Drugs used include 5-HT influencing drugs like Amitriptyline, Methysergide, Propranolol, Metoprolol, Nadolol, Nefedipine, Nimodipine,Verapamil, Pizotefen.

 Drugs used in Migraine

Ergotamine Flunarizine Sumatriptan
Indications 1. Migraine
2. Cluster headache
3.Vascular headache
4. Post-partum haemorrjage
1. Prophylaxis of classical and common migraine.
2. Vertigo and vestibular disorders.
3. Peripheral vascular disorders.
4. Resistant cases of Epilepsy as an adjuvant.
1. Acute severe migrane.
2. Clustur headache.
Contraindications 1. IHD
2. Peripheral Vascular disease.
3. Gangrene
4. Hipatic diseases.
5. Renal diseases.
6. High BP
7. Porphyria.
1. Hypersensitivity
2. Parkinsonism
3. Acute Porphyria
1. Hypersensitivity
2. IHD
3. Uncontrolled BP
Dose 1-2 mg twice or thrice daily. 10 mg / day as a single dose. 50-100 mg.
If poor response repeat 100mg every 2 hrly, maximum 300mg a day.
Adverse drug reactions Nausea/vomiting,diaeehoea, leg cramps,abdominal pain,myocardial ischaemia. Depression,skin rash, anusea,epigastric disorders, headache, drowsiness, insomnia, extrapyramidal reactions. Tightness in the chest, skin rash, hives, fatigue, dizziness, wheezing, ocular swelling.
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