Migraine

Migraine is a common neurological condition characterized by recurrent episodes of headache, often accompanied by nausea, vomiting, and sensitivity to light and sound. It can significantly impact the quality of life.

Causes:

  • Genetic Predisposition: Family history is a common factor.
  • Neurovascular Disturbances: Changes in brain chemicals, notably serotonin, and irregularities in brain blood flow.
  • Triggers: Vary greatly and can include dehydration, stress, hormonal changes (in women, often linked to menstrual cycle), certain foods and drinks, changes in sleep patterns, environmental factors, and certain medications.

Diagnosis:

  • Clinical History and Symptom Profile: Diagnosis is primarily clinical, based on the patient’s history and symptom characteristics. Key features include the nature of the headache (pulsating quality), duration (4 to 72 hours if untreated), and associated symptoms like photophobia, phonophobia, and nausea.
  • Diagnostic Criteria (ICHD): The International Classification of Headache Disorders provides specific criteria for migraine diagnosis, including frequency and number of episodes, pain characteristics, and associated symptoms.
  • Exclusion of Secondary Causes: Ensuring the headache is not attributable to another medical condition.

Differential Diagnosis:

  • Tension-Type Headache: Less severe, no accompanying symptoms like nausea or photophobia.
  • Cluster Headaches: Short, extremely painful headaches typically around one eye; more common in men.
  • Sinus Headaches: Associated with sinus infection symptoms.
  • Secondary Headaches: Due to another medical condition (e.g., brain tumor, hypertension).
  • Medication Overuse Headaches: Due to chronic use of headache medications.

Management:

Management strategies are usually categorized into acute treatment for headache attacks and preventive treatment.

  • Acute Treatment:
    • Analgesics:
      • Ibuprofen 600mg oral stat OR
      • Aspirin 900mg oral stat
      • 2nd line and pregnant Paracetamol 1000mg oral stat
    • Triptans: Serotonin receptor agonists for moderate to severe migraines.
      • Sumitriptan (Imigran) 50mg oral or 20mg nasal stat
    • Anti-nausea Medications:
      • Metoclopramide 10mg oral is first line
      • Second line: Ondansetron, Prochlorperazine, Domperidone
    • Rest and Avoidance of Triggers: Resting in a dark, quiet room during an attack.
  • Preventive Treatment:
    • Indicated for migraine > 2 x /month 
    • Medications:
      • Pizotofen (Sandomigran) 0.5mg oral nocte
        • s/e Weight gain
      • Beta-blockers: Propranolol 20mg oral nocte
      • ARB: Candesartan 4mg oral nocte
      • Calcium channel blockers: Verapamil 90mg oral nocte
      • TCA: Amitryiptyline 10mg oral nocte
      • Antiepileptic: Topirimate 25mg oral nocte
    • Lifestyle Modifications:
      • Regular exercise
      • Adequate hydration
      • Regular sleep patterns
      • Stress management techniques
      • Avoidance of known dietary triggers.
    • Hormonal Therapy: In women whose migraines are linked to the menstrual cycle.
    • Botox Injections: Approved for chronic migraine prevention.
    • CGRP Monoclonal Antibodies: A newer class of preventive medication.
  • Complementary Therapies:
    • Biofeedback and Relaxation Techniques: Can reduce the frequency and severity of migraine attacks.
    • Acupuncture: Some find relief through acupuncture.
    • Dietary Supplements: Magnesium, riboflavin, and Coenzyme Q10 have been used for prevention.

When to Refer:

  • Uncertain diagnosis, especially if the headache pattern changes or neurological signs appear.
  • Migraines refractory to standard treatments.
  • Patients experiencing severe or very frequent attacks.

Follow-up:

Regular follow-up is essential to monitor the effectiveness of treatment, adjust medications, and manage side effects. This ongoing care is vital for chronic migraine management.

Migraine management is highly individualized, and a combination of lifestyle changes, medication, and sometimes alternative therapies is often necessary to control symptoms effectively.

Diagnostic Criteria

The diagnosis of migraine is primarily clinical and is based on criteria established by the International Headache Society, as outlined in the International Classification of Headache Disorders (ICHD). The diagnostic criteria for migraine without aura, the most common form, are as follows:

  1. Headache Attacks: At least five attacks fulfilling criteria 2-4.
  2. Headache Duration: Headache lasting 4 to 72 hours (untreated or unsuccessfully treated).
  3. Headache Characteristics: At least two of the following four characteristics:
    1. Unilateral location (one-sided pain).
    2. Pulsating quality.
    3. Moderate or severe pain intensity.
    4. Aggravation by, or causing avoidance of, routine physical activity (e.g., walking or climbing stairs).
  4. During Headache, At Least One of the Following:
    1. Nausea and/or vomiting.
    2. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).
  5. Not Attributable to Another Disorder: The headache is not better accounted for by another ICHD-3 diagnosis or another disorder.

For Migraine with Aura, the criteria include at least two attacks of aura involving visual, sensory, speech/language, motor, brainstem, or retinal symptoms, each fully reversible and lasting between 5 and 60 minutes, followed by a headache meeting the above criteria for migraine without aura.

Note that while Migraine with Aura is a contraindication to the Combined Oral Contraceptive Pill, it is NOT a contraindication to Oestrogen containing HRT.

These criteria are designed to differentiate migraine from other types of headaches like tension-type headaches or cluster headaches, and to ensure accurate diagnosis and appropriate treatment. It’s important to note that these are guidelines; individual cases can vary, and professional clinical judgment is crucial in diagnosis.