🎯 Pathology

• a common type of primary headache

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💡 Causes

• there is a strong genetic component

  • it is more common in females

 

Triggers

• remember ‘MIGRAINED’

  • Menstruation (hormonal changes)

  • Insufficient sleep

  • Glare (bright lights)

  • Red wine (alcohol, especially red wine)

  • Anxiety and stress

  • Irregular meals or skipping meals

  • Nitrates (found in processed meats)

  • chEEse / chocolatE

  • Dehydration

 

Some of the different types of migraine

• migraine without aura

• migraine with aura

• silent migraine

• hemiplegic migraine

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🩺 Phases of a migraine

 

A migraine has 5 phases:

 

1. Prodromal phase

• can begin several days prior to the headache

• signs and symptoms such as yawning, food cravings and neck pain occur

  • linked to increased release of serotonin

 

2. Aura

• can last up to 60 minutes

• an aura is a sensory disturbance that occurs before the headache

• vision, sensation, or speech can be affected, although most auras are visual

• typically resolves before the headache

• it is hypothesised that it’s due to the cortical spreading depression which is essentially a transient and local suppression (depression) of electrical activity in the cortex (cortex) that moves slowly across the brain (spreading)

 

3. Headache

• lasts between 4 to 72 hours

• the patient may be sensitive to light and sound, and may also have a heightened sense of smell

• associated with poor concentration

 

4. Resolution

• can take up to 24 hours

• vomiting and sleep predominate in this phase

 

5. Recovery phase

• the patient returns back to normal

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🕵️‍♂️ Clinical features

• unilateral, severe pulsating headache that lasts up to 72 hours

• associated with nausea, and increased sensitivity to light and sound causing photophobia and phonophobia respectively

 

Silent migraine

• “migraine aura without headache”

 

Hemiplegic migraine

• rare subtype of migraine with aura

• motor weakness occurs as a manifestation of the aura

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💆‍♂️ Investigations

• clinical diagnosis

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💆‍♂️ Management

• acute management

  • adults

    • oral triptan + paracetamol, or

    • oral triptan + NSAID

• children aged 12-17 years

  • offer nasal triptan instead of oral

  • avoid the use of aspirin to avoid risk of Reye’s syndrome

• prophylaxis

  • propranolol

  • topiramate (teratogenic)

 

🧲 High-yield tips

• migraine with aura is associated with an increased risk of stroke therefore the combined oral contraceptive pill (COCP) should be avoided

• mechanism of action of triptans: 5-HT1B and 5-HT1D agonists

• triptans should be taken as soon as the headache starts, NOT when the aura starts

• two doses of triptans should not be taken for the same migraine attack