Migraine
last authored: Jan 2010, David LaPierre
last reviewed:
Introduction
Migraine is a common type of headache, affecting 1/30 children, 1/10 adults, and 1/4 physicians.
Classic migraines are preceded by aura, while common migraines are not. Complicated migraines include basilar, hemiplegic, and ophtalmoplegic varieties.
The International Headache Society describes criteria for common migraine as:
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The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis. To get students thinking.
Causes and Risk Factors
Identify and avoid triggers; a diary can be very helpful. Two strikes and you're out.
- chocolate
- red wine
- aged or processed cheese
- cured or processed meats
- monosodium glutamate, aspartame, or nitrates
- caffeine
Other triggers appear to include
- bright or flickering lights
- loud noises
- strong smells
- irregular sleeping patterns
- skipped meals
Many patients with migraines also have withdrawal-type headaches due to medication overuse.
Most women with migraines experience improvement with menopause.
Pathophysiology
One model suggests migraines originate from serotonergic dysfunction leading to activation of trigeminal nerves fibres that innervated the pia and dura vasculature. This leads to release of vasoactive mediators, inflammation, and pain. Vasoconstriction and vasodilation follow.
Signs and Symptoms
- history
- physical exam
History
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
Stroke or TIA should be ruled out.
Treatments
Many people find avoiding noise and lights, and attempting to sleep, can help.
Early therapy with effective doses are critical.
First line includes acetaminophen, ASA, and caffeine.
Second line includes NSAIDs, at moderately high dose. Third line includes 5-HT receptor agonists such as ergot derivatives or sumatripan.
Antiemetics such as metoclompramide, prochlorperazine, or domperidone should be added to decrease nausea and increase absorption of other drugs.
Benztropine can be added to prevent akathesia.
Other options include:
- intranasal lidocaine
- short course of oral prednisone
Last stage medications include:
- ketamine
- propofol
Prevention
Sleep well to prevent migraines; for many people, getting to sleep right away can reduce them.
Prophylactic medications can include: beta blockers, TCAs, valproic acid, or NSAIDs.
Consequences and Course
Resources and References
Topic Development
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reviewers:
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