Migraine

General information

Definition Clinical features

• Episodic and recurrent headache + visual and GI disturbances. Warning auras
• Headache is often throbbing/pulsatile/ thumping. Cerebral features e.g. tingling limbs,
• Other associated features: aphasia and weakness
- Sensitivity to light, sound or movement Hemianopic symptoms (cortex),
fortification spectra (jagged lines
- Nausea and vomiting accompanying the headache resembling battlements).
teichopsia (flashes)
Pathophysiology Unilateral patchy scotomata (retina),
• Headache is due to vasodilation of extracerebral blood vessels/dura Nausea and vomiting
mater  stimulation of nearby nerve endings and release of vasoactive Dysphasia (aura)
substances (e.g. NO, 5-HT, CGRP ).
• Cranial parasympathetic innervation drives symptoms i.e. neurovascular
• Genetic factors–e.g. mutation in the α1 subunit of a P/Q-type voltage-
gated calcium channel. Differential Diagnosis

Epidemiology 1. Meningitis or SAH

• Affects 10-15% of the population worldwide and the F:M ratio is 2:1 (sudden onset )
• Common around puberty and at the menopause
2. Thromboembolic TIAs
• Sometimes increases in severity with hormonal contraceptives,
pregnancy and hypertension. -- Hemiplegic, visual and
hemisensory symptoms
Precipitating factors:
(but in TIAs, maximum deficit is
• Chocolate, cheese (high in tyramine), alcohol (e.g. glass of wine), noise, present immediately + headache
Progression is unusual)

Prodromal symptoms  attack (headache, nausea, vomiting)  sleep 3. Sensory epilepsy

and feeling drained afterwards. (partial seizures)

ICE: questions to exclude differentials

General Questions
• Remember to use SOCRATES – this should elicit most symptoms
• The most important differentials are meningitis or SAH
o So ask about previous Hx (normally someone with migraine will have had the symptoms before)
o Ask about symptoms of meningitis: did you experience any neck pain/stiffness etc? Does bright light
hurt your eyes?
o Check for associated Fever
• Clarify onset: acute = vascular (or meningitis)= serious
o did the headache come on in seconds (SAH) or minutes (migraine etc)?

• Establish any prior Hx of head trauma

• Ask also about hemiplegia and dysphasia (i.e. is there any associated weakness/problems with speech) and
epilepsy (blackouts)
• Family Hx of cerebrovascular disease and migraine + ask about drugs: caffeine withdrawal and alcohol could
precipitate attacks
• Elicit warning auras (esp. visual), nausea and vomiting (quite characteristic of migraine)
Management
• Avoidance of triggering factors

• During attack: paracetamol or other simple analgesics +antiemetics (e.g.metoclopramide)

• Repeated use of analgesics leads to further headaches.

• Recurrent severe migraine: Triptans (5-HT1 agonists)