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migraine
It is a type of a vascular headache Of unknown aetiology In which final step of pathology of pain is constriction (producing the neurological symptoms of the prodroma and the aura) followed by diltation of one or more of branches of carotid artery or vertebrobasilar arteries Leading to stimulation of pain nerve endings surrounding artery by stretching -- producing the headache). Pain is prolonged by surrounding muscle contraction
Diagnostic criteria
Headache attacks lasting 4-72 hours (from several minutes to several days). Headache has at least two of the following four
Unilateral location (on one side of the head only ) Pulsating quality Moderate or severe intensity (inhibits or prohibits daily activities). Aggravation by walking stairs or similar routine physical activity.
It could be triggering an attack by the types of food they choose to eat during this time include red wine, some types of cheese, caffeine and the flavour enhancer monosodium glutamate. Other headache types not suggested or confirmed-- No evidence of Organic Headache. in premenstrual or menstrual migraine, It is not usually preceded by (aura) visual , sensory and speech disturbances as classic migraine , also it is familial
NB
It is necessary to assume that headache is physical in origin until sufficient time and repeated examination has excluded an organic origin
The only sign of migraine can be seen is dilatation of external carotid arteryon one side recognised by visible pulsation in superficial temporal artery Pain is temporary relieved by compression of common carotid artery and return op pain with increase of severity when compression is released
regularly, each
month
Classification of migraine by the International Headache Society, 1988 (with code numbers)
1.1 Migraine without aura 1.2 Migraine with aura 1.2.1 Migraine with typical aura 1.2.2 Migraine with prolonged aura 1.2.3 Familial hemiplegic migraine 1.2.4 Basilar migraine 1.2.5 Migraine aura without headache 1.2.6 Migraine with acute onset aura 1.3 Ophthalmoplegic migraine 1.4 Retinal migraine 1.5 Childhood periodic syndromes that may be precursors to or associated with migraine 1.5.1 Benign paroxysmal vertigo 1.5.2 Alternating hemiplegia 1.6 Complications of migraine 1.6.1 Status migrainosus 1.6.2 Migrainous infarction 1.7 Migrainous disorder not fulfilling above criteria
increase prostaglandin E
Decrease Vitamin B2
pain of migraine
Serotinin receptors
the various families of serotonin receptors
The 5-HT1B receptors are postsynaptic receptors on blood vessels. Intracranial blood vessels have a rich supply of these receptors. They are also, to a small degree, in the coronary arteries, which accounts for the reason selective serotonin receptor agonists are contraindicated in patients with occlusive coronary artery disease. The 5-HT1D receptors, on the other hand, are presynaptic receptors on the trigeminal nerve endings. Stimulation causes a reduction in the release of vasoactive polypeptides, such as calcitonin gene-related peptide (CGRP) and substance P, and, hence, a reduction in the degree of neurogenic inflammation. The excitatory 5-HT2 receptors are also important in the pathogenesis of migraine. Preventive medications, such as methysergide and propranolol, are 5-HT2 receptor antagonists. The 5-HT3 family of receptors is also relevant in migraine pharmacotherapy. The nausea and vomiting associated with migraine may be partly due to stimulation of 5-HT3 receptors in the nausea and vomiting center of the brain stem. 5-HT3 antagonists such as metoclopramide can provide relief of igraine-associated nausea and vomiting.
dopamine antagonists
Effective for the treatment of acute migraine include chlorpromazine (Thorazine), 12.5 mg; prochlorperazine, 5 to 10 mg; metoclopramide, 5 mg with DHE; and droperidol (Inapsine), 2.5 These agents serve as alternatives to 5-HT1 agonists in patients who present to the emergency department for the treatment of migraine. They are good choices for patients in whom the triptans are contraindicated. Intravenous diphenhydramine (50 mg) may also be useful in the emergency department setting, as may intravenous valproate (300 to 500mg).
Migraine Phases
Prodrome it occurs within hours or up to days before a migraine attack. Many physical and psychological symptoms are associated with prodrome. These symptoms may vary between individuals, but they usually remain consistent for an individual. Aura (+ or - ) it develops 5 20 minutes before a migraine attack and lasts no longer than an hour. Aura symptoms usually effect the senses, especially sight, but they can also effect muscle strength. Migraine headacheSymptoms that distinguish migraines from other headaches, include: Headache on one side of the head (unilateral), behind the eyes (retrorbital), or around the eyes (periorbital) Pain intensity that is moderate to markedly severe and worsened by physical activity Some migraines may develop on both of sides of the head and then shift to one side of the head. In other individuals, the pain may develop on one side of the head and then become more generalized. Postdrome (headache termination) While migraines subside during the postdrome phase, individuals will experience the following symptoms: Fatigue ,Irritability,Impaired concentration ,Scalp tenderness Mood changes
prophylaxis
To minimize the onset and the effects of migraines Non-Drug Prevention avoiding these trigger factors Modify life style Prevention using medication short-term rather than continuous treatment
NSAIDs
start 1 wk before expected headache during luteal phase)
Continuous ttt
also beta blockers or calcium channel blockers, taking continuously , the dose can be increased in the premenstrual or menstrual phase.
acute abortive measures focuses on stopping the migraine as it progresses. symptomatic measures focuses on treating the symptoms that result from migraines
Migraine prophylaxis
the treatments used for the prophylaxis of nonmenstrual related migraine are used, with the additional of hormonal therapy short-term prophylaxis (Intermittent Prophylaxis ) -when the association between migraine and menses has been confirmed with prospective records kept with a diary for a minimum of three cycles ---start 1 wk before expected headache during luteal phase) long-term prophylaxis (Daily Prophylaxis) --- when migraine occur at menses and also occur in the nonmenstrual period -- taking drugs continuously , but the dose should be increased in the premenstrual or menstrual phase.
Migraine prophylaxis
To minimize the onset and the effects of migraines Non-Drug Prevention avoiding these trigger factors (Foods , Medications , Hormonal Factors , Lifestyle Factors , Environmental Changes )could reduce the frequency of migraine attacks by half. individuals should exercise, get plenty of sleep, form regular sleeping habits, avoid missing meals, and discontinue smoking. Individuals may also find that relaxation, and stress management help to prevent migraines. Prevention using medication (prophylactic treatment) is only recommended in individuals when: Migraines occur twice a month, producing disability that lasts three days or longer Medication that treats symptoms or tries to stop an attack are not best for patients or are not working Pattern of migraine attacks are predictable, such as premenstrual and menstrual migraines Drugs--- short-term rather than continuous treatment Estrogen (establishment of a stable estrogen state )
taking continuously , the dose can be increased in the premenstrual or menstrual phase. Treating underlying causesas high blood pressure Stress management bec arteries can be affected by emotional state
non-pharmacological methods
to control either the frequency or severity of their migraines, these include biofeedback, relaxation therapy hypnosis, meditation, osteopathy, acupuncture, cognitive behavioural training and lifestyle changes such as identifying the possible aggravating factors e.g. stress, alcohol, coffee, cheese and chocolate.
avoiding red wine, some types of cheese, caffeine and the flavour enhancer monosodium glutamate. vitamin (B2 ,B6 ,E )and mineral (magnesium)supplements both before and during menstruation ?
A healthy lifestyle
a helpful preventive measure. Physical activities and exercise may be valuable in decreasing stress in addition to contributing to fitness and well-being. Early identification and monitoring of the signs of physical and psychological stress, such as tight neck muscles or an anxious feeling, will lead to early intervention and possible prevention of migraine get plenty of sleep discontinue smoking.
Estrogen
Because menstrual migraine can be triggered by falling estrogen levels that are either endogenously or exogenously induced (by week-off oral contraceptive or hormonal replacement therapy), prevention can be attempted by providing a more stable estrogen state Percutaneous estrogen in gel form applied for 7 days, beginning at least 2 days before the expected migraine, has been shown to decrease the frequency and severity of menstrual migraine The estradiol cutaneous patch may be less effective than gel but is used in many headache clinics, either alone or in combination with a small dose (20 mg) of methyltestosterone the birth control pill If used continuously (no break), it may also occasionally be effective
Prostaglandins may play a role in the initial vasoconstriction phase of migraine and in the pain and sensitization to the pain of headache and of dysmenorrhea, if present. Nonsteroidal antiinflammatory drugs (NSAIDs) are valuable both for prophylaxis of menstrual migraine and for analgesia; the agents inhibit prostaglandin synthesis and block neurogenic inflammation. Naproxen has been used effectively for prophylaxis (Typically, the drugs are started 7 days before the expected menses. Effective doses vary, but naproxen, 550 mg twice a day; ketoprofen (Orudis), 75 mg three times a day (or extended-release form [Oruvail], 200 mg once a day); ibuprofen, 300 mg two or three times a day; or mefenamic acid (Ponstel), 250 mg two or three times a day, may be helpful for prophylaxis If one class of NSAID is not effective, another should be tried.
NSAIDs
Depot progestogen
as it also inhibits ovulation and can improve migraine, provided amenorrhoea is achieved
Abortive therapy
the treatment of acute menstrual migraine is currently similar to any other type of acute migraine
focuses on stopping the migraine as it progresses. The earlier the treatment is given,the better the result All drugs should be considered on basis of therapeutic trial because responses of each individual women vary Rest in dark , quiet room Analgesic antiemetic drugs-- Dopamine antagonist antiemetics, such as metoclopramide and prochlorperazine, are effective, even if nausea is not prominent. Vasoconstrictor drugs (if prolonged , severe attack) caffeine (cerebral vessels vasoconstrictor) 5-HT1 agonists a class of new drugs called Triptans a class of old drugs eg ergot alkaloid agents
Triptans
Triptans can be divided into 2 groups: Group I: fast onset, relatively high headache response and pain free rates at 2 hours sumatriptan (Imitrex, Imigran), zolmitriptan (Zomig, Zomigon, Ascotop), rizatriptan (Maxalt), almotriptan (Axert, Almogran), and eletriptan (Relpax). Group II: slower onset and lower efficacy rates. naratriptan (Amerge, Naramig) and frovatriptan. Precautions: NOT to be given to pregnant or lactating women. Contraindicated in Ischemic heart disease, Prinzmetal angina Uncontrolled hypertension Decreased arterial flow, Raynaud's disease Impaired hepatic function Ingestion of any ergotamine-containing medication. within 24 hours (DHE, methysergide, ergotamine tartrate etc). MAO inhibitor use within 2 weeks Hypersensitivity to sumatriptan Basilar or hemiplegic migraine Age over 50, particularly males Cerebrovascular disease
Ergot derivatives
The ergot derivatives can be effective for both prophylaxis and treatment of menstrual migraine DHE is a serotonin receptor agonist with strong binding at the 5-HT1 receptor subtypes. Stimulation of these receptors constricts cerebral blood vessels, thus relieving headache. Methylergonovine maleate (Methergine), 0.4 mg orally followed by 0.2 mg three times a day for 2 days, may provide prophylaxis Dihydroergotamine (DHE) mesylate DHE is a serotonin receptor agonist with strong binding at the 5-HT1 receptor subtypes. Stimulation of these receptors constricts cerebral blood vessels, thus relieving headache. (D.H.E.) is used for acute moderate to severe pain; it is given parenterally (1 mg subcutaneously or intramuscularly or 0.5 mg intravenously), up to a maximum of 3 mg over 24 hours Metoclopramide (Maxolon, Octamide PFS, Reglan), 10 mg intravenously, can be given before DHE to provide relief from any associated nausea and vomiting.
Symptomatic therapy
focuses on treating the symptoms that result from migraines. analgesic For mild to moderate pain Acetaminophen with or without caffeine NSAIDs For moderate to severe pain NSAIDs Sumatriptan succinate (Imitrex DHE, dihydroergotamine mesylate; Agents for severe episodes Opioid agonists and antagonists narcotics neuroleptics (eg, chlorpromazine hydrochloride Antiemeticsused to relieve nausea and vomiting Sedatives Steroids Ergot-containing substances Serotonin agonists
severity
severity mild Migraine Headache Moderate Migraine Headache Severe Migraine Headache 4-6 hours <4 hours last <2 hours TTT analgesics (Aspirin, Acetaminophen , NSAIDS ) , Antiemetic refractory to above give Antiemetic , analgesics , Triptan agents . refractory to above give Other Antiemetic , Serotonin Agonist (Dihydroergotamine , Triptans) refractory to above Emergency ttt
6 to 72 hours
status migrainosus
over 72 hours
Mild migraine Simple analgesics NSAIDs Isometheptene (Midrin, etc.) Metoclopramide (Reglan) may be added to reduce nausea and enhance drug absorption Moderately severe migraine NSAIDs Isometheptene Ergotamine, oral or intranasal Sumpatriptan (Imitrex), oral or intranasal Zolmitriptan (Zomig), oral Naratriptan (Amerge), oral Rizatriptan (Maxalt), oral DHE, intranasal With oral agents, metoclopramide may be added to reduce nausea and enhance drug absorption Severe migraine Ergotamine plus an antiemetic, both administered by suppository Sumatriptan, subcutaneous injection, intranasal or oral Zolmitriptan, oral Naratriptan, oral Rizatriptan, oral DHE, intramuscular or intranasal Extremely severe migraine Ketorolac (Toradol), 60 mg intramuscularly DHE, intravenous, plus metoclopramide Dopamine antagonist Opioids
Tension headache Family history site Character Nausea, vomiting Awaken from sleep Uni or bilateral Dull aching rarley
Response to ergot
Favourable
There is much overlap between symptoms of migraine and tension headache And many patient suffer from both
Until researchers discover a cure, individuals can take precautions and communicate their symptoms to their healthcare providers to find relief from migraine attacks.