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  1. 1. MIGRAINE- Dr. Raajit Chanana 1
  2. 2. Introduction∗ Migraine headache is a complex recurrent headache that is one of the most common complaints in medicine. 2
  3. 3. Classification of Migraine 3
  4. 4. Migraine with Aura 4
  5. 5. Childhood periodic syndromes that are commonly precursors of migraine 5
  6. 6. Complications of migraine 6
  7. 7. Probable Migraine 7
  8. 8. Pathophysiology Vascular theoryIt was believed that ischemia induced by intracranial vasoconstriction is responsible for the aura of migraine and the subsequent rebound vasodilation and activation of perivascular nociceptive nerve resulted in headache.Based on 3 observations -:1. Extracranial vessels become distended and pulsatile during an attack2. Stimulation of an intracranial vessels in an awake person induces headache3. Vasoconstrictors improve the headache and vaso dilators provoke an attack 8
  9. 9. Patho Physiology contd… Neurovascular theory∗ Complex series of neural and vascular events initiates migraine∗ Migraine is primarily a neurogenic process with secondary changes in cerebral perfusion Cortical spreading depression∗ CSD is a well defined wave of neuronal excitation in the cortical grey matter that spreads from its site of origin at the rate of 2- 6mm/min∗ This cellular depolarization causes the primary cortical phenomenon aura phase, in turn, it activates trigeminal fibers causing headache. 9
  10. 10. Patho Physiology contd… Vasoactive substances and Neurotransmitters∗ Perivascular nerve activity results in release of substances such as substance P, neurokinin A, CGRP and NO which produce vessel dilation, protein extravasation and sterile inflammation stimulating the trigeminocervical complex. Cutaneous Allodynia∗ Secondary pain pathways of the trigeminophthalamic system become sensitized during a migraine attack. 10
  11. 11. Patho Physiology contd… Dopamine pathway∗ Some of the symptoms associated with migraine such as nausea, vomiting, yawning, hyperactivitycan be attributed to dopaminergic stimulation. Endothelial dysfunction Serotonin and migraine∗ Plasma extravasation mediated by vasoactive substances is blocked by ergots, sumatriptan, indomethacin, GABA agonists and benzodiazepines∗ 5HT-1D receptors in trigeminal sensory neurons and 5HT 1B receptors are present on smooth vessels in the meningeal vessels 11
  12. 12. Etiology∗ Approx 70% of patients have a first degree relative with a history of migraine. Familial Hemiplegic Migraine∗ Migraine with aura that is preceded or followed by hemiplegia that typically resolves∗ FHM type 1 - Linked to mutations in the calcium channel gene – chromosome 19.May be associated with cerebellar ataxia∗ FHM type 2 - mutation in the sodium channel gene ATP1A2 on chromosome 3∗ FHM type 3- mutation in a sodium channel alpha subunit coding gene 12
  13. 13. Etiology contd… Migraine in inherited disorders -:1. MELAS (mitochondrial myopathy, encephalopathy and lactic acidosis)2. CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)3. Genetic vasculopathies like RVCL (retinal vasculopathy with cerebral leukodystrophy) etc. 13
  14. 14. Epidemiology∗ Migraine accounts for 64% of severe headaches in females and 43% of severe headaches in males. Migrain Without Aura Migraine with Aura Boys Girls Boys Girls Peaks at 5 years 12-13 years 10-11 years 14-17 years∗ In individuals >12yr of incidence increases with age, reaching a peak at 30-40 yrs∗ F:M = 3.5:1 at 40yrs 14
  15. 15. Clinical presentation History∗ U/L, throbbing or pulsatile localized in the frontotemporal and ocular areas but be felt anywhere around the head or neck.∗ Pain builds over 1-2 hrs and become diffuse.∗ Many patient prefer to lie in dark room Other symptoms∗ Nausea, vomiting, anorexia and food intolerance occur in about 50 % of patients. Photophobia and phonophobia are commonly associated with headache.∗ Hemiparesis, confusion, apathy 15 numbness. and
  16. 16. Clinical presentation contd… Prodrome∗ About 60% of patients report premonitory symptoms that occur hours to days before headache onset.∗ Heightened sensitivity to light, sounds and odors.∗ Lethargy or uncontrollable yawning.∗ Food cravings∗ Mental and mood changes∗ Excessive thirst and polyuria∗ Anorexia∗ Constipation or diarrhea 16
  17. 17. Aura∗ It is a complex of neurologic symptoms that may precede or accompany the headache phase or may occur in isolation.∗ Usually develops over 5-20min and lasts less than 60 minutes.∗ Can be visual, sensory, motor or combination of these Negative symptoms -:∗ Negative scotoma∗ Negative visual phenomenon such as homonymous hemianopia, central scotoma, tunnel vision, altitudinal visual defects etc. 17
  18. 18. Aura contd… Positive symptoms∗ Scintillating scotoma-highly characteristic of migraine∗ Photopsia or flashes of light∗ Heat waves∗ Micropsia, macropsia Paresthesia Occurring in 40%of cases constitute the next most common aura.∗ Sensory symptoms rarely occurs in isolation and usually follows visual aura.∗ Motor symptoms may occur in 18% of patients∗ Speech and language disturbances have been reported in 17-20% of patients 18
  19. 19. Scintillating Scotoma 19
  20. 20. Central Scotoma 20
  21. 21. Multiple spotty scotoma 21
  22. 22. Half visual field loss 22
  23. 23. Migraine triggers∗ Stress∗ Excessive or insufficient sleep∗ Medications (OCP, vasodilators)∗ Strong odors eg. perfumes, cologne etc.∗ Hormonal changes such as pregnancy, menstruation∗ Head trauma∗ Weather changes∗ Metabolic or infectious disease∗ Physical exertion∗ Cold stimulus eg. ice cream 23
  24. 24. Migraine triggers contd…∗ Foods containing tyramine may provoke migraine1. Aged cheese2. Yogurt3. Bananas4. Vinegar5. Beans6. Peanuts 24
  25. 25. ∗ Family history∗ Approx 70% of patients have a first-degree relative with a history of migraine∗ Disability assessment∗ Simple questionnaires like MIDAS migraine disability assessment can be used to quantify the disability and for follow up 25
  26. 26. Physical Examination∗ Thorough neurologic examination is essential, results will be normal in majority∗ Possible findings may include∗ Cranial/cervical muscle tenderness∗ Horner syndrome∗ Tachycardia/ bradycardia∗ Conjunctival injection∗ Hypertension/hypotension∗ Hemisensory/ hemiparetic neurological deficits ( complicated migraine) 26
  27. 27. Physical Examination contd…∗ Findings that suggest a headache diagnosis other than migraine∗ Dim scotoma lasting a few seconds to several minutes ie amaurosis∗ Temporal artery tenderness∗ Meningisnus∗ Mental status changes∗ Focal neurologic deficit eg confusion, seizures 27
  28. 28. Physical Examination contd…∗ Focal neurologic findings that occur with headache and persist temporarily after the pain resolves suggests a migraine variant∗ U/L paralysis or weakness-hemiplegic migraine∗ Aphasia, dysarthria, vertigo, tinnitus, syncope, balance problems-basilar migraine∗ Third nerve palsy with sparing of pupillary response- ophthalmoplegic migraine 28
  29. 29. Diagnostic criteria∗ Migraine without aura Diagnostic criteria: A. At least 5 attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following characteristics: 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of routine physical activity (eg. walking or climbing stairs) 29
  30. 30. Diagnostic criteria contd…∗ D. During headache at least one of the following: 1. nausea and/or vomiting 2. photophobia and phonophobia∗ E. Not attributed to another disorder 30
  31. 31. Migraine with auraDiagnostic criteria -:A. At least 2 attacks fulfilling criterion BB. Migraine aura fulfilling criteria B and C for one of the subforms 1.2.1-1.2.6 as per the IHS classificationC. Not attributed to another disorder 31
  32. 32. Typical aura with migraine headacheA. At least 2 attacks fulfilling criteria B–DB. Aura consisting of ≥1 of the following, but no motor weakness: 1. fully reversible visual symptoms including positive and/or negative features 2. fully reversible sensory symptoms including positive and/or negative features 3. fully reversible dysphasic speech disturbance 32
  33. 33. Typical aura with migraine headache contd…C. At least two of the following: 1. homonymous visual symptoms and/or unilateral sensory symptoms 2. at least one aura symptom develops gradually over ≥5 min and/or different aura symptoms occur in succession over ≥5 min 3. each symptom lasts ≥5 and ≤60 minD. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 minE. Not attributed to another disorder 33
  34. 34. Complications of migraine∗ Chronic migraine Migraine headache that occurs more than 15 days a month for greater than 3 months∗ Status migrainosus Migraine attacks persists for >72 hours.∗ Persistent aura ( 30-60 min ) without infarction∗ Migrainous infarction∗ Migraine triggered seizures 34
  35. 35. Work up∗ Migraine is a clinical diagnosis.∗ Diagnostic investigations are performed due to following reasons∗ Exclude structural, metabolic and causes of heada∗ Rule out comorbid disease that could complicate headache and its treatment 35
  36. 36. ∗ Neuroimaging is usually not necessary except∗ Onset of migraine after 5o years of age∗ change in the pattern of previous migraine∗ First or worst severe headache∗ New onset of headache in a patient with cancer or HIV patient∗ Headache with an abnormal neurologic examination∗ Headache with fever∗ Migraine and epilepsy∗ New daily persistent headache∗ Escalation of headache frequency/intensity in the absence of medication overuse headache∗ Posteriorly located headaches in children 36
  37. 37. ∗ Visual field testing should be performed in patients with persistent visual phenomenon∗ Indications for lumber puncture include -:1. First or worst headache of a patients life2. Severe, rapid onset, recurrent headaches3. Progressive headaches4. Atypical chronic intractable headaches 37
  38. 38. Management∗ Acute attack∗ Preventive 38
  39. 39. General principles of management∗ Establish a diagnosis.∗ Educate migraine sufferers about their condition and its treatment.∗ Encouraging patients to track their own progress through the use of diary cards, flow charts, headache calendars and frequency and severity of attacks, the presence and degree of temporary disability, and associated symptoms such as nausea and vomiting.∗ Create a formal management plan and individualize management. Consider comorbidity/coexisting conditions (such as heart disease, pregnancy, and uncontrolled hypertension). 39
  40. 40. General principles of management contd..∗ Encourage the patient to identify and avoid triggers.∗ Guard against medication-overuse headache (“rebound headache” or “drug-induced headache”). Frequent use of acute medications (ergotamine [not DHE], opiates, triptans, simple analgesics, and mixed analgesics) is generally thought to cause medication-overuse headache.∗ Use migraine-specific agents (triptans dihydroergotamine [DHE]) in patients with moderate or severe migraine or whose mild-to- moderate headaches respond poorly to nonsteroidal anti- inflammatory drugs (NSAIDs) or combinations such as aspirin plus acetaminophen plus caffeine 40
  41. 41. Acute TreatmentGoals of acute migraine treatment are as follows:∗ Treat attacks rapidly and consistently without recurrence.∗ Restore the patient’s ability to function.∗ Minimize the use of back-up and rescue medications. (A rescue medication is used at home when other treatments fail and permits the patient to achieve relief without the discomfort and expense of a visit to the physician’s office or emergency department.)∗ Be cost-effective for overall management.∗ Have minimal or no adverse events 41
  42. 42. Specific medicationsTriptan (serotonin 1B/1Dreceptor agonists)∗ Effective and safe∗ acute management∗ Appropriate initial choice in patients with moderate to severe migraine∗ Routes-oral, subcutaneous and nasal∗ Drugs – sumatriptan-50-100mg tablet at onset , may repeat after 2hour (max 200mg/d)∗ Rizatriptan –most efficacious, early onset of action, 5-10 mg tablet at onset may repeat after 2hr max 30mg/d)∗ Naratriptan, almotriptan,frovatriptan, zolmitriptan 42
  43. 43. Specific medications contd…∗ Triptans should not be used more than 3 days weekly to avoid transformed migraine and medication overuse headache∗ Caution-avoid in patients of CAD∗ Adverse effects∗ Paresthesia, jaw or neck tightness, warm/cold sensation etc. 43
  44. 44. Specific medications contd…∗ Ergot alkaloids and derivatives-nonselective 5-HT1 agonists)∗ Ergotamine PO/PR (and caffeine combination) may be considered in the treatment of selected patients with moderate to severe migraine.∗ Dose 2mg PO, f/b 1-2mg every 30 min until attack is aborted, no more than 6mg/day∗ Adverse effects-vasospasm, angina, tachycardia, numbness of extremities, rebound headache, ergotism, gangrene etc 44
  45. 45. Specific medications contd…∗ Dihydroergotamine- alpha adrenergic blocking agent with a direct stimulating effect on smooth muscle of peripheral and cranial blood vessels. It is a non selective 5-HT1 agonist∗ Route- iv or nasal∗ Dose- 1mg iv/im repeated 1 hrly , no more than 3 mg for im and 2mg for iv∗ Nasal-1 spray 0.5mg in each nostril not more than 6 sprays/24hr∗ DHE nasal spray is safe and effective for the treatment of acute migraine attacks and should be considered for use in patients with moderate to severe migraine∗ DHE IV plus antiemetics IV is an appropriate treatment choice for patients with severe migraine 45
  46. 46. Non specific medications Antiemetics -:∗Oral antiemetics are an adjunct to treat nausea associated withmigraine .∗Metoclopramide IM/IV is an adjunct to control nausea and may beconsidered as IV monotherapy for migraine pain relief∗Prochlorperazine IV, IM, and PR may be a therapeutic choice formigraine in the appropriate setting∗Chlorpromazine IV∗ Serotonin receptor (5-HT3) antagonists may be considered asadjunct therapy to control nausea in selected patients with migraineattacks 46
  47. 47. Non specific medications contd…∗ NSAIDs, nonopiate analgesics, and combination analgesics.∗ Acetaminophen, alone, is not recommended for migraine .∗ NSAIDs (oral) and combination analgesics containing caffeine are a reasonable first-line treatment choice for mild to moderate migraine attacks or severe attacks that have been responsive in the past to similar NSAIDs or nonopiate analgesics 47
  48. 48. Non specific medications contd…∗ Opiate analgesics.∗ Butorphanol nasal spray is a treatment option for some patients with migraine (Grade A). Butorphanol may be considered when other medications cannot be used or as a rescue medication when significant sedation would not jeopardize the patient∗ Other medications.∗ Isometheptene and isometheptene combination agents may be a reasonable choice for patients with mild-to-moderate headache .∗ Corticosteroids (dexamethasone or hydrocortisone) are a treatment choice for rescue therapy for patients with status migrainosus . 48
  49. 49. Preventive treatment May be considered when -:∗ Frequency of migraine is >2/months∗ Duration of individual attack is longer than 24hrs∗ Headache causes major disruption in patients lifestyle∗ Abortive therapy fails or is overused∗ Symptomatic medications are ineffective∗ Use of abortive medications more than twice a week∗ Migraine variants such as hemiplegic migraine 49
  50. 50. ∗ The goals of migraine preventive therapy are to1) reduce attack frequency, severity, and duration2)improve responsiveness to treatment of acute attacks3)improve function and reduce disability 50
  51. 51. Pharmacotherapy 5 principal classes of drugs are used -:∗ Antiepileptics∗ Antidepressants∗ Antihypertenseives∗ Serotonin antagonists∗ NSAIDS 51
  52. 52. ANTIEPILEPTICS∗ Well tolerated∗ Valproic acid is useful as afirst line agent.400-600 mg BD∗ Carbamazepine∗ Gabapentin∗ topiramate 52
  53. 53. ∗ ANTIDEPRESSANTS∗ Tricyclic antidepressants∗ Amitriptyline- 10-75mg at night∗ Nortriptyline Selective serotonin reuptake inhibitors∗ Fluoxetine∗ Other antidepressants∗ Bupropion, mirtazepine, trazodone, venlafaxine 53
  54. 54. ∗ ANTIHYPERTENSIVES∗ Beta-blockers∗ Propranolol -40-120mg BD∗ Timolol∗ Calcium channel blockers∗ Diltiazem∗ Nimodipine∗ Verapamil 54
  55. 55. SEROTONIN ANTAGONISTS Methysergide-1-4mg OD∗ Flunarizine5-15mg OD∗ NSAIDS∗ Aspirin∗ Mefenamic acid∗ Ibuprofen∗ Naproxen/naproxen sodium∗ Other∗ Magnesium∗ Vitamin B2 55
  56. 56. ∗ Special considerations∗ Direct special attention to women who are pregnant or want to become pregnant. Preventive medications may have teratogenic effects.∗ Take coexisting conditions into account. Some (comorbid/coexisting) conditions are more common in persons with migraine.∗ Eg-beta blocker are preferred in young anxious patients, hypertensive patients, history of angina∗ TCA’s are preferred in patients of depression, underweight∗ Valproic acid is preferred in patients of epilepsy and mania 56
  57. 57. Non-pharmacological treatment∗ Biofeedback∗ Cognitive-behaviour therapy∗ Relaxation therapy∗ AVOIDANCE OF MIGRAINE TRIGGERS∗ Complimentary and alternative therapy∗ Body work eg. massage∗ Creative arts eg. dance, music∗ Yoga∗ Acupuncture and acupressure 57
  58. 58. Thank You! 58