Migraine in general practice, clinical view

1. Prepared by : Dr. Ahmed Ibrahim Eldesouky Abouelela
Family Medicine Registrar
MBBch Alexandria university
Family Medicine Master degree
MRCGP.int

2. 35 years old female patient coming to your clinic
complaining of recurrent attacks of severe headache
over the last 4 months. She describes the headache like
unilateral, pulsating pain that last more than 6 hours.
The attacks are accompanied by nausea and some times
vomiting. During the attacks she like to site in a dark
room and can’t make any activity.

3. If a patient coming to your clinic with a complain of a
headache, what will make you suspect that it could be a
migraine

4.  The patient: female, between 20 and 50 years.
 The headache: recurrent, unilateral, pulsating, long
lasting, inhibiting or prohibiting daily activities.
 Association: aura symptoms (visual, sensory, speech or
motor), nausea, vomiting, photophobia and
phonophobia.

5. Migraine is not only a headache
Sometimes migraine present with other symptoms
 Unilateral weakness, vertigo, impaired visual
symptoms, confusion and even abdominal pain could
be symptoms of a migraine.

6.  Migraine is a primary headache disorder characterized
by a recurrent headache that is moderate to severe
felt as a throbbing pain on one side of the head.
 Migraine is derived from the Greek word meaning
‘pain involving half the head’.
 Affects at least 1 person in 10.
 It is more common in females (18% of women, 6%
men).
 It’s peaks between 20 and 50 years.
 The frequency of headaches reduces after the age of 50.

7.  Some people have migraine attacks frequently, that
reach up to several times a week.
 Other people only have a migraine occasionally
possible years to pass between migraine attacks.

8. There are several types of migraine, including:
 Classic migraine (migraine with aura).
 Common migraine (migraine without aura).
 Unusual forms of migraine.

9.  A complex of neurological symptoms that occurs
before, during the headache or in isolation.
 Appears gradually over few minutes and generally last
less than 60 minutes.
 Can be visual, sensory, motor or combination of these.
 Visual occur in up to 99% of cases (scotoma,
hemianopia)
 Sensory (unilateral paraesthesia)

12.  The exact cause of migraine is unknown, but thought to
be a result of abnormal brain activity temporarily
affecting nerve signals, chemicals and blood vessels in
the brain due to genetic causes.
 Many possible migraine triggers have been suggested,
including hormonal, emotional, physical, dietary,
environmental and drugs.

13.  Some women trigger migraines during their period.
 Some women only experience migraines during the
period, which is known as pure Menstrual migraine.
 Many women find their migraines improve after the
menopause
 Menopause can trigger migraines in some women.

14.  Emotional triggers: stress, anxiety, tension, shock, depression
and excitement.
 Physical triggers: tiredness, poor quality sleep, poor posture,
neck or shoulder tension, jet lag, low blood sugar (fasting) and
exercise.
 Dietary triggers: missed, delayed or irregular meals,
dehydration, alcohol, food contain tyramine, caffeine products,
such as tea and coffee, specific foods such as chocolate, citrus
fruit and cheese.
 Environmental triggers: bright lights, flickering screens, such
as a television or computer screen, smoking (or smoky rooms),
loud noises, changes in climate, such as changes in humidity or
very cold temperatures, strong smells and a stuffy atmosphere.
 Medications: oral contraceptive pills, HRT and some types of
sleeping tablets.

15.  There's no specific test to diagnose migraine.
 Diagnosis depends on the criteria of the headache and
history given by the patient.
 International Headache Society (IHS) criteria and
guideline consider to be the cornerstone of diagnosis of
migraine with it’s different types.

16. A. At least two attacks fulfilling criteria B and C.
B. One or more of the following fully reversible aura
symptoms: visual, sensory, speech and/or language, motor,
brainstem, retinal.
C. At least two of:
1 - at least one aura symptom spreads gradually over at
least 5 minutes.
2 - each aura symptom lasts 5–60 minutes.
3 - at least one symptom is unilateral.
4 - headache follows aura within 60 minutes.
D. Not attributable to another disorder including TIA.

17. A. The patient should have had at least five attacks fulfilling
criteria B and D.
B. The headaches last 4–72 hours.
C. The headache must have at least two of the following:
1 - unilateral location.
2 - pulsing quality.
3 - moderate or severe intensity, inhibiting or prohibiting
daily activities.
4 - headache worsened by routine physical activity.
D. The headache must have at least two of the following:
1 - nausea and/or vomiting.
2 - photophobia and phonophobia.
E. Not attributable to another disorder.

18.  Hemiplegic migraine.
 Basilar migraine.
 Retinal migraine.
 Migrainous (vestibular) vertigo.
 Migrainous stupor.
 Ophthalmoplegic migraine.
 Migraine equivalents.
 Menstrual migraine.
 Status migrainosus.

19.  Hemiplegic migraine is referred to as a “migraine
variant”.
 Hemiplegic simply means paralysis on one side of the
body.
 A person with hemiplegic migraine will experience a
temporary weakness on one side of their body as part
of their migraine attack.
 This can involve the face, arm or leg and be
accompanied by numbness, or pins and needles.
 The patient may experience speech difficulties, vision
problems or confusion.
 Symptoms are similar to those of a stroke and TIA
and need a careful differential diagnosis.

20.  This weakness may last from one hour to several days but
usually, it goes within 24 hours.
 The head pain associated with migraine typically follows
the weakness, but a headache may precede it or be absent.
 There are two types of hemiplegic migraine:
1 - Familial hemiplegic migraine (FHM).
2 - Sporadic hemiplegic migraine (SHM).
 It is vital to refer the patient to confirm the diagnosis by a
specialist.
 Some guidelines consider hemiplegic migraine as a subtype
of classic migraine.

21.  Basilar migraine is recognized as a type of classic
migraine.
 Caused by vasoconstriction, or narrowing of the blood
vessels.
 Attacks are a described as episodes of dizziness, vertigo or
vision changes like lack of coordination and double vision
with migraine.
 The symptoms may last just a few minutes to an hour.
 Unlike most other types of migraine, the pain is often in the
occipital region.
 Also, basilar migraine pain might not be a throbbing pain.

22.  Migraine may present with symptoms of visual loss.
 Associated headache and nausea may not be present.
 Clinical features
1 - Zigzag lines or lights
2 - Multicolored flashing lights
3 - Unilateral or bilateral field deficit
4 - Resolution within a few hours

23.  Migraine is a relatively common cause of vertigo and often
unrecognized because of its many styles.
 It should be suspected if there is:
1) History and/or family history of migraine.
2) History of recurrent bouts of spontaneous vertigo or
ataxia that persist for hours or days in the absence of aural
symptoms.
 Vertigo takes the place of the aura that precedes the
headache or may be a migraine equivalent whereby
vertigo replaces the symptoms of headache.
 Nausea and vomiting may be present.
 Pizotifen or propranolol are recommended for prophylaxis.

24.  Confusion is the key, which may precede or follow a
headache.
 During the confused period, the patient is inattentive
and distracted and has difficulty maintaining speech
and other motor activities.

25.  Ophthalmoplegic migraine is a very rare type of a
migraine occurs mainly in young people.
 Symptoms will be due to the weakness of one or more
of the muscles that move the eye.
 Symptoms include dilation of the pupils, inability to
move the eye upward, downward or across, as well as a
drooping of the upper eyelid together with a headache.

26.  Migraine that presents in a form other than head pain.
 A diagnosis of migraine equivalent is determined by:
1 - A previous history or family history of migraine
attacks.
2 - No evidence of organic or physical lesions.
3 - Replacement of normal headaches by an equivalent
group of symptoms.
 Although not common, most of migraine equivalent is
“abdominal migraine”, which is characterized by
recurrent episodes of vomiting and abdominal pain
without a headache mainly in female children.

27.  A migraine equivalent may be characterized by visual
symptoms such as blind spots, partial vision,
neurologic deficits, or psychic disturbances without a
headache.
 It is easier to diagnose if these symptoms had
previously accompanied attacks associated with
headaches, but often the elderly develop the visual
symptoms for the first time without head pain.

28.  A specific condition where the timing of attacks is
limited to the menstrual cycle.
 There is no aura and it can last longer than other types.
 Affect fewer than 10% of women.
 The two most accepted theories on the cause are:
1 - Withdrawal of estrogen as part of the normal
menstrual cycle.
2 - Release of prostaglandin during the first 48 hours
of menstruation.

29.  A migraine that lasts for more than 72 hours.
 Often need admission at least in 24 - hour admission
sitting to relieve the pain and dehydrate the patient.
 More common with a classic migraine

30.  Treatment of acute attack.
 Health education.
 Provide action plan.
 Prophylaxis life style and medication.

31.  Commence treatment at the earliest impending sign.
 Mild headaches may require no more than conventional
treatment and a good lie down in a quiet dark room.
 Rest in a quiet, darkened, cool room.
 Place cold packs on the forehead or neck.
 Avoid drinking coffee, tea or orange juice.
 Avoid moving around too much.
 Do not read or watch television.
 For patients who find relief from simply ‘sleeping off’ an attack,
consider prescribing temazepam or diazepam in addition to the
medication.
 For moderate attacks use oral ergotamine or sumatriptan and for
severe attacks use injection therapy.

32.  Aspirin or paracetamol.
 Paracetamol or ibuprofen (for children).
 Consider NSAIDs (e.g. ibuprofen, naproxen, diclofenac
rapid).
 Triptan preparation: tablet, nasal spray or SC injection
used in moderate to severe attacks.
 Ergotamine in case of severe attacks.
 If nausea and vomiting is a feature: metoclopramide or
prochlorperazine should be added to the treatment.

33.  Avoid triptans in patients with coronary artery disease,
Prinzmetal angina, uncontrolled hypertension or during
pregnancy.
 Stop triptans if chest pain develops.
 Use triptans with caution in patients taking SSRIs,
MAOIs and lithium.
 Do not use ergotamine preparations if sumatriptan used
in previous 6 hours, and do not use sumatriptan if
ergotamine preparations used in previous 24-hours.

34.  Personal action plan
http://www.fvfiles.com/521060.pdf
 School action plan
https://www.spx.org/upload/Clinic/Migraine_Action_Pl
an_15.pdf

35.  Non-drug self-management with avoidance of any
known trigger factors is the key.
 Consider prophylactic therapy for frequent attacks that
cause disruption to the patient’s lifestyle and well-
being.
 Certainly, consider it for weekly attacks and a poor
response to therapy for the acute attack.

36. The most commonly used drugs include:
 Beta-blockers: propranolol 40 mg (o) bd or tds
(max. 320 mg/day), metoprolol, atenolol
 Tricyclic antidepressants: amitriptyline
 Sodium valproate
 Pizotifen 0.5–2.0 mg at night
 Cyproheptadine (ideal for children)
 Clonidine

37.  Methysergide (reserve for unresponsive severe
migraine) 1 mg tds after food—up to 4 months only
 Calcium-channel blockers: nifedipine, verapamil
 NSAIDs: naproxen, indomethacin, ibuprofen
 MAOIs: phenelzine, moclobemide
 Sumatriptan
 Gabapentin
 Topiramate
 Botulinum toxin

38.  Naproxen 550 mg (o) bd, 48 hours before expected
attack for 4–10 days or
 Estradiol gel 1.5 mg transdermally, once daily for 7
days.

39. Select the initial drug according to the patient’s medical
profile:
 Low or normal weight / Food-sensitive migraine:
Pizotifen.
 Hypertensive or looks tension: Beta blocker.
 Depressed or anxious: Amitriptyline.
 Cervical spondylosis: Naproxen.
 Menstrual migraine: Naproxen or Mefenamic acid or
Ibuprofen or Estradiol transdermal gel.

40.  Each drug should be tried for 2 months before it is
judged to be ineffective.
 Amitriptyline can be added to propranolol, pizotifen or
methysergide and may convert a relatively poor
response to very good control.

42.  Migraine can be classified to:
A. Common, uncommon.
B. Classic, non classic.
C. Common, classical and unusual.
D. Common, classical, unusual and complicated.

43.  Triggers of Migraine include which of these:
A. Poor quality sleep.
B. Foods contain tyramine.
C. Changes in humidity or very cold temperatures.
D. All of the above.

44.  Migraine variant is referred to:
A. Migrainous (vestibular) vertigo.
B. Basilar migraine.
C. Hemiplegic migraine.
D. Ophthalmoplegic migraine.

45.  Episodes of dizziness, vertigo or vision changes like
lack of coordination and double vision with
migraine describe which types of unusual migraine:
A. Migrainous (vestibular) vertigo.
B. Basilar migraine.
C. Hemiplegic migraine.
D. Ophthalmoplegic migraine.

46.  In Migrainous stupor:
A. Confusion is the key symptom.
B. Vertigo is the key symptom.
C. Visual impairment is the key symptom.
D. Unilateral weakness is the key symptom.

47.  In treatment of acute migraine:
A. Ergotamine and sumatriptan can be combined
together.
B. Ergotamine and sumatriptan can’t be combined
together.
C. Ergotamine and sumatriptan can be used together
with some time space.
D. Ergotamine and sumatriptan can be combined
together just if metoclopramide is added.

48.  One of the best medication for Menstrual migraine
prophylaxis:
A. Estradiol gel 1.5 mg transdermally, once daily for 7
days.
B. Methysergide 1 mg tds after food.
C. Beta-blockers: propranolol 40 mg (o) bd or tds.
D. Pizotifen 0.5–2.0 mg at night.

49.  If Migraine prophylaxis medications was
recommended:
A. It should be tried for 1 month.
B. It should be tried for 2 months.
C. It should be tried for 3 months.
D. It should be tried for 4 months.

50. ‫االستماع‬‫حسن‬‫علي‬ ‫ا‬‫ر‬‫خي‬‫هللا‬ ‫اكم‬‫ز‬‫ج‬