This document provides information on migraine including classification, pathophysiology, treatment of acute attacks, and preventive therapy. It notes that migraine is a recurrent headache disorder characterized by attacks lasting 4-72 hours with symptoms like throbbing pain and sensitivity to light/sound. Treatment involves analgesics, triptans, or ergot derivatives for acute attacks and medications like propranolol, amitriptyline or topiramate for prevention. The pathophysiology involves dilatation and constriction of cranial blood vessels triggered by the trigeminal nerve.

2. • Clinical Manifestations, Differential
Diagnosis & Classification
• Pathophysiology
• Treatment of Acute Attack
• Preventive Therapy
• Non Pharmacological
• Pharmacological

3. • Migraine is a common,chronic,incapacitating
neurovascular disorder characterized by
recurrent attacks of throbbing headache
• May or may not be associated with aura
• Headache without aura (common migraine) is
associated with nausea ,vomiting ,photophobia ,
phonophobia , visual disturbances
• Aggravated by emotional,physical stress,lack or
excess sleep, missed meal ,alcohol ,food,
menstruation and OCP.

4. FOOD ITEMS

5. • If not treated, attack last 4-72 hours
• May start at any age
• Common early to middle adolescence
• One year prevalence 11%
• 6% among men
• 15-18% among women
• 10% have weekly attacks
• 20% attacks lasting 2-3 days.

6. • Differential Diagnosis
• Cluster headache
– Middle age men, unilateral
– Occur at night, at same time, days, weeks or
months
– Associated with red eye, tearing ,nasal
congestion and Horner's syndrome.
• Tension headache
– Constant daily headache
– Aggravated by stress, fatigue,noise
– No aura

7. • Classification
– Common migraine (without aura) 65%
– Classical migraine (with aura) 15%
• Lateralized throbbing headache
• Often give a family history of migraine
– Combined type 15%
– Only aura without pain 5%

8. • Basilar artery migraine:
Uncommon variant with
* Blindness or visual disturbance
* Dysarthria
* Tinnitus
* Vertigo
* Distal paraesthesia
* Transient loss or impairment of
consciousness or confusion
• It is followed by throbbing occipital headache
often with nausea and vomiting

9. • Ophthalmoplegic migraine:
* It is rare
* Lateralized pain in the orbit
* Ophthalmoplegia due to 3rd
and
6th
nerve palsy
* Ophthalmic division of 5th
nerve
may also be involved
* Symptoms outlast days or
weeks

10. Modified Diagnostic criteriaModified Diagnostic criteria
For common migraine (Without aura)For common migraine (Without aura)
• Migraine is defined as episodic attack of
headache lasting 4-72hrs
• With 2 0f the following symptoms
• Unilateral pain
• Throbbing
• Aggravation on movement
• Pain of moderate or severe intensity
• And one of the following symptoms
– Nausea or vomiting
– Photophobia or phonophobia

11. PathophysiologyPathophysiology
• Pain sensitive structures in the
cranium
– Extracranial vessels
– Proximal intracranial vessels
– Dura matter
• Pain mechanism
– Cranial blood vessels
– Trigeminal innervations of cranial vessels
• Calcitonin gene related peptide/ neurogenic
inflammation in the dura
– Connection between trigeminal system

12. – Neural events results in dilatation of blood
vessels
– Dysfunction of ion channels in the brainstem
nuclei that modulate cranio-vascualar afferent
– Cranial parasympathetic out flow -
vasodilatation - pain
PathophysiologyPathophysiology

13. – Dilatation of intracranial vessels -Short phase
of hyperemia causes flashing of lights
– Trigeminal nerve (sensory input)
– Trigeminal ganglion - trigeminocervical
complex
– Thalamus – parasympathetic out flow
– Constriction of intracranial blood vessles -
Oligemia that pass across the cortex,
resulting in depressed neuronal function aura

14. Trigemino vascular inputTrigemino vascular input

15. PathophysiologyPathophysiology

16. PathophysiologyPathophysiology
• Genetic factors
• Familial hemiplegic migraine
– Mutation in voltage gated Ca channels have
been identified
– Other ion channels may be involved in
migraine without aura

17. TreatmentTreatment
Acute attack
Preventive therapy

18. TreatmentTreatment
• Acute attack
–Analgesics and NSAIDS
–Metochlopramide / Sedatives
–Ergot derivatives
–Triptans
–methysergide

19. Analgesics and NSAIDSAnalgesics and NSAIDS
– Most respond well to simple Rx
– Should take at the onset of headache
– Adequate doses (Aspirin 900mg, Ibuprofen
400-800mg)
– Anti emetics: facilitate the absorption of 1ry
drug
– Overuse of drug to be avoided
– Maintaining headache diary
– Severity and the response may vary with each
attack

20. Ergot derivativesErgot derivatives
• Ergot derivatives
– Long experience
– Disadvantages
• Complex pharmacology
• Erratic
pharmacokinetics
• Lack of evidence on
effective dose
• Adverse vascular events
• High risk of overuse
syndrome
• Rebound headache
• Dose
– 1 to 2 mg at the onset
of headache, followed
by 1mg every 30
minutes
– Up to 6mg per attack
– Upton 10mg per week
Contridications
pregnancy, PVD, IHD

21. TriptansTriptans
• 5HT1B/1D receptor agonist
• Expensive/Restriction on presence of
Cardiovascular disease
• Advantages
– Selective pharmacology
– Simple and consistent pharmacokinetics
– Evidence based prescription instructions
– Efficacy based on well controlled trials
– Moderate side effects
– Well established safety records

22. Triptans - actionsTriptans - actions
• Cranial vasoconstriction
• Peripheral neuronal inhibition
• Inhibition of transmission of the 2nd
order
neurons of trigeminal cervical complex
• Via 5Ht 1B / D receptors
These actions
inhibit the effects of nociceptive trigerminal
afferents and control the acute attack of
migraine

23. Triptan - actionsTriptan - actions

24. TriptansTriptans
• Sumatriptan 50-100mg
• Rizatriptan 10mg More effe
• Eletriptan 80mg
• Naraptriptan 2.5mg
• Zolmitryptan
• Almotriptan

25. TriptansTriptans
• Sumatriptan
– Improvement in headache in 2hrs – 55-65%
– Headache free at 2hrs - 25-35%
– sc, intra nasal,rectal and oral
Side effects
Tingling paresthesia ,sensation of warmth
Dizziness ,flushing, neck pain, stiffness
Contraindicated in IHD,CVA ,HT (uncontrolled)

26. Preventive therapyPreventive therapy
• Non pharmacological
• Keeping a diary. Time/ duration/activity/food
• Regular meals / type of food
• Extremes of temperature
• Sleep
• Gentle massage-pressing temporal artery
• Hot or cold compresses
• Relaxation
• meditation

27. Preventive therapyPreventive therapy
• Pharmacological – when to start
– Patient’s selection
– Consider if >2attacks/month
– If >5 attacks consider seriously
– Frequency – increasing frequency
– Duration
– Severity: Migraine severity assessment score
(MIDAS)
– Nonspecific, moderate efficacy, substantial side
effects

28. Preventive therapyPreventive therapy
Proven or well accepted
• Propranolol 40-120mg BD
• Amitryptiline 25-75mg/D
• Valproate 400-600mg BD
• Flunarizine 5-15mg/d
• Serotonin antagonist: Pizotifen 0.5-3mg/d

29. Preventive therapyPreventive therapy
Widely used with poor evidence of
benefit
• Verapamil 160 -320 mg/d
• SSRI

30. Preventive therapyPreventive therapy
Promising results
• Gabapentine 900-2400mg/d
• Topiramate 25-200mg/d

31. • Chinese restaurant syndrome
• Caused by monosodium glutamate /a food
additive
• Pain in the forehead, temple, tightness
around the face
• Hot dog headache
• Bacon ,ham- as a result of eating cured
meat.
• Frontal headache / throbbing /after ½ hour
• Flushing and redness of face
• People with migraine are more prone

32. • Ice cream headache
• Sharp pain after eating cold food/ cool
drink
• Local pain in palate/throat/face/head
• People who are more prone to migraine
are three times more likely to suffer from
this.