Migraine - Overview & Management

2. What is a Migraine?
• A migraine is a severe painful headache
that is often preceded or accompanied
by sensory warning signs such as flashes
of light, blind spots, tingling in the arms
and legs, nausea, vomiting, and increased
sensitivity to light and sound. The
excruciating pain that migraines bring
can last for hours or even days.

3. History of Migraines
• Have been with us for at least 7,000 years.
• In ancient Greece, Galen attributed these
painful headaches as “ascent of vapors” or
humors from the liver to the brain. He called
them Hemicranias.
• Hemicrania Megrim Migraine
• In the 17th century, the idea of rising humors
was replaced by increased blood flow.
• In the 1980s, Harold G. Wolff of New York-
Presbyterian Hospital, said that migraine pain
stems from the dilation and stretching of brain
blood vessels, leading to the activation of pain-
signaling neurons.

4. What Actually Happens During a Migraine?
THEORIES
• Vascular Theory
Brain Scans suggest that Migraines arise from an
increase in blood flow of about 300% preceding the
headache.
• Neurogenic Theory
Spreading depression of cortical electrical activity
followed by vascular phenomena.

5. 4 PHASES OF A MIGRAINE
• Prodrome
• Aura
• Headache
• Postdrome

6. Cortical Spreading Depression
• Wave of hyperactivity followed by a wave
of inhibition and it usually occurs in the
visual cortex.
• 2-6mm per wave
• This is what is thought to happen during
migraines with aura.

7. Neurogenic Inflammation
Retrograde Transmission In Afferent
Nerves
Release of Mediators
(5-HT,Neurokinin,SubstanceP,CGRP,NO)
Vascular Phenomena

8. Prodrome
• Stage of Migraine that is characterized
by difficulty concentrating, yawning,
fatigue and/or sensitivity to light and
noise.
• Duration: A few hours to a few days

9. Aura
• Stage of migraine that is characterized by
visual illusions of sparks and lights, often
followed by blind or dark spots in the same
place as the bright hallucinations
• Duration: 20-60 minutes

10. Headache
• Stage characterized by excruciating or
throbbing pain along with sensitivity to light
and sound.
• May be accompanied by nausea and
vomiting
• Sometimes only half of the head or part of
the head is in pain.
• Duration: 4 – 72 hours

11. Postdrome
Characterized by:
• sensitivity to light and movement
• Lethargy
• Fatigue
• Difficulty focusing
• Also called a “zombie phase”
• Duration: A few hours to a few days

12. Ways to Treat Migraines
• Avoiding Trigger Factors
• Simple Non-Drug Treatment
• Pain Medications
• Prophylactic Medications
• “Abortive Medications”
(acute, specific medications)

13. Avoiding Trigger Factors
• For reasons unknown, migraines can be
set of by many factors like alcohol,
perfume, dehydration, excessive exercise,
menstruation, stress, weather changes,
seasonal changes, allergies, lack of sleep,
altitude, flickering lights and hunger.

14. Simple Non-Drug Treatments
• Ice to head
• Heat to head
• Massages

15. Drug Therapy
Drug Therapy has to be Induvidualized
based on
• Severity
• Frequency of Attacks
• Response of an Induvidual to a Drug

16. Based on Severity and
Frequency the attacks can be
classified into
 Mild Migraine
 Moderate Migraine
 Severe Migraine

17. Mild Migraine
Cases having fewer than oneattack per month of throbbing but
tolerableheadache lasting upto 8 hours
Medications:
 Simple analgesics like Paracetamol (0.5–1 g) or aspirin (300–600
mg)
 Nonsteroidal antiinflammatory drugs(NSAIDs) and their
combinations
• Ibuprofen (400–800 mg 8 hourly),
• Naproxen (500mg followed by 250 mg 8
hourly),
• Diclofenac(50 mg 8 hourly),
• Mephenamic acid (500 mg 8 hourly)
 Antiemetics
• Metoclopramide (10 mg oral/i.m.)
• Domperidone(10–20 mg oral)
• Prochlorperazine (10–25 mg oral/i.m.)

18. Moderate Migraine
Throbbing headache is more intense, lasts for 6–24 hours, nausea/vomiting
and
other features are more prominent and the patient is functionally impaired.
Simple Analgesics are not Effective so
Stronger NSAID’S are used.
Specific Drugs like Triptans and Ergot
Preparations with AntiEmetics are used.

19. Severe Migraine
2–3 or more attacks per month of severe throbbing
headache lasting 12–48 hours
Analgesics/NSAIDs and their combinations
usually do not afford adequate relief. So Specific
AntiMigraine Drugs are used such as
 Ergotamine
 Dihydroergotamine
 Sumatriptan
 Rizatriptan..,etc

20. Ergotamine
(Oral/Sublingual)
• Most Effective Ergot Alkaloid for Migraine.
• Given Early in attack, Relief is often Dramatic and Lower
Doses Suffice
M/A:
Ergotamine acts by constricting the dilated cranial
vessels and/or by specific constriction of carotid A-V shunt
channels
• These actions appear to be mediated through partial
agonism at 5-HT1D/1B receptors in and around cranial
vessels.
• Dihydroergotamine (DHE) preferred for parenteral
administration because injected DHE is less hazardous.

21. Triptans
(Selective 5-HT1D/1B agonists)
• First Line Drugs for Patients who Fail to
Respond to Analgesics
Ex: Sumatriptan,Rizatriptan,

22. Sumatriptan
• Sumatriptan is as effective and better tolerated
than ergotamine.
M/A:
• Antimigraine activity of sumatriptan has been
ascribed to 5-HT1D/1B receptor mediated
constriction of dilated cranial blood vessels,
especially the arterio-venous shunts in the
carotid artery, which express 5-HT1D/1B
receptors.
• Dilatation of these shunt vessels during migraine
attack is believed to divert blood flow away from
brain parenchyma.

23. • Pharmacokinetics - Sumatriptan is absorbed
rapidly and completely after s.c. injection. Oral
bioavailability averages only 15%.
Side effects - Tightness in head and chest, feeling of heat
and other paresthesias in limbs, dizziness, weakness are
short lasting, but dose related side effects
• Contraindications - Ischaemic heart
disease,hypertension, epilepsy, hepatic or renal
impairment and pregnancy are the contraindications.
Patients should be cautioned not to drive

24. PROPHYLAXIS OF MIGRAINE
Regular medication to reduce the frequency and/or severity
of attacks is recommended for moderate-to-severe migraine
when 2–3 or more attacks occur per month.
 B-Adrenergic blockers (Propranolol,Timolol, metoprolol,
atenolol)
 Tricyclic antidepressants (Amitriptyline)
 Calcium channel blockers (Verapamil,Flunarizine)
 Anticonvulsants (Valproic acid and Gabapentin)
 5-HT antagonists (Methysergide and Cyproheptadine)

25. β-Adrenergic blockers
• Propranolol is the most commonly used drug: reduces
frequency as well as severity of attacks in upto 70%
patients
• The starting dose is 40 mg BD, which may be increased
upto 160 mg BD if required.
• Nonselective (timolol)
• β1 selective (metoprolol, atenolol) agents are also
effective.
• Pindolol and others having intrinsic sympathomimetic
action are not useful.

26. Tricyclic antidepressants
Amitriptyline (25–50 mg at bed time)
Produces more side effects than
propranolol
Antimigraine effect is independent of
antidepressant property
 better suited for patients who suffer from
depression.

27. Calcium channel blockers
• Verapamil
• Flunarizine
• Frequency of attacks is often reduced
• claimed to be a cerebro-selective Ca2+ channel
blockerreducing intracellular Ca2+ overload due
to brain hypoxia and other causes.
• Side effects : sedation, constipation, dry mouth,
hypotension, flushing,weight gain and rarely
extrapyramidal symptoms

28. Anticonvulsants
• Valproic acid (400–1200mg/day)
• Gabapentin (300–1200 mg/day)
• Topiramate
• Efficacy of anticonvulsants in migraine is
lower than that of β blockers.
• Indicated in patients refractory to other
drugs or when propranolol is
contraindicated.

29. 5-HT antagonists
• The prophylactic effect of
methysergide and cyproheptadine is
less impressive than β Blockers.
• They are rarely used now for
migraine

30. Hey My
Migraine is
Goneeeee!!!!!..