A Short presentation on Migraines for Junior Doctors with Guideline Recommendations and Tips for treatment and approach.

1. Dept. of Medicine, AKMMCH
MIGRAINES
1

2. HEADACHES

3. “
*Global Burden of Disease Study 2013, Collaborators (22 August 2015), The Lancet
Headache is one of the most commonly
experienced of all physical discomforts.
Tension headaches are the most common,
affecting about 1.6 billion* people followed by
Migraines which affect about 848 million*
3

4. 4
CLASSIFICATION
OF HEADACHES*
*International Classification of Headache Disorders- 3rd Edition

5. 5
CLASSIFICATION OF
HEADACHES*
*International Classification of Headache Disorders- 3rd Edition

6. 6 6
RED FLAG SIGNS
REQUIRING FURTHER INVESTIGATIONS
• New Onset of Headache
Particularly in >50 year olds
• Headaches lasting ≥72hrs
Visual, Sensory or Language
symptoms lasting >1hr
• Escalation of headache
frequency/intensity in the
absence of medication
overuse headache
• Very Sudden onset
Headache/ Neurological
symptoms
• Abnormal Neurologic
Examination
• Associated fever, systemic
Illness or epilepsy
• Posterior Located
Headaches

7. MIGRAINES

8. “
*Peter J. Goadsby, Annals of Indian Academy of Neurology 2012 Aug
**Charles Andrew, Migraine: NEJM, 2017
Migraine is in essence a Familial, Episodic
disorder whose Key Marker is Headache, with
certain Associated Features.*
It is also associated with increased risks of several
other disorders, including asthma, stroke, anxiety
and depression, and other pain disorders**
8

9. 9
*PATHOPHYSIOLOGY OF MIGRAINE
1 2 3 4 5

10. • Unilateral (70%)
But may also be Bilateral
• Throbbing (Pulsating/
Banging in <18yrs) in
Character, Gradual Onset
• Headache lasts 4-72hrs (2-
72hrs<18yrs)
• Moderate-Severe Intensity
• May or may not be
associated with visual or
sensory Auras
• Nausea/ Vomiting
• Allodynia and avoidance of
routine activities
HISTORY
10

11. • Females are usually more
affected
• Episodes may occur
during Menstrution
• Peak Age: 35-39 years
• Skipped Meals
• Irregular Caffeine Intake
• Stress
• Lack of Sleep
• OCP
• SSRIs
• Nasal Decongestants
• PPIs
• Opioids
• Barbiturates
HISTORY
11

12. Premonitory
Phase
Mood Changes,
Fatigue, Unusual
Thirst
(Lasts 1-24 Hrs)
12
Aura
Visual, Sensory
or Speech
Disturbances
(Present in 70%
of Migraine
cases)
Headache
Gradual Onset
with Crescendo
Pattern
(Lasts 4-72
hours in adults,
2-72 hours in
children)
Resolution
Headache
gradually/
suddenly wears
off
Postdrome
Consists of
similar
symptoms as the
Premonitory
Phase
*PHASES OF MIGRAINE
1 2 3 4 5

13. 13
CLASSIFICATION OF
MIGRAINES*
*International Classification of Headache Disorders- 3rd Edition

14. AURA
A Reversible, Perceptual
Disturbance that is
experienced by SOME
individuals with Migraines
or a Seizures BEFORE the
Headache or Seizure
begins
AURANICE, 2015
AURAS INCLUDE
• VISUAL SYMPTOMS that may be positive
(eg. flickering lights, spots or lines)
and/or negative (eg. Partial vision loss)
• SENSORY SYMPTOMS that may be
positive (eg. Tingling) and/or negative
(eg. Numbness)
• SPEECH DISTURBANCES

15. Dx CRITERIA
*International Classification of
Headache Disorders- 3rd Edition

16. 3. Headache has at least TWO of the
following four characteristics:
a. Unilateral location
b. Pulsating quality
c. Moderate or severe pain intensity
d. Aggravation/causing avoidance of
routine physical activity
4. During headache at least ONE of the
following:
a. Nausea and/or Vomiting
b. Photophobia and/or Phonophobia
5. Not Better Accounted for by any other
ICHD-3 Diagnosis
FIVE
FULFILLING ‘2’
‘4’
LASTING 4-72
HOURS
16*International Classification of Headache Disorders- 3rd Edition

17. TWO
FULFILLING ‘2’
‘3’
2. ONE OR MORE
17
3. At least TWO of the following Four
characteristics:
a. At least one aura symptom
spreads gradually over ≥5 min,
and/or two or more symptoms
occur in succession
b. Each individual aura symptom
lasts 5-60 min
c. At least one aura symptom is
unilateral
d. The aura is accompanied, or
followed within 60 minutes, by
headache
4. Not Better Accounted for by any other
ICHD-3 Diagnosis
*International Classification of Headache Disorders- 3rd Edition

18. BASED ON
FREQUENCY
OF
HEADACHES
• EPISODIC MIGRAINES:
• CHRONIC MIGRAINES:
18*International Classification of Headache Disorders- 3rd Edition

19. PLAN OF Mx
!

20. 20
TREATMENT OPTIONS
ACUTE ATTACK
1 2 3 4 5

21. 21
ACUTE ATTACK: TREATMENT FACTS
NICE, 2015
• Offer combination therapy with an oral TRIPTANS AND AN NSAID/
PARACETAMOL
• For people who prefer to take only one drug, consider Monotherapy
with oral:
a. Triptan
Zolmitriptan(2.5mg) Stat; repeat dose after 1hr if attack does not subside
b. NSAIDs/Aspirin (900 mg)/Paracetamol
• Consider an Anti-emetic (Metoclopramide, Chlorpromazine) EVEN IN the
absence of nausea and vomiting

22. 22
ACUTE ATTACK: TREATMENT FACTS
NICE, 2015
• Never give Ergots or Opioids
• For people in whom oral preparations are ineffective or not
tolerated, Offer:
a. Non-oral preparation of Metoclopramide/ Prochlorperazine
AND
b. A non-oral NSAID or Triptan

23. ≥2
OR
1
INDICATION OF
PROPHYLAXIS

24. 24
TREATMENT OPTIONS
PROPHYLAXIS
1 2 3 4 5

25. 25
TREATMENT PROPHYLAXIS
NICE, 2015
• Offer TOPIRAMATE (25-100mg-Twice Daily) OR Propranolol
according to the person's comorbidities and risk of adverse events
(Advise women and girls of childbearing potential that Topiramate is associated
with a risk of fetal malformations and can impair the effectiveness of hormonal
contraceptives. Ensure they are offered suitable contraception if needed)
• Consider AMITRIPTYLINE (10-150mg-Daily) according to the
person's comorbidities and risk of adverse events.
• Do not Give Gabapentin for the prophylaxis

26. 26
TREATMENT PROPHYLAXIS
NICE, 2015
• If BOTH Topiramate and Propranolol[12] are UNSUITABLE OR
INEFFECTIVE, consider a course of up to 10 sessions of
Acupuncture over 5–8 weeks according to the person's
comorbidities and risk of adverse events
• RIBOFLAVIN (400 mg once a day) may be effective in
reducing migraine frequency and intensity for some people
• REVIEW at 6 months after the start of prophylactic treatment.

27. 27
CGRP: THE NEXT FRONTIER FOR ACUTE
MIGRAINE
Andrew D. Hershey, NEJM 2017
ANTIBODIES DIRECTLY ACTING ON CGRP
• Eptinezumab
• Fremanezumab
• Galcanezumab
ANTIBODIES TARGETTING CGRP RECEPTOR
• Erenumab

28. 28
FREMANEZUMAB
FOR THE
PREVENTIVE
TREATMENT OF
CHRONIC
MIGRAINE
Stephen D. Silverstein, NEJM 2017

29. 29
SELECTED PREVENTIVE THERAPIES *Charles Andrew, Migraine: NEJM, 2017

30. 30
MENSTRUATION
RELATED MIGRAINE
*NICE, 2015

31. 31
MIGRAINE WITH
COMBINED HORMONAL
CONTRACEPTIVE USE
*NICE, 2015

32. 32
MIGRAINE IN
PREGNANCY
ACUTE Rx:
*NICE, 2015

33. 33
MIGRAINE IN
PREGNANCY
PROPHYLAXIS:
*NICE, 2015

34. 34
FEATURES TTH MIGRAINE CLUSTER HEADACHE
Pain Location Bilateral Unilateral/ Bilateral Unilateral around eye
Pain Quality Tightening
(Non-Pulsating)
Pulsating (Throbbing in 12-17
year olds)
Variable
Intensity Mild-Moderate Moderate-Severe Severe-Excruciating
Effect on Activities Not Aggravated by routine
activity
Aggravated or causes
avoidance of routine activities
Restlessness or Agitation
Other Symptoms None Unusual sensitivity to light
and/or sound or nausea and/or
vomiting
Aura
Symptoms can occur with or
without headache
• Fully Reversible
• Developing over at least
5mins
• Lasts 5-60 mins
On the SAME side as the
headache:
• Red and/or watery eye
• Nasal congestion and/or
runny nose
• Swollen eyelid forehead and
facial sweating
• Constricted pupil and/or
drooping eyelid
Headache Duration 30 Mins- Continuous 4-72 hours (1-72hrs in <17yrs) 15-180 mins
Treatment
(NICE,2015)
Acute Attack Aspirin or NSAIDs for Acute
Phase
Oral Triptans with NSAIDS/
Paracetamol+ Anti emetics
Oxygen AND Nasal Triptans
Prophylaxis 10 sessions of Accupuncture
over 5-8 wks
Topiramate or Propranolol;
Amitryptyline; Riboflavin
Verapamil*

35. TAKE HOME
MESSAGE

36. TAKE HOME
MESSAGE

37. TAKE HOME
MESSAGE

38. THANK
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