This document provides an overview of migraines including: - Migraines affect 10-20% of the general population and are characterized by recurrent attacks of headache that vary in intensity and duration. - Triggers include disturbed sleep, hormones, drugs, exertion, and sensory or weather stimuli. Attacks progress through prodrome, aura, headache, and postdrome phases. - Treatment involves avoiding triggers, acute abortive medications like triptans for pain relief, and preventive medications if attacks are frequent or debilitating to reduce severity and frequency. - Both pharmacological and non-pharmacological approaches are used to manage migraines, establish diagnoses, educate patients, and improve quality of life

1. MIGRAINE
A Concise Presentation
By
Mr. Deepak Sarangi M.Pharm

2. CONTENTS:
 Introduction
 Definition
 Migraine triggers
 Phases
 Classification
 Pathophysiology
 Diagnosis
 Goals for treatment
 Management
 Guidelines
 Summary of prevention
 Conclusion
 References
2

3. INTRODUCTION:
 Migraine is one of the common causes of
recurrent headaches.
 According to IHS, migraine constitutes 16% of
primary headaches.
 Migraine afflicts 10-20% of the general
population.
 In India, 15-20% of people suffer from
migraine.
 Migraine is under diagnosed and undertreated. 3

4. “Migraine is a familial disorder
characterized by recurrent attacks of headache
widely variable in intensity, frequency and
duration. Attacks are commonly unilateral and are
usually associated with anorexia, nausea and
vomiting”.
DEFINITION:
4

5. MIGRAINE TRIGGERS:
 Disturbed sleep pattern
 Hormonal changes
 Drugs
 Physical exertion
 Visual stimuli
 Auditory stimuli
 Olfactory stimuli
 Weather changes
 Hunger
 Psychological factors 5

6. PHASES:
Prodrome
Aura
Headache
Postdrome
6

7. PRODROME:
 Vague premonitory symptoms that begin
from 12 to 36 hours before the aura and
headache.
Symptoms:
 Yawning
 Excitation
 Depression
 Lethargy
 Craving or distaste for various foods
Duration: 15 to 20 min. 7

8. AURA:
Aura is a warning or signal before onset of
headache.
Symptoms:
Flashing of lights
Zig-zag lines
Difficulty in focussing
Duration : 15-30 min.
8

9. HEADACHE:
 Headache is generally unilateral and is
associated with SYMPTOMS like:
1. Anorexia
2. Nausea
3. Vomiting
4. Photophobia
5. Phonophobia
6.Tinnitus
 Duration: 4-72 hrs.
9

10. POSTDROME:
Following headache, patient complains of -
 Fatigue
 Depression
 Severe exhaustion
 Some patients feel unusually fresh
Duration: Few hours or up to 2 days.
10

11. CLASSIFICATION:
According to Headache Classification
Committee of the International
Headache Society, Migraine has been
classified as:
 Migraine without aura (common migraine)
 Migraine with aura (classic migraine)
 Complicated migraine
11

12. PATHOPHYSIOLOGY:
VASCULAR THEORY:-
o Intracranial/Extracranial blood vessel vasodilation –
headache.
o Intracerebral blood vessel vasoconstriction – aura.
SEROTONIN THEORY:-
o Decreased serotonin levels linked to migraine.
o Specific serotonin receptors found in blood vessels of
brain. 12

13. Release of
Neurotransmitter
Arterial Activation
Worsening of Pain
13

14. DIAGNOSIS:
 Medical History
 Headache diary
 Migraine triggers
 Investigations
EEG
CT Brain
MRI
14

15. GOALS FOR TREATMENT:
 Establish diagnosis.
 Educate patient.
 Discuss findings.
 Establish reasonable expectations.
 Involve patient in decision.
 Encourage patient to avoid triggers.
 Choose the best treatment.
 Create treatment plan.
15

16. LONGTERM TREATMENT:
 Reducing the attack frequency and severity.
 Avoiding escalation of headache medication.
 Educating and enabling the patient to manage the
disorder.
 Improving the patient’s quality of life.
16

17. MANAGEMENT:
 Non-pharmacological treatment:-
 Identification of triggers
 Meditation
 Relaxation training
 Psychotherapy
 Pharmacotherapy:-
 Abortive therapy
 Preventive therapy
17

18. ABORTIVE THERAPY
Non-specific treatment:
18
Drug Dose Route
Aspirin 500-650 mg Oral
Paracetamol 500 mg-4 g Oral
Ibuprofen 200- 300 mg Oral
Diclofenac 50-100 mg Oral/IM
Naproxen 500-750 mg Oral

19. SPECIFIC TREATMENT:
19
Drug Dose Route
Ergot alkaloids
Ergotamine 1-2 mg/d; max-6
g/d
Oral
Dihydroergotamine 0.75-1 mg SC
5-HT receptor agonists
Sumatriptan 25-300 mg
6 mg
Orally
SC
Rizatriptan 10 mg Orally

20. PREVENTIVE THERAPY:
Drugs Dose (mg/d)
1. Betablockers
 Propranolol 40-320
2. Calcium Channel
Blockers
 Flunarizine
 Verapamil
10-20
120-480
3. TCAs
 Amitriptyline 10-20
4. SSRIs
 Fluoxetine 20-60
20

21. GUIDELINES:
 Migraine significantly interferes with patient’s daily
routine, despite acute treatment.
 Acute medications ineffective, intolerable, or
overused.
 Frequent headache.
 Uncommon migraine conditions.
 Cost considerations.
 Patient preference. 21

22. SUMMARY OF PREVENTION:
 Use preventive medications when needed.
 Treat long enough.
 Avoid acute medications overuse.
 Take coexisting conditions into account.
 Use drug with best efficacy for individual
patient.
22

23. CONCLUSION:
 It is more common in adults than children and in women
than men. While researchers have some idea of what
happens within the brain during migraine attacks, much
remains to be discovered about its underlying causes and
mechanisms.
 In addition, treatment focuses on avoiding those things
that seem to trigger attacks, identifying drugs that
prevent or reduce the severity of attacks and drugs that
reduce the intense pain of a severe attack.
 The good news is that several classes of drugs are
effective for different kinds of migraine and most
migraine sufferers can work with their doctor to
minimize migraine's effects. 23

24. REFERENCES:
 Headache Classification Committee The International
Classification of Headache Disorders. 2nd edition.
Cephalalgia. 2004;24:1–160.
 Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML,
Stewart WF. Migraine prevalence, disease burden, and the
need for preventive therapy. Neurology. 2007;68:343–9.
 Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M.
Prevalence and burden of migraine in the United States:
Data from the American Migraine Study II. Headache.
2001;41:646–657.
 Radat F, Swendsen J. Psychiatric comorbidity in migraine:
A review. Cephalalgia. 2004;25:165–178.
 Lipton RB, Hamelsky SW, Kolodner KB, Steiner TJ,
Stewart WF. Migraine, quality of life and depression: A
population-based case control study. Neurology.
2000;55:629–35. 24

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