2. outline
• Pathophysiology
• Clinical features and triggers, hits and
misses..
• What can happen if untreated
• Management….
– Last 20 years
– Last 02 years
• Anything else that we can do /advice to
the patient.
3. Migraine headache is a complex recurrent headache that
is one of the most common complaints in medicine.
3
Introduction
4. Neurovascular theory
Migraine is primarily a neurogenic process with secondary
changes in cerebral perfusion
Cortical spreading depression
CSD is a well defined wave of neuronal excitation in the cortical
grey matter that spreads from its site of origin at the rate of 2-
6mm/min
This cellular depolarization causes the primary cortical
phenomenon aura phase, in turn, it activates trigeminal fibers
causing headache.
Patho Physiology
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5. Vascular theory
It was believed that ischemia induced by intracranial
vasoconstriction is responsible for the aura of migraine and the
subsequent rebound vasodilation and activation of perivascular
nociceptive nerve resulted in headache.
Based on 2 observations -:
1.Extracranial vessels become distended and pulsatile during an
attack
2.Vasoconstrictors improve the headache and vaso dilators provoke
an attack
Pathophysiology
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6.
7. Approx 70% of patients have a first degree relative with a history
of migraine.
Familial Hemiplegic Migraine
Migraine with aura that is preceded or followed by hemiplegia
that typically resolves
FHM type 1 - Linked to mutations in the calcium channel gene –
chromosome 19.May be associated with cerebellar ataxia
FHM type 2 - mutation in the sodium channel gene ATP1A2 on
chromosome 3
FHM type 3- mutation in a sodium channel alpha subunit coding
gene
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Etiology
8. Migraine in inherited disorders -:
8
lactic
1.MELAS
acidosis)
2.CADASIL
(mitochondrial myopathy, encephalopathy and
(cerebral autosomal dominant arteriopathy with
vasculopathy with
subcortical infarcts and leukoencephalopathy)
3.Genetic vasculopathies like RVCL (retinal
cerebral leukodystrophy) etc.
Etiology
contd…
10. History
U/L, throbbing or pulsatile localized in the frontotemporal and
ocular areas but be felt anywhere around the head or neck.
Pain builds over 1-2 hrs and become diffuse.
Many patient prefer to lie in dark room
Other symptoms
Nausea, vomiting, anorexia and food intolerance occur in about
50 % of patients. Photophobia and phonophobia are commonly
associated with headache.
Hemiparesis, confusion, apathy and numbness.
15
Clinical
presentation
11. Prodrome
Heightened sensitivity to light, sounds and odors.
Lethargy or uncontrollable yawning.
Food cravings
Mental and mood changes
Excessive thirst and polyuria
Anorexia
Constipation or diarrhea
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Clinical presentation contd…
12. It is a complex of neurologic symptoms that may precede or
accompany the headache phase or may occur in isolation.
Usually develops over 5-20min and lasts less than 60 minutes.
Can be visual, sensory, motor or combination of these
Negative symptoms -:
Negative scotoma
Negative visual phenomenon such as homonymous hemianopia,
central scotoma, tunnel vision, altitudinal visual defects etc.
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Aura
13. Positive symptoms
Scintillating scotoma-highly characteristicof migraine
Photopsia or flashes of light
Heat waves
Micropsia, macropsia
Paresthesia
Occurring in 40%of cases constitute the next most common aura.
Sensory symptoms rarely occurs in isolation and usually follows visual
aura.
Motor symptoms may occur in 18% of patients
Speech and language disturbances have been reported in 17-20% of
patients 13
Aura contd…
18. Stress
Excessive or insufficient sleep
Medications (OCP, vasodilators)
Strong odors eg. perfumes, cologne etc.
Hormonal changes such as pregnancy, menstruation
Head trauma
Weather changes
Metabolic or infectious disease
Physical exertion
Cold stimulus eg. ice cream
18
Migraine
triggers
19. Thorough neurologic examination is essential, results will be
normal in majority
Possible findings may include
Cranial/cervical muscle tenderness
Horner syndrome
Tachycardia/ bradycardia
Conjunctival injection
Hypertension/hypotension
Hemisensory/ hemiparetic neurological deficits
( complicated migraine)
Physical
Examination
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20. Findings that suggest a headache diagnosis other than
migraine
Dim scotoma lasting a few seconds to several minutes ie
amaurosis
Temporal artery tenderness
Meningisnus
Mental status changes
Focal neurologic deficit eg confusion, seizures
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21. Focal neurologic findings suggests a migraine variant
U/L paralysis or weakness-hemiplegic migraine
Aphasia, dysarthria, vertigo, tinnitus, syncope, balance
problems-basilar migraine
Third nerve palsy with sparing of pupillary response-
ophthalmoplegic migraine
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Physical Examination contd…
22. Migraine without aura
Diagnostic criteria:
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or
unsuccessfully treated)
C. Headache has at least two of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4.aggravation by or causing avoidance of routine physical
activity (eg. walking or climbing stairs)
22
Diagnostic
criteria
23. D. During headache at least one of thefollowing:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder
Diagnostic criteria contd…
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25. 30 year female
Hemiparesis
k/p/o migraine
She had a recent
migraine episode
1week back
Can it be a migrainous infarct?
Migrainous infarct happens
at the height of headache..
…..
27. Specific medications
Triptan (serotonin 1B/1Dreceptor agonists)
acute management
Appropriate initial choice in patients with moderate to severe
migraine
Routes-oral, subcutaneous and nasal
Drugs – sumatriptan-50-100mg tablet at onset , may repeat after
2hour (max 200mg/d)
Rizatriptan –most efficacious, early onset of action, 5-10 mg
tablet at onset may repeat after 2hr max 30mg/d)
Naratriptan, almotriptan,frovatr
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iptan, zolmitriptan
28. Specific medications contd…
• Ergot alkaloids and derivatives-nonselective 5-HT1 agonists)
Ergotamine PO/PR (and caffeine combination) may be
considered in the treatment of selected patients with
moderate to severe migraine.
Dose 2mg PO, f/b 1-2mg every 30 min until attack is aborted,
no more than 6mg/day
Adverse effects-vasospasm, angina, tachycardia, numbness of
extremities, rebound headache, ergotism, gangrene etc
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29. May be considered when -:
Frequency of migraine is >2/months
Duration of individual attack is longer than 24hrs
Headache causes major disruption in patients lifestyle
Abortive therapy fails or is overused
Symptomatic medications are ineffective
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Preventive
treatment
