(Presented by Dr.
Ravin N. Das, October 2001, IMA Hall)
Definition
(I.H.S – International Headache Society, 1988)
Defines migraine as –
Idiopathic, recurring headache disorder, manifesting in
attacks lasting 4-72 hours, in which headaches are typically unilateral,
throbbing, of moderate to severe intensity, aggravated by routine physical
activity and accompanied by nausea, photophobia, phonophobia. May or
may not be associated with aura.
I.H.S Classification
of Migraine
The following are
NOT classified as migraine headaches –
(Not classified as a migraine category by the I.H.S, but are distinct
and common/uncommon entities).
- Menstrual headaches – headaches present at the
beginning of (within 2 days of onset), or through the period of menstruation,
or after (within 2 days); associated with or without aura.
- Episodic or chronic tension-type headaches
- Analgesic-abuse headaches
- Cluster headaches
- Chronic paroxysmal hemicrania
- Post-traumatic headaches
- Headaches from Brain Tumours
- Idiopathic stabbing headache
- Cervicogenic headaches
- Cough headaches
- Coitus headaches
- Exercise induced headaches
- Hemicrania continua (a chronic continuous, fluctuating
unilateral headache absolutely and rapidly suppressed by indomethacin).
- Postural headaches from lumbar punctures, dural rents,
and shunts
- Sinus headaches
- Headaches in Giant Cell Arteritis (Temporal or Cranial
Arteritis)
- Whiplash headaches
- Thunderclap headaches – include headaches of sudden,
worst-severe headaches – caused by sub-arachnoid hemorrhage,
"crash migraine", idiopathic and unclassifiable headaches, cerebral
(or central) venous sinus thrombosis, un-ruptured arterial aneurysm
at the circle of Willis, dissection of a carotid or vertebral artery,
and also includes – benign exertional or coital headache.
- Trigeminal neuralgia
- Febrile headaches
- Hypoglycemic headaches
Diagnostic criteria
(I.H.S)
(NB: aura is not considered a diagnostic criterion - but is used to
classify the migraine)
- At least 5 attacks
- Headache attacks lasting 4-72 hours
- Headache has at least 2 of the 4 characteristics
- Unilateral location
- Pulsating quality
- Moderate or severe intensity (inhibits or prohibits
daily activities)
- Aggravation by walking stairs or similar routine
physical activity
- During headache at least one of the following accompaniments
–
- Nausea and/or vomiting
- Photophobia and phonophobia
- Other headache types not suggested or confirmed
Investigations?
According to the Quality Standards Committee of the American
Academy of Neurology, 1994 – In adult patients with recurrent
headaches that have been defined as migraine… with no recent change
in pattern, no history of seizures, and no other focal neurologic signs
or symptoms, the routine use of neuroimaging is not warranted.
Aura
Auras are idiopathic recurring disorders manifesting as
attacks of neurological symptoms unequivocally localizable to cerebral
cortex or brain stem, usually developing over 5-20 minutes and lasting
less than 60 minutes, and followed or accompanied by migraine
headache and its associated features.
Pathogenesis – not known
Inference
These new theories put together provide rationale for
combining two or three different types of medications to achieve more
effective, long-lasting relief – for example, a medication that
works on the neurotransmitter serotonin, coupled with an anti-inflammatory
medication that could curtail some of the inflammation provoked by the
trigeminovascular system.
Triggers in migraine
Edibles
- Alcohol, Red Wine
- Cheese & Old home-made cheese
- Veg. and Non-veg. pickles
- Smoked Fish
- Sour cream
- Curds & yogurt
- Yeast and yeast preparations
- Chocolates
- Cigars and Cigarettes
- Citrus fruits
- Butter
- Onions, raw tomatoes, tamarind
- Nuts
- Beans
- Tea and coffee
- Oily foods
- Preservatives (Class 2)
Environment
- Bright lights, flickering lights
- Fluorescent lighting
- Perfumes, strong smells
- Environmental pollution
- Industrial pollution
- Sudden changes in atmospheric temperature
- Long journeys
Life-style
- Mental or physical exertion
- Lack of, or excessive sleep
- Extremes of mood
- Death, mourning
- Untimely meals
- Smoking
- Drinking
- Drug-abuse
Medicines
- Anti-hypertensive medications
- Nitroglycerines
- Diuretics
- Amilophylines, and anti-asthma medications
- Analgesic-abuse
Hormones
- Intercourse - sexual
- Menses
- Pregnancy
- Delivery
- Drugs used for inducing abortion
- Contraceptives
- HRT
Miscellaneous
- Head and neck injury
- Diagnostic injections
- Spinal anesthesia
- Cervical arthritis
Source:
Migraine The Complete Guide American Council For Headache
Education, Copyright 1994... and other sources.
Compiled by Dr. Ravin N. Das on 23 January 1999.
Ophthalmoplegic migraine –
Refers to a type of migraine that is associated with ocular
motor nerve anomalies, such disturbances occurring at the height of
the headache and not preceding the onset of the headache. Usually
fully reversible and does not last for more than one hour. Ptosis, diplopia,
and photophobia commonly occur.
Sir Stewart Duke Elder defines Ophthalmoplegic
migraine as – a clinical syndrome characterized by an association
of severe headaches with recurrent ocular palsy which tends to recover
only to relapse subsequently and finally may become permanent. Also
called Mobius’ disease; trigemino-ophthalmoplegic syndrome.
Retinal migraine –
This rare form of migraine is more common in younger individuals
(under 10 years of age for oculomotor nerve) (and adolescents and young
adults in case of retinal vessel spasm, usually with history of typical
migraine disturbances).
The vasospastic phase of the migraine may affect the optic
nerve or retinal vessels, wherein temporary or permanent spasm of the
retinal vessels may lead to temporary or permanent field defects corresponding
to the area of ischemic retina. When the loss of vision is complete
and temporary the clinical picture of "amaurosis fugax" is described.
It is frequently noted with evidence of vasomotor instability elsewhere,
such as migraine, menstrual and ovarian disturbances, reflex factors
such as vaginal douching, antral wash, changes of posture, and toxic
influences such as influenza, malaria, zoster and toxemia of pregnancy.
Exogenous poisons like lead, alcohol, tobacco and quinine and its derivatives
may also be responsible and have to be ruled out. Frequently evidences
of angiospasm in other regions are noted in addition to migraine, like
temporary loss of hearing,
Basilar migraine
Also called – Basilar artery migraine (BAM), Posterior
fossa migraine, Bickerstaff syndrome (1961), vertebro-basilar migraine,
vertebro-vascular migraine.
Refers to a disturbance whose symptoms may be attributed
to vasospasm within the distribution of the basilar artery. Cortical
visual disturbances such as hemianopias or bilateral visual loss, diplopia,
ataxia, paresis, and paresthesia are such symptoms. Basilar migraine
occurs more commonly in adolescent girls. There is usually a positive
family history for the illness. There may occasionally be loss of consciousness
if the reticular activating system is involved.
Cluster headaches
(Alias – Histamine cephalalgia, Horton’s syndrome,
Raeder’s syndrome and Haris’ neuralgia)
More common in young males (2nd to 3rd
decades), in the fronto-temporal region, associated with epiphora on
the same side, nasal congestion or watering, and conjunctival hyperemia.
There may be associated sympathetic miosis or/and ptosis.
Characteristically occurring in clusters over a few weeks,
and then disappearing for the rest of the year. Thus may mimic
seasonal variation.
Therapy of migraine
Alleviatives and abortives
Patients with mild to moderate headaches respond
well to –
- Aspirin
- Acetaminophen
- Ibuprofen
- Caffeine
- Naproxen sodium
The above can be used singly or in combinations such as
–
- Caffeine – acetaminophen
- Caffeine – acetaminophen – aspirin
- Aspirin – metoclopramide
- Acetaminophen – ibuprofen
Patients with moderate to severe headaches respond
well to –
- Aspirin with metoclopramide
- Dihydroergotamine and other ergotamines
- Sumatriptan – sub-cutaneous/oral and other triptans
- Ergotamine + caffeine
- Opiods – should not be prescribed as a first line
treatment for acute pain due to the chances of addiction and abuse.
- Tranquilizers – chlorpromazine, prochorperazine,
haloperidol and droperidol have the advantage of anti-nausea effect;
but have to be administered IM or IV.
- Isometheptene
- Lidocaine nose drops – considered more effective
than placebo.
Preventives
Indicated when 2 or more migraine attacks occur per month.
The choice of the initial and subsequent preventives to prescribe should
be based on the patient’s physical and mental condition and associated
symptoms. For example, a patient subject to down moods and insomnia
would be more suitable for amitriptyline than propranolol, for the former
lifts mood and promotes sleep, whereas the latter may induce depression.
- Propranolol – good for nervous patients, contraindicated
in asthmatics and should not be used in diabetics. Dose 40-240 mg
increased gradually monitoring pulse, blood pressure and side effects
such as tiredness (exercise intolerance) and depression.
- Amitriptyline – tricyclic anti-depressant –
start with a small bedtime dose of 10 mg in women and 25 mg in men,
increased every few weeks as needed and tolerated. Sedation, oral
dryness, tachycardia, and weight gain from increased appetite. Given
reluctantly to the obese. Good for patients with down mood or insomnia.
- Divalproex – anti-epileptic – starting with
250 mg BD – not to be used in pregnant women and in the presence
of hepatic disease. For long term therapy liver function has to be
monitored regularly.
- Calcium channel blockers – Flunarizine, Cinnarizine,
Verapamil, and Nifedipine – weight gain and sedation (initially).
Flunarizine is prescribed @ 10 mg at bedtime for body weight >
40 kg and 5 mg for body weight < 40 mg.
- Magnesium
- Cyproheptadine
- Fluoxetine
- Aspirins and NSAIDS – as good as placebos in prevention
of migraine
- Roboflavin (B2) – large dose of 400 mg daily.
- Oestrogen – in case of menstrual migraine, 2 days
before to 2 days after the menstrual period.
- Lisinopril