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Subject: Headache, Migraine
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Most frequent subtypes of migraine 1:
Rare but important subtypes 1:
Affects >28 million Americans
Adults: women 18%; men 6%
No longer believed to be primarily vascular in etiology; rather, cortical spreading depolarization/depression
Trigeminovascular hypothesis: Hyperexcitable trigeminal sensory neurons in brainstem are stimulated and release neuropeptides, such as substance P and calcitonin gene-related peptide (CGRP),leading to vasodilation and neurogenic inflammation.
>80% of patients have a positive family history.
Familial hemiplegic migraine has been shown to be linked to chromosomes 1, 2, and 19 1.
Family history of migraine
Menstrual cycle, hormones
Sleep pattern disruption
Diet: skipped meals (40-56%), alcohol (29-35%), chocolate (19-22%), cheese (9-18%), caffeine overuse (14%), monosodium glutamate (MSG) (12%), and artificial sweeteners (e.g., aspartame, sucralose)
Medications: estrogens, vasodilators
Avoid precipitants of attacks.
Biofeedback, education, and psychological intervention
Lifestyle modifications are the cornerstone of prevention: sleep hygiene, stress management, healthy diet, and regular exercise.
Prophylactic medication if attacks are frequent, severely debilitating, or not controlled by acute interventions
Depression, psychiatric disorders
Sleep disturbance (e.g., sleep apnea)
Cerebral vascular disease
Peripheral vascular disease
Irritable bowel syndrome
Patent foramen ovale (PFO)
Medication overuse headache (MOH)
Screening mnemonic “POUND”: Pulsating, duration of to 72 hOurs, Unilateral, Nausea, Disabling
Headache usually begins with mild pain escalating into unilateral (30-40% bilateral) throbbing (40% nonthrobbing) pain lasting 4 to 72 hours.
Intensified by movement and associated with systemic manifestations: nausea (87%), vomiting (56%), diarrhea (16%), photophobia (82%), phonophobia (78%), muscle tenderness (65%), light-headedness (72%), and vertigo (33%)
May be preceded by aura
Obtain headache profile: number of headaches per month, number of days per month headaches limit daily activities, and frequency and amount of all headache medications used.
Migraine disability assessment (MiDAS) is a useful tool to assess level of disability and correlates well with headache diaries.
Identify possible triggers (e.g., stress, sleep disturbance, food, caffeine, alcohol).
Gait abnormalities and other new cerebellar findings
Loss of gross and/or fine motor function
Altered mental status including possible hallucinations (visual, auditory, olfactory)
Short-term memory loss
Other primary headache syndromes
If focal neurologic signs/symptoms are present, consider transient ischemic attack (TIA) or stroke.
Secondary headaches: tumor, infection, vascular pathology, prescription, or illicit drug use (MOH).
Rarely, atypical forms of epilepsy
New onset in patient >50 years of age
Change in established headache pattern
Atypical pattern or unremitting/progressive neurologic symptoms
Prolonged or bizarre aura
Type of imaging: Data are insufficient to make evidence-based recommendations regarding relative sensitivity of MRI compared with CT in the evaluation of migraine or other nonacute headache.
EEG is NOT indicated unless evaluating loss of consciousness or altered mental status.
Frequency may decrease in 2nd and 3rd trimesters.
Nonpharmacologic methods are preferred.
No treatment drug has FDA approval in pregnancy
Most patients manage attacks with self-care.
Cold compresses to area of pain
Withdrawal from stressful surroundings
Sleep is desirable.
See also “General Prevention.”
First-line abortive treatments
Contraindications to treatments
Second-line abortive treatment
First-line preventative treatment
The American Migraine Prevalence and Prevention Study suggests prophylactic treatment when:
Prevention of episodic migraine, divalproex, valproate, topiramate, metoprolol, and timolol are effective in reducing frequency/severity 6[A].
Obscure diagnosis, concomitant medical conditions, significant psychopathology
Unresponsive to usual treatment
Analgesic-dependent headache patterns
Butterbur (Petasites hybridus; Petadolex): 50 to 75 mg BID 8[A]—Use caution with CYP3A4 meds.
Riboflavin (vitamin B2): 400 mg/day 8[B]
Magnesium: 400 mg/day 8[B]
MIG-99 (Feverfew): 6.25 mg TID 8[B]
Histamine SC: 1 to 10 ng twice weekly 8[B]
Acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment and has fewer adverse effects 9[B].
Consider if diagnosis not clear; status migrainosus; may need to exclude intracranial bleeds; TIA; stroke; monitor vital signs and patient comfort.
Fluids are a necessary part of inpatient management. Keeping patients hydrated and on antiemetics around the clock may be helpful.
Discharge criteria judgment based on patient's overall clinical status and patient's ability to tolerate PO medications
Early intervention is key at the onset of an attack.
Preventative treatment to decrease frequency and severity of attacks, make acute treatments more efficacious, and minimize adverse drug reactions.
Monitor frequency of attacks, pain behaviors, and medication usage via headache diary.
Encourage lifestyle modifications. Counsel patients and manage expectations.
With increasing age, there may be a reduction in severity, frequency, and disability of attacks.
Most attacks subside within 72 hours.
Status migrainosus (>72 hours)
Cerebral ischemic events (rare)
MOH: headache occurring 10 or more days/month for >3 months as a consequence of regular overuse of an acute or symptomatic headache medication. Likelihood with butalbital > opiates > triptans > NSAIDs.
Migraine is a chronic headache disorder of unclear etiology often characterized by unilateral, throbbing headaches that may be associated with additional neurologic symptoms.
Accurate diagnosis of migraine is crucial.
Consider nonspecific analgesics for mild attacks; migraine-specific treatments for more severe attacks
Avoid opiates and barbiturates as well as frequent (>8/month) use of triptans or NSAIDs to avoid creating an MOH.
All patients should be counseled on lifestyle modifications and trigger identification.
In those with frequent or highly debilitating migraines, prophylactic treatment should be encouraged.