Migraine Headache

Migraine Headache is the 2nd most common primary headache disorder that can present with or without aura.

ETIOLOGY/ PATHOGENESIS

  • Affects more women than men.
  • Peak prevalence 25-45 years of age
  • Risk of migraine headache increases in patients with positive family history of migraines.
  • Two types: Migraine With Aura (Classic Migraine) affects 85% of patients and Migarine Without Aura (Common Migraine) affects 15% of patients.
  • Two theories exist regarding pathogenesis.
  • Vasogenic theory: intracranial vasoconstriction is responsible for the aura symptoms and the headache results from a rebound dilation and distention of cranial vessels and activation of peirvascular nociceptive axons.
  • Neurogenic theory: identifies the brain as the generator of the headache and the vascular changes that occur during the migraine are a result rather than the cause of the attack.

PERTINENT HISTORICAL FINDINGS/ CLINICAL SYMPTOMS

  • Both types of migraines can present with prodromol symptoms that begin 24-48 hours before attack: hyperactivity, mild euphoria, lethargy, depression, craving for certain foods, fluid retention.
  • Aura: Transient episodes of focal neurologic dysfunction appearing 1-2 hours before the onset of headache and resolving within 60 minutes.
  • Aura symptoms: homonymous visual disturbance, expanding scotoma, unilateral paresthesias and or numbness affecting distal ends of the extremities or perioral region of face; unilateral weakness and dysphagia.
  • Sometimes aura symptoms localize to brain stem causing vertigo, dysarthria, tinnitus, fluctuating hearing loss, diplopia, bilateral weakness, ataxia, bilateral paresthesias, & decreased level consciousness.
  • Headache phase consists of 4- 72 hours of unilateral, throbbing head pain that is moderate to severe in intensity and worsened by routine physical exertion and associated with nausea, photophobia, phonophobia.

 PERTINENT PHYSICAL EXAM FINDINGS

  • No significant findings on exam other than the neurologic findings described as part of the aura or prodromal symptoms.

 DIFFERENTIAL DIAGNOSIS

  • Transient ischemic attacks
  • Cerebrovascular accident
  • Subarachnoid hemorrhage
  • Vaculitis
  • Brain tumors/masses
  • Post-traumatic headache
  • Hypoglycemia
  • Glaucoma
  • Sinusitis

DIAGNOSTIC EVALUATIONS

  • Routine labs are done to rule out other concurrent disorders but no specific lab or imaging studies are diagnostic.

MEDICAL MANAGEMENT

  • Non-pharmacological therapy:  behavior modification, biofeedback, relaxation training, establish regular meal schedule, avoidance of trigger factors, consistent sleeping schedule.
  • Mild attacks: analgesics (acetaminophen), NSAIDs (aspirin, ibuprophen, naproxen).
  • Moderate attacks:  combination of acetaminophen, isometheptene mucate, and dichloralphenazone; butalbital combined with caffeine, aspirin or acetaminophen.
  • Moderate to severe attacks: dihydroergotamine, 5-HTB/D receptor agonist (sumatriptan), 2nd generation sumatriptan-like drugs (naratriptan, zolmitriptan, rizatriptan), ergotamine.

SURGICAL MANAGEMENT (when applicable)

  • Not applicable

 EMERGENCY MANAGEMENT (when applicable)

  • Severe attacks may be treated with: Dihydroergotamine administered subcutaneously or intravenously; Meperidine, intramuscularly; Intravenous neuroleptics for severe, unresponsive, or prolonged attacks.

 PATIENT EDUCATION/ MAINTENANCE – PREVENTION

  • Avoid triggers such as tyramine-containing foods, meats preserved with nitrites, chocolate, MSG, sleep deprivation, strong odors, stress, menses, fasting, caffeine, red wine, smoking, some oral contraceptives.
  • Preventive/ Prophylactic therapy is recommended if headaches limit work or normal daily activity 3 or more days per month.
  • Β-adrenergic blockers: propranolol, atenolol, nadolol, timolol, metoprolol.
  • NSAIDs: aspirin, naproxen, ketoprofen.
  • Tricyclic antidepressants: amitriptyline, nortriptyline.
  • Calcium channel antagonists: verapamil, flunarizine.
  • Anticonvulsants: divalproex sodium, topiramate, gabapentin, topiramate.
  • Serotoninergic drugs: methysergide, cyproheptadine.
  • Monoamne oxidase inhibitor: phenelzine.
  • Angiotensin II receptor blocker: candesartan.

 migraine-headache-symptoms

 Dr. Zachary Lahlou

 

 

 

 

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