Download Migraine with aura - The Holly Private Hospital

Migraine
John McAuley
Consultant Neurologist and Honorary Senior
Lecturer
Epidemiology
• 10-12% of general population are active
migraineurs (at least one attack in last year).
• > 5% have at least 18 migraine days per year.
• Female: Male ratio 3:1 – this ratio rises from
menarche, peaks at 42, then declines.
Pathophysiology
• Must explain:
– Individual susceptibility
– Attacks
– Associated neurological symptoms
• General mechanism:
Lowered threshold + Trigger Attack
+/- Aura
The Migraine Generator
• Individual with low
threshold (genetic,
hormonal, fatigue)
• Various sensory/
environmental
triggers may input on
migraine generator in
upper brainstem,
producing:
1) Trigeminovascular
reaction → headache
2) Spreading cortical
depression/ cerebral
vasospasm → aura,
complicated migraine
3) Visceral responses →
nausea
"Migraine Generator"
Occipital Cortex Spreading Depression
Dorsal Raphe Nucleus Trigeminovascular
response
Area Postrema - Visceral
response
Trigeminovascular Response
• Dorsal raphe
nucleus outputs via
cranial
parasympathetics
to dural nerve
terminals:
– anterogradely triggers
nociceptive information
centrally.
– retrogradely triggers
release of substance P,
neurokinin A, calcitonin
gene related peptide
(CGRP) via axon reflex
triple response:
vasodilatation, oedema,
inflammatory cell &
platelet activation.
Diagnostic Criteria for Migraine
Migraine without aura
• Attacks 4 to 72 hours if untreated
• Two or more of:
–
–
–
–
unilateral
pulsing
severe enough to disturb daily activities
aggravated by movement
• At least one of:
– nausea or vomiting
– photophobia or phonophobia
Diagnostic Criteria for Migraine ctd.
Migraine with aura
• One or more transient focal symptoms
(cortical or brainstem)
• Develop slowly over > 4 minutes
• Last no more than 60 minutes
• Headache accompanies or follows within 60
minutes.
Case History 1
• 45 year old woman with explosive onset of
headache in occiput after sexual intercourse.
• Background of years of occasional headaches
lasting several hours with nausea and
tiredness.
• Normal neurological examination.
Case History 2
• 25 year old woman with episodic headache
over 6 years lasting hours, unilateral and
associated with nausea, helped by sleeping.
• Recent change in character over one month
to a constant severe generalised headache
not relieved by painkillers.
• Examination normal.
Case History 3
• 25 year old woman complaining of 10 years of
episodic unilateral headaches 1/week with
nausea, phonophobia, relieved by sleep.
• Examination normal.
• Not taking excessive analgesia. Already tried
propranolol, pizotifen and topiramate.
Case History 4
• 30 year old man with mild bifrontal headache
of constant character over 2 months.
• No other symptoms.
Case History 5
• 45-year-old man developed tingling in right
face and hand, which progressed over 10
minutes to weakness of right hand and with
language difficulty.
• Admitted to A&E one hour after symptom
onset. Headache and nausea. CT scan of head
normal. On examination, right face weak,
right arm hemiparesis, dysphasia.
• Thrombolysis call.
Case History 6
• 40 year old woman with 5 year history of
unilateral headaches lasting several hours and
associated with nausea. Now occurring on a
daily basis, sometimes waking her at night.
• Very agitated with headaches.
• Examination and imaging normal.
• No response to propranolol 80 mg nocte for 6
months. No attack relief from triptans.
Real Life Migraine
• Diagnostic criteria meant to be specific rather
than sensitive
• Diagnosis not always straightforward – there
is an important differential
• Overlapping aetiologies
Real Life Migraine Differential Diagnosis
Category
Cause
Infective
Meningitis - bacterial/ viral/ TB
Sinusitis
Abscess
Inflammatory
Meningeal irritation
Vasculitis/ giant cell arteritis
Haemorrhagic
Subarachnoid haemorrhage
Subdural/ Intracerebral haemorrhage
Vascular
AVM (migraine, cluster headache)
Muscular
Tension type headache
Neuropathic
Hemicrania, neuralgia
Pressure
Raised intracranial pressure/ venous
thrombosis
Real Life Causes of Episodic Headache
•
•
•
•
•
•
•
•
Tension headache
Migraine
Cluster headache
Trigeminal neuralgia
Other neuralgiform headaches
Paroxysmal hemicrania
SUNCT syndrome
Hypnic headache
Real Life Migraine: Taking the History
•
•
•
•
•
•
•
•
Character: tight, pounding, boring, stabbing
Location: unilateral, vertex, eye
Duration
Time of day, timing
Autonomic features
Triggers: mechanical, cutaneous, posture, cough, sex
Analgesic use
Associated nausea, photophobia, visual or hearing
disturbance, or vertigo, reduced consciousness,
hemibody disturbance
Real Life Migraine: Conducting the
Examination
•
•
•
•
•
Encephalopathic?
Fundoscopy
Eye movements
Pupils
Hemi-paresis, hemi-hyperreflexia, hemiataxia
• Gait ataxia
Clinical Features of Migraine Aura
• Typically gradual onset, spreading
• Experienced by a third of migraineurs
• Of such patients:
–
–
–
–
99% have visual auras
31% have sensory auras
18% have aphasic auras
6% have motor auras
• Investigate if atypical
– sudden onset, or no headache
– always reflect a single vascular territory
– onset at age >50.
Visual Aura
Transformed Migraine
• Presents as chronic daily headache, defined
as headache >4 hours/day occurring >15
days/month.
• Commonly occurs in association with
analgesia misuse.
• The differential diagnosis now includes other
causes of chronic headache.
Lifestyle Treatment of Migraine
• Avoid overuse of analgesics, caffeine.
• Avoiding putative triggers has no
demonstrated efficacy. No good evidence for
specific diets.
• If a particular factor identified, e.g. chocolate,
alcohol, prolonged exercise, sensible to avoid.
• Cranial massage if associated tension type
headache.
Drug Treatment of Migraine
From Pathophysiology:
•Anti-inflammatories for
triple response e.g.
NSAIDs.
•Vasoconstrictor 5HT1
agonists
•Central and peripheral
pain inhibition
•Central nausea inhibition
•?Intracerebral
vasodilatation
Real life Treatment of Migraine Attacks
• NSAIDs, simple analgesia
• Caffeine-like compounds
• Migraleve = buclizine (pink), paracetamol,
codeine.
• Domperidone for absorption, nausea (non
dopaminergic to avoid extrapyramidal side
effects, but prolonged QT interval)
Specific Migraine Attack Treatments
• Ergot alkaloids
• Triptans – oral, dissolving, subcutaneous, nasal
spray.
• Cyproheptadine.
• Flunarizine for migraine aura.
• Calcitonin gene related peptide (CGRP)
transmitter in trigeminal nerve mediating
nociceptive response – olcegepant is a CRGP
antagonist (triptans also antagonise CGRP and
are serotonin 1B/1D agonists to cause
vasoconstriction).
Role of Prophylactic Agents
• To prevent migraines by regular medication
• Appropriate if e.g. >2 attacks/ month
• Depends on individual patient
Prophylactic Drug Treatments
• CNS absorbed b-blockers (propranolol,
metoprolol)
• Tricyclic drugs (amitriptyline, nortriptyline)
• 5HT receptor antagonists (pizotifen,
methysergide)
• Non-selective Ca channel blocker (flunarizine)
for aura.
• Anti-epileptics (valproate).
Other Prophylactic Treatments
•
•
•
•
•
•
•
•
Ca antagonists e.g. verapamil.
Clonidine (a2- agonist)
Other antiepileptics (gabapentin, topiramate)
NSAIDS
Cyproheptadine
Fever few
Riboflavin
Botulinum Toxin
Real Life Choice of Agent
• First choice in females and most males
propranolol if not asthmatic.
• Pizotifen for children.
• Amitriptyline/ gabapentin first choice if also
tension-type headache.
• Valproate may be most powerful – but
teratogenicity
• Topiramate associated with weight loss.
• Flunarizine if aura is the main symptom.
Menstrual Migraine
• Strictly defined as migraine without aura starting on day
1 of period +/- 2 days.
• Occurs in up to 60% of female migraineurs.
• Similar attack treatments as for other migraines
• Short-term preventatives, starting 3 days before period,
continuing to end:
–
–
–
–
Mefenamic acid 500mg BD, or try different NSAIDs
Amitriptyline
Transdermal oestradiol
Oral magnesium
Migraine in Pregnancy
• Usually improves (fortunately!) but in 1-10% of
migraineurs, their migraine started in pregnancy.
• Lifestyle measures, cranial massage.
• FDA categories of safety
• Attacks: Paracetamol, NSAIDs (not 3rd trimester),
caffeine, low dose codeine, should avoid triptans.
• Nausea: Domperidone has no data (category C), but I
prefer to metoclopramide
• Preventatives: Metoprolol class B, other b-blockers
may reduce birth weight, cyproheptadine (class B),
verapamil (class C) probably safe.
Migraine and Breastfeeding
• Attacks: paracetamol, low dose caffeine,
NSAIDs, not triptans.
• Preventatives: b-blockers, verapamil,
valproate (does not pass into breast milk)
• Or b***** feed!
Case History 1
• 45 year old woman with explosive onset of
headache in occiput after sexual intercourse.
• Background of years of occasional headaches
lasting several hours with nausea and
tiredness.
• Normal neurological examination.
Case History 1 Answer
• Admitted to hospital.
• CT head scan normal, LP normal.
• MR angiogram normal
 Benign migraine-related sex headache
Rx Physiotherapy to neck, migraine attack advice
Learning points:
• Just because  negative does not mean should not have
been referred!
• A warning bleed of SAH will herald the subsequent bleed
by no more than a week or two.
• Sex headache and ice pick headaches are quasi-migrainous
or from acute muscle strain.
Case History 2
• 25 year old woman with episodic headache
over 6 years lasting hours, unilateral and
associated with nausea, helped by sleeping.
• Recent change in character over one month
to a constant severe generalised headache
not relieved by painkillers.
• Examination normal.
Case History 2 Answer
• Referred to Neurology outpatients.
• Drug history included 7 sumatriptans a week, and 20
paracetamols a week.
• New headache associated with tightness in neck muscles
and temporalis muscles
 Analgesia headache with tension headache features
Rx Stop analgesia, start amitriptyline, physiotherapy – this
resovled symptoms so scan not necessary.
Learning point:
• Change of character does not always indicate a sinister
cause; always review analgesia history.
Case History 3
• 25 year old woman complaining of 10 years of
episodic unilateral headaches 1/week with
nausea, phonophobia, relieved by sleep.
• Examination normal.
• Not taking excessive analgesia. Already tried
on propranolol, pizotifen and topiramate.
Case History 3 Answer
 Treatment resistant common migraine
Rx Much better after propranolol 160 mg nocte and Epilim Chrono 500
mg nocte, cranial osteopath, Maxalt melt for residual attacks.
Learning Points:
• Detailed drug history: doses, durations, ineffective vs not
tolerated, concurrently on analgesia.
• Consider concurrent causes e.g. tension type headache triggering
migraine, menstrual cycle.
• Optimise attack treatment with triptans and antiemetic at
symptom onset.
• Non-medical therapies – botulinum toxin.
Case History 4
• 30 year old man with mild bifrontal headache
of constant character over 2 months.
• No other symptoms.
Case History 4 Answer
• Referred to Neurology outpatients.
• Examination revealed mild difficulty heel-toe walking, mild
papilloedema.
• MRI brain showed glioblastoma multiforme.
 Malignant brain tumour
Rx Palliation
Learning point:
• Headache is often non-specific, but a 30-year old who
cannot heel-toe walk is specific, even if “mild”.
Case History 5
• 45-year-old man developed tingling in right
face and hand, which progressed over 10
minutes to weakness of right hand and with
language difficulty.
• Admitted to A&E one hour after symptom
onset. Headache and nausea. CT scan of head
normal. On examination, right face weak,
right arm hemiparesis, dysphasia.
• Thrombolysis call.
Case History 5 Answer
• Waited 30 minutes, neurological symptoms resolving,
headache worsening. Past history of migrainous
headaches became apparent later.
 Complicated migraine
Learning points:
• Age consistent with stroke or migraine
• Clue was gradual onset
• Safer to thrombolyse normal brain than stroke brain!
Case History 6
• 40 year old woman with 5 year history of
unilateral headaches lasting several hours and
associated with nausea. Now occurring on a
daily basis, sometimes waking her at night.
• Very agitated with headaches.
• Examination and imaging normal.
• No response to propranolol 80 mg nocte for 6
months. No attack relief from triptans.
Case History 6 Answer
• Patient responded to a course of indometacin 50 mg
BD.
 Paroxysmal Hemicrania (continua variant)
Learning points:
• Not all cases are typical. Cluster headache does occur
in women and not all hemicrania headaches have eyewatering. These neuralgiform headaches have
“continua” variants.
• Reconsider diagnosis when failure to respond.
Thank you