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    2 Migraine

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    Tommy Arisandy
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    Yyyuyyuu

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    15 views3 pages

    2 Migraine

    Uploaded by

    Tommy Arisandy
    Yyyuyyuu

    Copyright:

    © All Rights Reserved
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    of 3

    Migraine

    Clinical Picture
    What Symptoms Occur During a Migraine Attack?
    Migraineurs have recurrent, severe, and disabling attacks of headache, often unilateral and pulsating, along with
    symptoms of sensory disturbance, such as light, sound, and odor sensitivity. Nausea and neck stiffness are other
    common symptoms, and symptoms can be aggravated by movement.
    Some patients experience dizziness during attacks.
    About 2030% of patients experience aura and neurological symptoms (e.g., visual disturbances), which usually
    precede the headache phase of an attack.
    Premonitory symptoms such as yawning, irritability, tiredness, cravings, and difficulty concentrating sometimes
    precede headache onset.

    What Is Migraine Aura, and What Symptoms Can Occur?


    An aura is any neurological symptom that occurs shortly before the headache attack. Visual symptoms (e.g., flickering
    lights or zigzag phenomena), somatosensory symptoms (e.g., paresthesias), speech problems, and rarely, motor
    symptoms can occur during aura.
    Symptoms usually last >5 and <60 minutes.
    Before migraine can be diagnosed, other possible neurological deficits must first be excluded.
    Cortical spreading depression (see below) is thought to be the pathophysiological cause.

    What Can Trigger a Migraine?


    Menstruation
    Shortness of sleep, irregular sleep, or too much sleep
    Stress (or in some patients, relaxation from stress)
    Alcohol (e.g., red wine)
    Caffeine (e.g., coffee, chocolate)
    Foods containing glutamate or aspartame
    Dehydration
    Vasodilating drugs (e.g., nitrates)

    Epidemiology
    How Many People Are Affected by Migraine?
    Women: about 1318% of the population
    Men: about 510% of the population
    Numbers may be lower in Asian populations

    Chronic Migraine
    About 4% of the adult population experiences chronic headache, i.e., headache on 15 or more days a month. About half
    of this group has chronic migraine, and the other half has chronic tension-type headache [7].

    Disorders/Abnormalities That Can Be Comorbid with Migraine


    Anxiety
    Depression
    Fibromyalgia
    Back pain
    Hypertension
    Stroke and cardiac disease
    Childhood vomiting

    Pathophysiology
    Migraine Pathophysiology
    Migraine was considered to be vascular in origin for much of the 20th century [6], but today it is considered to be a
    disorder of the brain, with abnormalities in the vasculature occurring secondary to the primary neuronal events. Migraine
    has a strong inherited component, and a large genetic study suggests the involvement of glutamate pathways in migraine
    pathogenesis [1]. Genetic variations on chromosome 19 have been reported for rare forms of familial hemiplegic migraine
    (FHM1 and 2).

    Migraine Aura Pathophysiology


    Cortical spreading depression (CSD), a process transiently compromising cortical function at a speed of about 3 mm per
    minute [5] is thought to be the underlying mechanism of aura [2]. It is possible that CSD is also implicated in the
    generation of migraine headache.

    Definition/Diagnosis/Differential Diagnosis
    The International Classification of Headache Disorders
    Distinguishes primary headache syndromes from secondary, symptomatic headache diseases. Migraine and tension-
    type headache are the most common types of primary headache. The classification of primary headache disorders is
    based on a phenomenological (operational) categorization. In contrast, secondary headaches, which have to be ruled
    out, are classified according to their etiology (e.g., headache attributed to a tumor or a vascular abnormality). Some
    types of migraine can be classified based on genetic markers (familial hemiplegic migraine).
    Defines episodic migraine as migraine attacks occurring on fewer than 15 days a month and chronic migraine as
    attacks occurring on 15 or more days a month.
    Other potential causes of headache such as intracranial/spinal pathology, musculoskeletal pathology,
    inflammatory/autoimmune diseases, systemic illnesses, or drug-related headaches have to be ruled out by clinical
    history, neurological examination, and additional diagnostic tests, when appropriate, in order to diagnose migraine.

    Migraine: Diagnostic Criteria (ICHD-2) [4] Without Aura


    A. At least 5 attacks fulfilling criteria B-D
    B. Headache attacks lasting 472 hours (untreated or unsuccessfully treated)
    C. Headache has at least 2 of the following characteristics:
    unilateral location
    pulsating quality
    moderate or severe pain intensity
    aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
    D. During headache at least 1 of the following:
    nausea and/or vomiting
    photophobia and phonophobia
    E. Not attributed to another disorder

    Therapy
    How Can Migraine Attacks Be Treated?
    Simple analgesics (e.g., aspirin, acetaminophen/paracetamol)
    NSAIDs (e.g., naproxen, ibuprofen, diclofenac)
    Triptans (e.g., sumatriptan)
    Second choice treatment: ergot derivatives (e.g., dihydroergotamine)
    In the future, CGRP-receptor antagonists such as telcagepant may be a new option for the treatment of acute attacks
    [3].
    Compound analgesics, such as those containing aspirin, acetaminophen/paracetamol, and caffeine have been shown
    to be more effective than single analgesics. However, they are thought to increase the risk of medication overuse
    headache (see below).

    What to Do When Nausea Is an Issue


    Antiemetics/prokinetics, such as domperidone or metoclopramide, can improve nausea.
    These medications are sometimes given before the analgesics to improve absorption of the medication.
    Preventive Pharmacological Therapy in Episodic Migraine
    Preventive therapy is suitable for patients with frequent and/or severe, disabling attacks.
    A large number of different medications with differing mechanisms of action have been tested in randomized placebo-
    controlled trials and are available for treatment. Propranolol, topiramate, valproate, flunarizine, and amitriptyline are
    examples of medications that are frequently used and have proven efficacy [3].
    On average, a 50% decrease in headache frequency can be expected for half the patients using one preventive
    medication.

    Preventive Pharmacological Therapy in Chronic Migraine


    Best scientific evidence exists for use of topiramate or Botulinum toxin injections for pharmacological prevention of
    chronic migraine.
    Specialist treatment is useful in patients with chronic migraine or refractory migraine.

    Medication Overuse
    Is defined as consumption of triptans, ergotamine, opioids, or combination analgesics on 10 days or more per month,
    or simple analgesics on 15 days or more a month.
    Is an important issue in migraine therapy and needs to be identified and managed.
    Can produce rebound headache.
    Can reduce the efficacy of preventive therapy.
    Can mask the headache phenotype.

    Nonpharmacological Management of Migraine


    Patient education
    Identify and avoid triggers
    Maintain regular daily activities
    Maintain a regular sleep/wake cycle
    Aerobic exercise
    Consider weight reduction in overweight patients
    Biofeedback
    Acupuncture
    Relaxation techniques
    Cognitive-behavioral therapy
    There is currently no evidence supporting homeopathy for migraine treatment
    There is no convincing evidence regarding efficacy of closure of patent foramen ovale (PFO) for migraine treatment.
    PFO closure should not be performed outside of clinical trials.
    Migraine surgery, such as surgical cauterization of the superficial blood vessels of the scalp or the removal of
    muscles or nerves thought to be trigger sites, is advocated by some plastic surgeons, but there is poor scientific
    evidence and no convincing rationale to support this measure. Migraine surgery is currently not recommended
    outside of clinical trials.

    Neuromodulation Approaches
    The efficacy of migraine therapy using electrostimulation of peripheral nerves is currently being investigated in studies
    (see the fact sheet on Neuromodulation in Primary Headaches). Results are pending.

    References
    [1] Anttila V, Stefansson H, Kallela M, et al. Genome-wide association study of migraine implicates a common susceptibility variant on
    8q22.1. Nat Genet 2010;42:86973.
    [2] Dalkara T, Nozari A, Moskowitz MA. Migraine aura pathophysiology: the role of blood vessels and microembolisation. Lancet
    Neurol 2010;9:30917.
    [3] Goadsby PJ, Sprenger T. Current practice and future directions in the prevention and acute management of migraine. Lancet
    Neurol 2010;9:28598.
    [4] Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache
    Disorders, 2nd edition. Cephalalgia 2004;24(Suppl 1):9160.
    [5] Lashley K. Patterns of cerebral integration indicated by the scotomas of migraine. Arch Neurol Psychiatry 1941;46:3319.
    [6] Moskowitz MA, Buzzi MG, Sakas DE, Linnik MD. Pain mechanisms underlying vascular headaches: progress report 1989. Rev
    Neurol (Paris) 1989;145:18193.
    [7] Scher AI, Stewart WF, Lipton RB. Epidemiology of chronic daily headache. In: Goadsby PJ, Silbersten SD, Dodick DW, editors.
    Chronic daily headache for clinicians. Ontario: BC Decker; 2005. p. 311.

    Copyright 2011 International Association for the Study of Pain

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