Migraine
PATHOPHYSIOLOGY
■ Slowly spreading wave of neuronal depolorization across the brain →ion
dysfunction and vasoconstriction →prodrome and aura (seen in 20%).
■ Trigeminovascular activation and release of peptides →inflammation of
the pain-sensitive areas and vasodilation.
Many factors can directly or indirectly trigger this neurovascular activation:
■ Menstruation, contraceptive estrogens, pregnancy
■ Certain foods or drinks, such as chocolate, caffeine, hard cheese, alcoholic
beverages (especially red wine), monosodium glutamate (MSG), nitrites
■ Alterations in circadian rhythm
SYMPTOMS
Migraine without aura (“common migraine”):
■ Slow onset and lasts 4–72 hours
■ Unilateral and pulsating
■ Nausea, vomiting, and photo- or phonophobia
Migraine with aura (“classic migraine”):
■ Headache follows aura within 60 minutes.
■ Aura develops gradually over minutes, lasts <1 hour and is fully reversible.
■ Types of auras
■ Visual is most common →scintillating scotomata or visual field deficit.
■ Motor→hemiparesis, ophthalmoplegia, aphasia.
■ Sensory→hemiparesthesia, dysesthesia.
■ Brainstem (basilar migraine) →vertigo, ataxia.
DIFFERENTIAL
■ Includes subarachnoid hemorrhage, giant cell arteritis, cerebrovascular
disease, and other secondary headaches
DIAGNOSIS
■ Typically a clinical diagnosis
■ Further evaluation (CT/LP) to rule out a secondary cause is needed in patients
with new onset migraine or symptoms different from their typical migraine.
TREATMENT
■ Goal is to abort or decrease the neurovascular effects.
■ Triptans (eg, sumatriptan): Selective 5-HT (serotonin) agonists
■ Should not be used in patients with hypertension or other cardiovascular
disease
■ Do not use within 24 hours of other ergotamine-containing medication.
■ Dihydroergotamine (DHE): Nonselective 5-HT agonist
■ Again contraindicated in patients with cardiovascular disease or within
24 hours of triptan use
■ Nausea and vomiting are common side effects.
■ Antiemetics(eg, prochlorpromazine, metoclopromide)
■ NSAIDs(eg, indomethacin, ibuprofen)
NEUROLOGYTriptans and DHE are
vasoconstrictors and should
not be used in patients with
HTN or cardiovascular
disease.