Migraine & types

Migraine and headache same?

• The term migraine is originated from Greek word

“hemicrania” meaning “one side of the head”.

• Migraine headache as an episodic neurovascular

phenomenon is characterized by recurrent attacks

of unilateral headache while headache is

recognized as the most well-known symptom of

migraine

Silberstein, S.D. (2004). Migraine. Lancet, Vol.363, No., pp.381-391

Migraine• Migraine has been regarded as a vascular disorder

because of the throbbing nature of the pain.

• Characterized by pulsating headache, usually restricted

to one side (unilateral), which comes in attacks lasting

4-48 hours

• Mostly associated with nausea, vomiting, sensitivity to

light and sound, vertigo, loose motions and other

symptoms.

Worldwide burden Migraine affects 18% of women and 6% of men in

the United States, and has an estimated worldwide

prevalence of about 10%.

For both men and women, the prevalence of migraine

rises throughout early adult life and falls after midlife.

In girls and women, the rate almost triples between

age 10 and 30 years.

Clin J Pain 2009;25:446–452

Causes• Family history of migraine headaches (70-80%)

• Medications (birth control pills, vasodilators)

• Fatigue or emotional stress

• Specific foods or alcohol & caffeine

• Exertion

• Lack of sleep

• Noise, light, diet

Clin J Pain 2009;25:446–452

Types of migraine

• Common migraine(without aura)

• Classical migraine(with aura)

• Mild (1/month, upto 8 hr)

• Moderate (> 1/ month, intense, 6-24 hr, nausea, vomiting

associated)

• Severe (2-3/month, severe throbbing, 12-48 hr, vertigo,

vomiting associated)

Classical migraine• Migraine with aura (ophthalmic, hemiplegic migraine) is defined

as a recurrent disorder involving headache attacks appearing

gradually over 5-20 minutes and lasting for less than 60 minutes.

• The aura encompasses focal neurological symptoms that precede

or accompany at the onset of migraine attacks.

• Aura can involve reversible visual and sensory symptoms

and speech weakness.

International Classification of Headache Disorders II. (2004). Cephalalgia, Vol.24, Sup.1, pp.1-160

Common migraine• Migraine without aura (hemicrania simplex, common migraine) is a specific

neurological disorder characterized by unilateral, pulsating quality, aggravation

on movement, and moderate to severe headache, nausea and photophobia.

• Most migraineurs suffer from this subtype of migraine, and there are

higher frequency and more severe attacks in comparison with migraine

with aura.

• Owing to strong relationship between migraine without aura with menstrual

cycle, the menstrual migraine (i.e. pure menstrual migraine and menstrually-

related migraine) is categorized in this subtype.International Classification of Headache Disorders II. (2004). Cephalalgia, Vol.24, Sup.1, pp.1-160

Is it a migraine? Think “POUND”

Pathophysiology • The frequency with which migraine attacks occur may

vary from once in a lifetime to almost daily.

• Attacks are initiated when internal or environmental

triggers are of sufficient intensity to activate a series of

events which culminate in the generation of a migraine

headache.

Pathophysiology• In susceptible individuals, the trigeminovascular

neurons release neurotransmitters, such as calcitonin

generelated peptide(CGRP) and substance P, when

headache triggers are encountered.

• This leads to vasodilation, mast cell degranuation,

increased vascular permeability and meningeal

edema, resulting in neurogenic inflammation.

• Involvement of the neurotransmitter 5-HT

• Dopaminergic stimulationClin J Pain 2009;25:446–452

The role of foods and supplementsin migraine

• Skipped meals and fasting were reported migraine

triggers in over 56% in a population-based study and

40% to 57% in subspeciality clinic-based studies

• The mechanism by which fasting and skipping meals

triggers headaches may be related to alterations in

serotonin and norepinephrine in brainstem

pathways or the release of stress hormones such as

cortisol.

Clin J Pain 2009;25:446–452

External triggers

Migraine: Molecular Basis and Herbal Medicine 2012

Internal triggers• The most common internal triggers are sex hormones

(neurosteroids and ovarian steroids).

• The key stages of reproduction including first

menstruation, pregnancy and menopause are

associated with frequency or severity of migraine.

• Interestingly only attacks of migraine without aura occur

during the perimenstrual time period and attacks of

migraine with aura happen equally during the menstrual

cycle. Migraine: Molecular Basis and Herbal Medicine 2012

Prodrome & aura phase• Many migraineurs experience vague vegetative or affective

symptoms as much as 24 hours prior to the onset of a

migraine attack. This phase is called the prodrome

• The aura phase consists of focal neurological symptoms

that persist up to one hour.

• Symptoms may include visual, sensory, or language

disturbance as well as symptoms localizing to the

brainstem.

Typical headache & resolution phase

• Within an hour of resolution of the aura symptoms, the

typical migraine headache usually appears with its

unilateral throbbing pain and associated nausea,

vomiting, photophobia, or phonophobia.

• Without treatment, the headache may persist for up to

72 hours before ending in a resolution phase often

characterized by deep sleep.

Management of migraineThe management of migraine begins with an explanation of certain things to the

patient:

• Migraine is an inherited tendency to cerebral dysfunction, and cannot be cured

• Migraine can be modified and controlled by lifestyle adjustment and the use of

medicines

• Migraine is neither life threatening nor associated with serious illness. however

migraine can and often does make life a misery

• Migraine management takes time and co-operation when information, such as

that from a headache diary, has to be collected.

Intern Med J 2003; 33: 436–442

Medications• Abortive Medications

– Analgesics with caffeine (PCM,acetaminophen, aspirin

and caffeine).

– Analgesics with caffeine and barbiturates

– Non steroidal antiinflammatory drugs (NSAIDs) such

as ibuprofen,naproxen sodium.

– Triptans (suma,riza,nara,algo,zolmi-5HT1B/1D agonist)

– Antiemetics (domperidone)

Oral options in acute management

Intern Med J 2003; 33: 436–442

Comparison of available triptans

Annals of Indian Academy of Neurology, August 2012, Vol 15, Supplement 1

Medications• Preventive Medications

– Beta blockers (propranolol, timolol maleate, and

metoprolol. )

– Calcium-channel blockers (diltiazem, nifedipine).

– Antidepressants (fluoxetine, paroxetine,sertraline).

– Anticonvulsants (valproic acid or divalproex sodium).

– NSAIDs (ketoprofen, naproxen sodium).

Preventative therapy for migraine

Annals of Indian Academy of Neurology, August 2012, Vol 15, Supplement 1

General Principles of Preventive Treatment

• Start with a low dose and increase slowly

• Use an adequate trial of 2 to 3 months

• Avoid medication interactions/contraindications

• Monitor with calendar or diary

• Monitor for medication overuse

• Consider comorbid conditions

• Consider preventive medication combinations in refractory

patients

• Taper when headaches are controlledContinuum Lifelong Learning Neurol 2012;18(4):764–782.

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