Migraine Headache
meduploader - 05-14-09 13:41

Mostly young women. Strong family history.
Benign, recurrent headaches, unilateral pulsating pain associated with symptoms such as photophobia, phonophobia, anorexia, nausea, and vomiting.
Episodes typically last 4–72 hours, improvement with resting in a dark, quiet room.
Classic migraine (migraine with aura): Occurs in 20% of patients.
The most common auras are visual, including “fortification spectra” and scotomas (blind spots).
Common migraine: Most migraine patients do not have preceding auras.
Migraine variants: Named for associated focal neurologic deficits and/or vascular territories; include
hemiplegic migraine, basilar migraine (brain stem symptoms such as ataxia, vertigo, and slurred
speech), and ophthalmoplegic migraine (unilateral CN III palsy and pupillary abnormality).
Patients with classic and common migraines have normal neurologic exams.
In patients with headache and focal neurologic deficits, a migraine variant remains a diagnosis of
exclusion. These patients require workup for other causes of headache and focal deficits (e.g., vascular
event, infection, intracranial mass).

If migraine inherited from mother ----> it will get precipitated during menstruation
If migraine inherited from father ----> they have migraine WITH aura
Rx: Identify and avoid dietary “triggers,” including: Caffeine withdrawal , Nitrates and nitrites in preserved meats, Phenylethylamines in aged cheeses, red wines, beer, champagne, chocolate, and monosodium glutamate in Asian and other prepared foods , Dairy products ,Fatty foods
Recommend specific behavioral therapies for migraine patients, including relaxation training, biofeedback, or cognitive-behavioral therapy
Use migraine-specific agents (e.g., triptans, dihydroergotamine, ergotamine)
- in patients with severe migraine
- in those whose headaches have responded poorly to NSAIDs or combination analgesics such as aspirin plus acetaminophen plus caffeine.
Triptans first choice because they are more effective and cause less nausea.
Contraindications to the use of triptans include all of the following:
Coronary artery disease
Uncontrolled hypertension
Use of an MAO inhibitor within the last 2 weeks
Use of an ergot preparation within the last 24 hours
Others:
Acetaminophen/butalbital/caffeine (Fioricet): Butalbital is a barbiturate and has addictive properties.
Isometheptene/dichloralphenazone/acetaminophen (Midrin): Avoid in patients taking MAOIs.
Antiemetics: Prochlorperazine, promethazine.
Preventive Rx
Indications for daily preventive drug treatment in patients with significant disability related to frequent or severe migraine attacks (usually at least 2 per month):
Recurrent headaches that interfere with daily routine
Contraindication to acute (abortive) therapy , Failure or overuse of acute therapy , Adverse effects from acute therapy , A preference for preventive therapy
à Choose among the following effective classes of agents, listed in order of strength of evidence for efficacy:
Non-selective, β-antagonists
Anticonvulsants : VALPROIC ACID, TOPIRAMATE à Be aware that valproate is the only antiepileptic drug approved by the FDA for migraine
Antidepressants, calcium antagonists, ARB ( Candesartan)
Consider perimenstrual preventive treatment with a triptan for menstrually associated migraines. ( also ocpills without off period, Seasonale etc).
Try a drug therapy for at least 2 months before changing the agent.
Consider tapering or discontinuing preventive treatment after a sustained reduction in headache frequency that lasts 6 to 12 months.
If patient has BA give amitryptiline.
Amitriptyline is used on a daily basis as preventive therapy (LEAST likely to cause medication-overuse or rebound headache)
Migraine Pt is headache free ---> when will u discontinue his medication (Prophylactic) ---> should be headache free for 6 month.
Keep in mind the common side effects of medications (migraine prophylaxis) and the appropriateness in your specific patient. For example,
Valproate would be a bad choice for many patients, secondary to weight gain.
Propranolol may cause hypotension.
Amitriptyline may cause cognitive difficulties and worsen urinary retention in elderly patients. Topiramate may actually cause weight loss, and impaired cognition is common
Referral
Refer the following to a migraine specialist:
Intractable migraine (status migrainosus)
Medication-overuse headache or chronic migraine (sometimes described as “rebound” headache, transformed migraine, or chronic daily headache)
Analgesic dependency (especially narcotic analgesics)