Migraine

Pathophysiology

CSD = Cortical spreading depression CGRP = Calcitonin gene-related peptide

Migraine triggers

Classification

A. Episodic

• Low frequency: <10 headache days per month
• High frequency: 10 – 14 headache days per month

B. Chronic

• 15 or more headache days per month for more than 3 months

C. With our without aura

Diagnostic criteria

Migraine without aura

Migraine with aura

4 Phases of Migraine

🚩Red flags of headache

Mnemonic: SNOOP

Acute treatment of migraine

Management of Migraine in emergency settings

For patient who are having severe pain, not responding to usual analgesics

Identification of any red flag symptoms

For rapid effect & relief, IV or IM route is preferred. Always consider the presence of allergies & co-morbid illnesses.

Preventive therapy

Indications:

1. Attacks significantly interfere with pt’s daily routines despite acute treatment.
2. Frequent attacks (>= 4 monthly headache days)
3. Contraindication to, failure of, or overuse of acute treatments (Medication Overuse Headache), with overuse defined as:
   – 10 or more days per month for ergot derivatives, triptans, opioids, combination analgesics, & a combination of drugs from different classes that are not individually overused.
   – 15 or more days per month for non-opioid analgesics, PCM, & NSAIDs
4. Side effects with acute treatment
5. Patient preference

Drug Therapy for Prophylaxis of Migraine

Supplements to consider for migraine prevention

Headache diary

Complications of migraine

1. Status migrainous: Debilitating migraine > 72 hours
Diagnostic criteria:
A. Headache criteria fulfilling criteria B & C (as mentioned above)
B. Occurring in a patient with migraine +/- aura, & typical of previous attacks except for its duration & severity.
C. Both of the following characteristic:
– Unremitting for > 72 hours
– Pain &/or associated symptoms that are debilitating
D. Not better accounted for by another ICHD-3 diagnosis

2. Persistent aura without infarction: Aura symptoms > 1 week without evidence of infarction on imaging

3. Migrainous infarction
One or more aura symptoms occurring in association with an ischaemic brain lesion in the appropriate territory demonstrated by neuroimaging, with onset during course of a typical migraine with aura attack.
Diagnostic criteria:
A. A migraine attack fulfilling criteria B & C
B. Occurring in a patient with migraine with aura and typical of previous attacks except that one or more aura symptoms persists > 60 mins.
C. Neuroimaging demonstrates ischaemic infarction in relevant area
D. Not better accounted by another ICHD-3 diagnosis

4. Migraine-aura triggered seizure
Seizure triggered by an attack of migraine with aura, occurring during or within 1 hour after a migraine attack.

Special issues in Migraine

A. Menstrual migraine (caused by oestrogen withdrawal trigger & release of uterine prostaglandins during menses –> excitability & neurogenic inflammation)
Attacks of migraine +/- aura occurring on day 1 or 2 of menstruation in at least 2 out of 3 menstrual cycles
Short term perimenstrual prevention (‘mini-prophylaxis’)
– Either NSAIDs (if no contraindication; naproxen sodium 550 mg bd with GI protection) or triptans (sumatriptan 25 mg TDS or frovatriptan 2.5 mg OD) or combinations can be given perimenstrually, especially for women with regular cycle.
– Start 2 days prior or at onset of menstrual migraine for a total duration of 5 days.

B. Migraine, stroke & hormonal contraceptives
Migraine with or without aura in presence with 2 vascular risk factors are associated with stroke in younger women of < 55 y/o.
COC should be used cautiously in clinical practice for women of reproductive age with high migraine prevalence.

If a young woman who is already taking the COC pill develops new persisting headache/new-onset migraine aura/dramatic increase in headache frequency & intensity/unusual & prolonged auras, the COC should be stopped.

Medication overuse headache