MIGRAINE

A Concise Presentation

By

Mr. Deepak Sarangi M.Pharm

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CONTENTS: Introduction Definition Migraine triggers Phases Classification Pathophysiology Diagnosis Goals for treatment Management Guidelines Summary of prevention Conclusion References

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INTRODUCTION: Migraine is one of the common causes of

recurrent headaches.

According to IHS, migraine constitutes 16% of primary headaches.

Migraine afflicts 10-20% of the general population.

In India, 15-20% of people suffer from migraine.

Migraine is under diagnosed and undertreated.

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“Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting”.

DEFINITION:

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MIGRAINE TRIGGERS: Disturbed sleep pattern Hormonal changes Drugs Physical exertion Visual stimuli Auditory stimuli Olfactory stimuli Weather changes Hunger Psychological factors

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PHASES:

Prodrome

Aura

Headache

Postdrome

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PRODROME: Vague premonitory symptoms that begin

from 12 to 36 hours before the aura and headache.

Symptoms: Yawning Excitation Depression Lethargy Craving or distaste for various foods

Duration: 15 to 20 min.

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AURA:

Aura is a warning or signal before onset of headache.

Symptoms:Flashing of lightsZig-zag linesDifficulty in focussing

Duration : 15-30 min.

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HEADACHE: Headache is generally unilateral and is

associated with SYMPTOMS like: 1. Anorexia2. Nausea3. Vomiting 4. Photophobia5. Phonophobia6.Tinnitus

Duration: 4-72 hrs.

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POSTDROME:Following headache, patient complains of - Fatigue Depression Severe exhaustion Some patients feel unusually fresh

Duration: Few hours or up to 2 days.

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CLASSIFICATION:According to Headache Classification

Committee of the International

Headache Society, Migraine has been

classified as: Migraine without aura (common migraine) Migraine with aura (classic migraine) Complicated migraine

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PATHOPHYSIOLOGY:

VASCULAR THEORY:-o Intracranial/Extracranial blood vessel vasodilation –

headache.o Intracerebral blood vessel vasoconstriction – aura.

SEROTONIN THEORY:-

o Decreased serotonin levels linked to migraine.o Specific serotonin receptors found in blood vessels of

brain.

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Release of Neurotransmitter

Arterial Activation

Worsening of Pain

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DIAGNOSIS: Medical History Headache diary Migraine triggers Investigations

EEGCT BrainMRI

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GOALS FOR TREATMENT: Establish diagnosis. Educate patient. Discuss findings. Establish reasonable expectations. Involve patient in decision. Encourage patient to avoid triggers. Choose the best treatment. Create treatment plan.

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LONGTERM TREATMENT: Reducing the attack frequency and severity. Avoiding escalation of headache medication. Educating and enabling the patient to manage

the disorder. Improving the patient’s quality of life.

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MANAGEMENT: Non-pharmacological treatment:-

Identification of triggers Meditation Relaxation training Psychotherapy

Pharmacotherapy:- Abortive therapy Preventive therapy

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ABORTIVE THERAPYNon-specific treatment:

Drug Dose Route

Aspirin 500-650 mg Oral

Paracetamol 500 mg-4 g Oral

Ibuprofen 200- 300 mg Oral

Diclofenac 50-100 mg Oral/IM

Naproxen 500-750 mg Oral

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o

SPECIFIC TREATMENT:

Drug Dose Route

Ergot alkaloidsErgotamine 1-2 mg/d; max-6

g/dOral

Dihydroergotamine 0.75-1 mg SC

5-HT receptor agonistsSumatriptan 25-300 mg

6 mgOrallySC

Rizatriptan 10 mg Orally

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PREVENTIVE THERAPY:Drugs Dose (mg/d)

1. Betablockers Propranolol 40-320

2. Calcium Channel Blockers Flunarizine Verapamil

10-20120-480

3. TCAs Amitriptyline 10-20

4. SSRIs Fluoxetine 20-60

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GUIDELINES: Migraine significantly interferes with patient’s daily

routine, despite acute treatment.

Acute medications ineffective, intolerable, or overused.

Frequent headache.

Uncommon migraine conditions.

Cost considerations.

Patient preference.

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SUMMARY OF PREVENTION: Use preventive medications when needed. Treat long enough. Avoid acute medications overuse. Take coexisting conditions into account. Use drug with best efficacy for individual

patient.

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CONCLUSION: It is more common in adults than children and in women

than men. While researchers have some idea of what happens within the brain during migraine attacks, much remains to be discovered about its underlying causes and mechanisms.

In addition, treatment focuses on avoiding those things that seem to trigger attacks, identifying drugs that prevent or reduce the severity of attacks and drugs that reduce the intense pain of a severe attack.

The good news is that several classes of drugs are effective for different kinds of migraine and most migraine sufferers can work with their doctor to minimize migraine's effects.

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REFERENCES: Headache Classification Committee The International

Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004;24:1–160.

Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343–9.

Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: Data from the American Migraine Study II. Headache. 2001;41:646–657.

Radat F, Swendsen J. Psychiatric comorbidity in migraine: A review. Cephalalgia. 2004;25:165–178.

Lipton RB, Hamelsky SW, Kolodner KB, Steiner TJ, Stewart WF. Migraine, quality of life and depression: A population-based case control study. Neurology. 2000;55:629–35.

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