Migrane
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Migraine is a common type of headache disorder characterized by recurrent headaches that can cause severe throbbing pain, nausea, vomiting, and sensitivity to light and sound. It is believed to involve changes in brain activity and inflammation of the blood vessels around the brain. Migraines can be further classified based on whether an "aura" occurs before the headache, as well as other associated neurological symptoms. Common triggers include hormonal changes, stress, foods, and environmental factors. Treatment involves managing acute attacks with over-the-counter or prescription medications as well as lifestyle changes and preventive medications to reduce frequency and severity of migraines.
Migrane
- 2. Definition of headache: • Headache is pain in any region of the head. Headaches may occur on one or both sides of the head, be isolated to a certain location, radiate across the head from one point, or have a viselike quality. • A headache may appear as a sharp pain, a throbbing sensation or a dull ache. Headaches can develop gradually or suddenly, and may last from less than an hour to several days
- 3. Symptom Migraine headache Tension headache Cluster headache Location Unilateral (one sided) in 60 to 70 percent; occurs on both sides of the forehead or all over the head in 30 percent of cases Bilateral (involves both sides of the head) Always unilateral, usually begins around the eye or temple Characteristics Gradual in onset, builds up over time; pulsating; moderate or severe intensity; aggravated by routine physical activity Pressure or tightness which waxes and wanes Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality Activity Prefers to rest in a dark, quiet room May remain active or may need to rest Remains active Duration 4 to 72 hours Variable 30 minutes to 3 hours Associated symptoms Nausea, vomiting, photophobia (bothered by light), phonophobia (bothered by sound); may have aura (usually visual, but can involve other senses or cause speech or motor problems) None Tearing and redness of the eye on the same side as the headache; stuffy, runny nose; pallor; sweating; eye drooping; rarely neurologic deficits; sensitivity to alcohol Characteristics of common headache syndromes
- 5. Migraine • Migraine is a common episodic neurologic disorder characterized by disabling headache preceded in one third of patients by various combinations of neurologic, gastrointestinal, and autonomic phenomena (termed the “aura”) • The prevalence of migraine is up to 18% in women and 6% in men
- 6. Migraine: Men vs Women Around the time of a girl’s first menstruation, there is a rapid rise in the incidence of migraine for this gender. The ratio of 3:1 (female migraineurs to male) reflects this trend. In women, the incidence of migraine with aura peaks between ages 12 and 13 and migraine without aura between ages 14 and 17. Oestrogen levels are a key factor in the increased prevalence of migraine in women. Evidence for this includes the following: Migraine prevalence increases at the time of first menstruation Oestrogen withdrawal during menstruation is a common migraine trigger factor Oestrogen in oral contraceptives and HRT can trigger migraines Migraine typically decreases during the second and third trimesters of pregnancy when oestrogen levels are high Migraine is common immediately after the birth as oestrogen levels fall Migraine generally improves with the onset of menopause
- 7. Pathophysiology of Migraine • factors include a genetic predisposition, a susceptibility of the central nervous system to certain stimuli, hormonal factors, and a sequence of neurovascular events. • A positive family history • the etiology of migraine in the majority of patients remains unknown.
- 8. • One of the key structures in the mechanism of pain in migraine is the trigeminal vascular system. Stimulation of the trigeminal nucleus caudalis can activate serotonin receptors and nerve endings on small dural arteries and result in a state of neurogenic inflammation.
- 9. Biologic Basis Of Migraine Headaches: 5/24/2017 9 • Aura is a spreading depression of neuronal activity accompanied by REDUCED BLOOD flow of the cerebral hemisphere HYPOPERFUSION. • Patients who have migraine without aura DO NOT show HYPOPERFUSION. • However, the pain of both types of migraine ??due to extracranial and intracranial arterial VASODILATION, release of neuroactive molecules, such as substance P, neurokinin A, and calcitonin gene–related peptide.
- 10. Alarm Symptoms: • Comes on suddenly, becomes severe within a few seconds or minutes, or that could be described as "the worst headache of your life" • Is severe and occurs with a fever or stiff neck • Occurs with a seizure, personality changes, confusion, or passing out • Begins quickly after strenuous exercise or minor injury • Is new and occurs with weakness, numbness, or difficulty seeing. While migraine headaches can sometimes cause these symptoms, you should be evaluated urgently the first time these symptoms appear.
- 11. Migraine Triggers Migraine triggers or trigger factors do not cause migraine but they can help to bring about an attack. • Travel (motion sickness) • Sleep related triggers – sleep deprivation or disturbance, irregular sleeping patterns, too much sleep • Changes in routine e.g changing to shiftwork • Increases in stress or anxiety levels • Excitement or other positive stressors • Foods and Beverages – Cheese, chocolate, products containing MSG (e.g. hot dogs, Chinese food), citrus fruits, dairy products, nuts, wheat, fatty foods, nitrates and marinated or pickled foods
- 12. Trigger Factors Continued: • Lack of food, delayed meals, irregular eating patterns, fasting and dieting (all lead to lowered blood sugar levels) • Alcohol, especially red wine • Caffeine products or withdrawal from caffeine, • Hormonal changes in women. Puberty, menstruation, pregnancy, HRT and menopause are all potential triggers. • Meteorological Triggers – change of seasons, high atmospheric pressure, heat or cold • Environmental Triggers – smoke, strong smells, high altitude, loud noise, bright, irregular or flickering lights, glare (e.g. from sunlight, from wet surface while driving) • Exercise – too much exercise may act as a trigger, although lack of exercise can also be a trigger • Long periods in front of a computer screen • Head, neck or back injury, High Blood Pressure and other physiological irregularities.
- 13. Types of migraine 1-Migraine Without Aura: 70% of patients The most common symptoms of Migraine without Aura are: • Intense throbbing headache, usually on one side of the head, worsened by movement and lasting from 4-72 hours. • Nausea, sometimes vomiting • Sensitivity to light • Sensitivity to noise • Sensitivity to smells • Stiffness of the neck and shoulders. • Blurred vision
- 14. 2-Migraine With Aura:15% of patients Migraine with Aura refers to a range of neurological disturbances that occur before the headache begins, usually lasting about 20-60 minutes. The disturbances are usually visual e.g. • Blind spots • Flashing lights • Zig-zag patterns • Aura can also present in other ways: • Pins and needles on one side usually starting in the fingers/ arm, sometimes spreading up into the face • Slurring of speech • Muscular weakness • Loss of co-ordination • Confusion
- 15. 3-Vestibular Migraine including, but not limited to; • Severe dizziness • Vertigo • Other motion problems in the head, eyes or body, • Diminished eye focus • Photo-sensitivity (light) • Phono-sensitivity (sound) • Tinnitus • Nausea and vomiting • Ataxia (loss of control over bodily movement) • Neck pain • Muscle spasms in the upper spine area • Confusion • Disorientation • Anxiety/panic
- 16. 4-Basilar Migraine • Basilar migraine is a rare form of migraine that includes symptoms such as loss of balance, double vision, blurred vision, difficulty in speaking and fainting. During the headache, some people lose consciousness. • These are very frightening sensations for the migraine sufferer, and often people describe the feeling of terror and fear that they are about to suffer a stroke. • Basilar migraine occurs when the circulation in the back of the brain or neck is affected. It usually affects young women but is sometimes seen in children too.
- 17. 5-Hemiplegic Migraine • Hemiplegic migraine is another rare but severe form of migraine where reversible paralysis occurs, usually on one side. In some people, aura symptoms can last for days or weeks. • Hemiplegic migraine often begins in childhood and there is frequently a strong family history. Diagnosing this condition usually requires a full neurological examination to rule out other causes, as the symptoms can be indicative of other diseases.
- 18. 6-Ophthalmoplegic Migraine • Ophthalmoplegic migraine is a very rare type of migraine that occurs mainly in young people in which there is weakness of one or more of the muscles that move the eye. • In addition to headache, symptoms of ophthalmoplegic migraine include dilation of the pupils, inability to move the eye upward, downward or across, as well as a drooping of the upper eyelid.
- 19. Chronic (Transformed) Migraine • Chronic migraine is diagnosed if you have migraine on 15 or more days a month over a period of at least six months. • As time passes, some people with migraine may begin to experience additional or almost daily headache. As the frequency increases, the headache pain and other symptoms associated with migraine become milder, but may also become less responsive to treatment. • People will usually experience more typical ‘breakthrough’ migraine attacks on top of the new milder ‘background’ headache. Depression and irregular sleeping are other effects of chronic migraine.
- 20. Treatment of Migraine • relieving acute attacks; and preventing pain and associated symptoms of recurrent headaches • It is important that the patient keep a headache diary :covert headache triggers, assists in monitoring headache frequency and response to treatment, and actively involves the patient in the management of the condition.
- 22. • Many attacks of migraine respond to simple analgesics, such as acetaminophen, aspirin, or nonsteroidal anti-inflammatory agents (NSAIDs) with monitor (overuse) • anti-emetic agent early in an attack (Phenothiazine) • serotonin agonist drugs (sumatriptan ) triptans, :largely circumvented the problem of emesis and gastroparesis in migrainepatients resulting in greater effacacy • Preventive treatment: β-adrenoceptor blockers (Propranolol, Metoprolol ,Timolol ) Antiepileptic drugs (Divalproex sodium ,Topiramate ,Gabapentin) Antidepressants (Amitriptyline ,Nortriptyline ) Calcium channel blockers (Verapamil ) others: Flunarizine*
- 24. Future of Migraine Treatment • Te most signifcant recent advance in acute migraine treatment relates to calcitonin gene-related peptide (CGRP) receptor antagonists. Stimulation of trigeminal ganglia neurons results in release of CGRP; telcagepant, a CGRP receptor antagonist has been found to have similar efficacy to oral triptan therapy. Greater insights into the genetic basis for migraine has enhanced our understanding of ion channel dysfunction in this disorder, and are likely to lead to new therapeutic targets.
Editor's Notes
- #16: Vestibular Migraine or Migraine Association Vertigo (MAV) is a disorder which involves a problem with the coordination of the sensory information sent to your brain from the eyes, muscles & bones, and the vestibular organs inside the ears.