Migraines

• Migraine is a complex neurological condition causing episodes or attacks of headache and associated symptoms.
• Migraine is common, tends to affect women more often than men and is most common in teenagers and young adults.
• Migraine can be categorised into four main types: Migraine without aura, Migraine with aura, Silent migraine (migraine with aura but without a headache), and Hemiplegic migraine.
• The pathophysiology of migraine has been studied for decades and it is likely a combination of structural, functional, chemical, vascular and inflammatory factors.
• There are five stages of migraine: Premonitory or prodromal stage (can begin several days before the headache), Aura (lasting up to 60 minutes), Headache stage (lasts 4 to 72 hours), Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping), and Postdromal or recovery phase.
• These stages vary between patients and some patients may only experience one or two of the stages.
• The prodromal stage may involve days of subtle symptoms such as yawning, fatigue or mood change before the headache starts.
• Migraine headaches last between 4 and 72 hours and are usually unilateral but can be bilateral, moderate-severe in intensity, pounding or throbbing in nature, and may cause photophobia, phonophobia, and osmophobia.
• Aura can affect vision, sensation or language and visual symptoms are the most common.
• Visual symptoms may include sparks in the vision, blurred vision, lines across the vision, loss of visual fields (e.g., scotoma), and sensation changes may include tingling or numbness.
• Language symptoms may include dysphasia (difficulty speaking).
• The main feature of hemiplegic migraines is hemiplegia (unilateral limb weakness) and other symptoms may include ataxia (loss of coordination) and impaired consciousness.
• Triptans are used to abort migraines when they start to develop and bind to and stimulate serotonin receptors 5-HT 1B and 5-HT 1D.
• Migraines tend to become less frequent and severe or stop altogether with time, particularly after menopause.
• Triptans have various mechanisms of action, including cranial vasoconstriction, inhibiting the transmission of pain signals, and inhibiting the release of inflammatory neuropeptides.
• Migraines are associated with a slightly increased risk of stroke, particularly when associated with aura.
• Patients may develop strategies for managing symptoms, often retreating to a dark, quiet room and sleeping.
• Migraine triggers vary between patients and may include: stress, bright lights, strong smells, certain foods, dehydration, menstruation, disrupted sleep, trauma.
• Prophylactic medications to reduce the frequency and severity of attacks include propranolol, amitriptyline, topiramate, pizotifen, candesartan, sodium valproate, monoclonal antibodies, and more specialist options.
• Prophylactic triptans are an option for menstrual migraines and symptoms tend to occur two days before until three days after the start of menstruation.
• It is essential to exclude a stroke with sudden-onset hemiplegia.
• Medical options for an acute attack include NSAIDs, paracetamol, triptans, antiemetics, and opiates are not used to treat migraines and may make the condition worse.
• A headache diary can help identify the triggers and assess the response to treatment.
• The main contraindications for triptans relate to risks associated with vasoconstriction, for example, hypertension, coronary artery disease or previous stroke, TIA or myocardial infarction.
• The risk of stroke is further increased with the combined contraceptive pill, making them a contraindication to the combined pill.
• Familial hemiplegic migraine is an autosomal dominant genetic condition characterised by hemiplegic migraines that run in families.
• Triptans should halt the attack and if the attack resolves and then reoccurs, another dose can be taken.
• Hemiplegic migraines can mimic a stroke or TIA.