Migraines are recurring headaches which are typically unilateral and tend to be described as a throbbing pain.
Triggers
- Stress
- Caffeine
- Cheese
- Menstruation
- Lack of sleep
Clinical Features
- Unilateral throbbing/pulsatile headache, usually described as being behind the eye.
- Moderate/severe intensity – usually disruptive to everyday activity
- Associated symptoms include
- Nausea/Vomiting
- Nasal congestion
- Photophobia (sensitivity to light)
- Phonophobia (sensitivity to sound)
- Osmophobia (sensitivity to smell)
- Patients tend to want to sleep or lie down, particularly in a dark room.
- Aura: Reversible neurological symptoms which are usually sensory but can also be motor. Examples include:
- Visual: Positive symptoms e.g. visual hallucinations, glimmering shapes, flickering lights, zigzags, floaters or negative symptoms e.g. loss of vision, scotoma,
- Somatosensory: Paraesthesia, numbness
- Motor: Weakness
- Speech disturbances: Mild speech impairments, aphasia
- Menstrual related migraine: Occurs mainly 2 days before or 3 days after the start of menstruation in 2 out of 3 consecutive cycles
Migraine Attack Stages
- Prodrome: May display signs of an oncoming migraine 24-48 hours prior to headache onset. Features include irritability, mood changes, sensitivity to light/sound/smell, food cravings.
- Aura: Patients may or may not experience an aura. Auras are reversible symptoms that can last between 5 and 60 minutes. The headache tends to begin shortly after the aura.
- Headache: The headache itself – migraine attacks can last between 4 hours and 3 days.
- Post-Drome: Malaise, fatigue following the initial headache.
Differential Diagnosis
- Cluster headache: Tends to affect men and are associated with autonomic symptoms e.g. redness, watery eyes.
- Tension type headache: Tends to be bilateral, like a tight band.
- Raised intracranial pressure: Tend to get headache, projectile vomiting and disturbances in GCS/consciousness
- Meningitis: Headache, nausea, vomiting, neck stiffness and photophobia can occur here as well. However, a fever is more likely to be present in meningitis considering it is an infective process.
Acute Attack Management
Triptans are the mainstay of acute migraine management. They are a class of 5HT receptor agonists and act on arterial smooth muscle to cause vasoconstriction. They help terminate acute migraine attacks. Contraindications to triptans include:
- Ischaemic heart disease
- Uncontrolled hypertension
- History of stroke
- Peripheral arterial disease
NICE recommend the following:
- Combination therapy of oral triptan + simple analgesic (paracetamol/NSAID)
- Monotherapy can be used with paracetamol or NSAIDs in cases where triptans cannot be used
- Nasal triptans are preferred for patients 12-17
- Frovatriptan/zolmitriptan for patients with menstrual-related migraine to be taken on the days migraines are expected to occur
Other supportive measures such as anti-emetics should also be considered.
Prophylactic Treatment
First line
- Topiramate or propranolol: Women and girls on topiramate who are of childbearing potential should be counselled of the risk of foetal malformations alongside risk of reduced efficacy of hormonal contraceptives. Appropriate contraception should be considered.
Alternative Therapies
- Amitriptyline
- Riboflavin has been shown to help reduce migraine severity and frequency in some patients
- Courses of acupuncture have been recommended by NICE where topiramate/propranolol have been ineffective
Clinical Considerations
- Advise patients to avoid triggers where possible
- Female patients with aura should not be prescribed any combined oral contraceptives as they are at a higher risk of ischaemic stroke. They should be prescribed non-hormonal contraceptives or progesterone only contraceptives instead.
References
https://www.nice.org.uk/guidance/cg150/chapter/Recommendations#assessment
https://www.ncbi.nlm.nih.gov/books/NBK560787/#:~:text=Migraine%20without%20aura%20is%20a,sensitivity%20(photophobia%20and%20phonophobia).
