Classical Migraine

Migraine is a medical condition that involves severe, recurring headaches and associated symptoms. It occurs in stages and can last for hours to days, can be so intense to affect persons daily life and activities

Definition of classical migraine

Migraine with aura, it is a recurring headache that strikes after or at the same time as sensory disturbances called the aura. Aura can start within an hour before the headache begins and generally lasts less than 60 minutes. Sometimes there can be the only Aura with little or no headache.

Aura can be

Visual signs and symptoms

Temporary signs and symptoms which tend to start in the center of the field of vision and spread outward which might include :

1.Blind spots, which are sometimes outlined by simple geometric designs.

2.Zig Zag lines float gradually across the field of vision.

3.Shimmering spots or stands.

4.Changes in vision are vision loss.

5.Flashes of lights.

Aura can also be :

1.Numbness

2.Tingling in hands, face, limbs.

3.Speech language difficulties.

4.Muscle weakness, nausea, vomiting, ringing in ears, chills, Hot flushes.

Diagnostic criteria for migraine

Repeated attacks of headache: lasting  for 4-72 hours, that have the  following features and normal findings on physical Examination

At least 2 of – unilateral pain, throbbing pain, aggravated by movement.

At least 1 of – photophobia and phonophobia, nausea and Vomiting.

Types of migraine with aura

1.Migraine with aura: with or without headache is also called a classic migraine.

2 .Migraine with Brain stem aura: This is the aura that starts in the base of the brain.

3.Hemeplegic migraine: rare type and associated with weakness on one type of the body.

4.Retinal Migraine: Associated with vision changes in one eye which start before the migraine.

 Etiology and pathogenesis

Several chemical mediators play a role in migraine, according to the theory, a wave of nerve cell activity spread across the brain and triggers trigeminal neuralgia, there is the release of a variety of neurotransmitters ultimately causing an inflammatory process and pain, waves moving across the part of the brain which process signals produce an aura.

Predisposing risk factors

1. Age:10-40 yrs
2. Sex: a young woman has three times more risk than men
3. Family history of migraine
4. Other medical conditions like depression, anxiety, bipolar disorder, epilepsy, sleep disorders

Triggering factors

1. Menstrual cycle
2. Foods like cheese, alcohol, nitrates
3. Skipping meals
4. Caffeine: too much caffeine or sudden withdrawal from caffeine
5. Changes in weather
6. Loud noises, bright lights, strong smells
7. Medications like vasodilators
8. Sleep disturbances
9. Tobacco

Diagnosis

1. Clinical history
2. Eye examination
3. CT, MRI ,EEG

Prevention

1. Identify and avoid triggering factors
2. Stress management and relaxation techniques
3. Proper diet habits
4. Adequate fluid intake
5. Rest
6. Regular physical exercise

Prophylactic Medicines

B blockers : propranolol , metaprolol

Anticonvulsants : valproate, gabapentin etc

Antidepressants : Amitriptyline, nortriptyline

Serotonin antagonists : Methysergide

Acute Migraine (oral medication) management

NON SPECIFIC TREATMENT

Aspirin -900 mg

Acetaminophen- 1000 mg

Naproxen- (250 -500) mg

Ibrufen- (400- 800) mg

SPECIFIC TREATMENT

Ergotamine – 1-2 mg

TRIPTANS

Sumatriptan : 50-100 mg 

Naratriptan : 2.5 mg

Rizatriptan : 10 mg

Zolmitriptan : 2.5 mg

Electriptan : 40 – 80 mg

Amlotriptan : 12.5 mg

DITANS  

Almotriptan

Electriptan 

Frovatriptan

OPIODS

ANTI EMETICS : chlorpromazine , Metaclopromide, prochloroperazine

NON PHARMACOLOGICAL TREATMENT

1 Adequate sleep and rest

2 Adequate fluids

3 Transcranial magnetic stimulation

4 Gama core which is a Vagus nerve stimulator

 

REFERENCES

1 Wall and Melzack , text book of pain

2 Bonica , management of pain 5^th Edition

3 Simon Rp, et all , Headache and facial pain in clinical neurology

4 Wed.MD Medical reference