Dr David PB WatsonHamilton Medical Group Aberdeen

Theories of MigraineAcute TreatmentPreventionCase Studies

A chronic disorder with episodic attacks

Complex changes in the brain

During attacks – Headache– Several associated

symptoms– Functional disability

In-between attacks – Enduring predisposition to

future attacks– Anticipatory anxiety

TGS = trigeminal system; TNC = trigeminal nucleus candalis.Bigal ME et al. Neurology. 2008;71:848–855; Brandes JL. Headache. 2008;48:430–441; Coppola G et al. Cephalalgia. 2007;27:1429–1439; Goadsby PJ et al. N Engl J Med. 2002;346:257–270; Haut SR et al. Lancet Neurol. 2006;5:148–157; Lovati C et al. Headache. 2008;48:272–277; Pietrobon D. Neuroscientist. 2005;11:373–386.

Cortical events

BrainstemNeuropeptides

Trigeminalganglion

Meninges and other peripheral structures

TNC

Cady R et al. Headache. 2002;42:204–216.Linde M. Acta Neurol Scand. 2006;114:71–83.Linde M. Cephalgia. 2006; 26; 712–721.

Headache

Post headache TimePreheadache ModerateMild Severe

Premonitory

Mood changes FatigueCognitive changesMuscle painFood craving

Fully reversibleNeurological changes: Visual somatosensory

Aura

Dull headacheNasal congestionMuscle pain

Early Headache

UnilateralThrobbingNauseaPhotophobiaPhonophobiaOsmophobia

Advanced Headache

FatigueCognitive changesMuscle pain

Postdrome

Cady R et al. Headache. 2002;42:204–216. Linde M. Acta Neurol Scand. 2006;114:71–83.Linde M. Cephalgia. 2006; 26; 712–721.

Headache Phase

Postheadache TimePreheadache Severe

UnilateralThrobbingNauseaPhotophobiaPhonophobia

Advanced Headache

The case for the sensitive migraine brain

Normal life events trigger or are associated with attacks in those predisposed

CNS = central nervous system.Coppola G et al. Cephalalgia. 2007;27:1429–1439; Kelman L. Cephalalgia. 2007; 27:394–402; Pietrobon D et al. Nat Rev Neurosci. 2003;4:386–398.

Dehydration

Diet

Environmentalstimuli

Changes in oestrogenlevel in womenStress

Hunger

Sleep

disturbance

Beware of using painkillers more than 2 days a week

Medicines taken during a headache to reduce or put the pain away and to help sickness

Painkillers Anti-sickness medications Migraine specific medicines

Triptans Ergotamine (Cafergot, Migril includes

cyclizine and caffeine)

Best evidence ASPIRIN 900 mg IBUPROFEN 400 mg In pregnancy PARACETAMOL

1000mgTake early in headacheMay be combined with anti-sickness

medicines such as Domperidone, Metoclopramide and Prochloroperazine

Migraleve = paracetamol, codeine, (yellow) buclizine (pink)

MigraMax = aspirin and metoclopramide

Paramax = paracetamol and metoclopramide

Clotam Rapid = Tolfenamic Acid

AlmotriptanEletriptanFrovatriptanNaratriptanRizatriptanSumatriptanZolmitriptan

Decreased pain transmissionDecreased pain

transmissionDecreased pain transmissionDecreasain transmissioned p

BBbBionDecreased pain transmission

Brain

Nerve

Blood Vessel

Early in the headache phaseNot during auraCan repeat after 2hours if migraine

recursNo response, don’t repeatResponse idiosyncratic

Tablet ( gastric absorption)Melts (gastric absorption)Nasal Spray ( Gastric and nasal

absorption) Injection ( subcutaneous)

Most patients have few problems

Sensations of tingling, heat, heaviness, pressure, tightness of throat or chest

FlushingDizzinessFeeling of weakness, fatigueNausea and vomiting

Take early in headache phaseRescue Treatment (include rectal)Naproxen

Consider if frequent debilitating migraine

Not a cureGood response is works in 50 out of

100 patients to reduce headache frequency and severity by half

Can be combinedNeed adequate doses

Patient 1 Preventer

B BlockersTricyclic Antidepressants Anti EpilepticsPizotifenVenlafaxineCandesartan (Flunarazine) (Methysergide)

Propranolol 80-240 mgAvoid in asthmaSide Effects (rarely a problem)

Fatigue Coldness of extremities Sleep disturbance and nightmares Gastro intestinal disturbance Dizziness Headache

Amitriptyline 10 -125 mgNortriptyline 10-125 mgPatient Information Leaflet = anti-

depressantSide effects

Sedation Dry mouth Constipation Headache

Sodium Valproate 600-1200 mg daily Weight gain Hair Loss Nausea, Diarrhoea

Topiramate 50-150 mg daily Weight Loss Sedation and slowed thinking Irritability and Depression Pins and Needles

Start low and aim highCombinations can be effectiveConsider reducing/stopping in 6-12

months

25 year old ladyMigraine with aura twice a month,

always with menstruation. Can vomit late in headache. Menstrual migraine can be 2 days

Never misses workMigraine can be present on wakingAspirin 2 tabs partially helps some

headaches

Consider Dose. Aspirin 900 mg helps day time

migraine Timing. Taken early in headache works

better Nausea/vomiting . Required triptan for

menstrual migraine Rescue = triptan

37 year old lady, 4 migraine without aura a month, last 2 days each

Misses 3 days of work a monthCan vomit within 2 hoursNaratriptan helps some time

Consider Take triptan early Faster acting triptan Nasal triptan Naproxen Rescue Rx suppositories