Migraine

Definition:

• Recurrent headaches associated with visual and GI disturbance
• The borderline between migraine and tension headaches is vague
• Over 10% of any population sampled admit to these symptoms

Clinical patterns:

Migraine can be separated into phases:

• Occasionally, a feeling of well-being prior to the attack
• Prodromal symptoms
• Headache and associated features

Classical migraine (migraine with aura):

The prodrome lasts from 15 minutes to 1 hour or more. It usually comprises:

• Visual symptoms (caused by depression of visual cortical function)
• Unilateral patchy scotomata
• Cortical hemianopic symptoms
• Teichopsia (flashes)
• Fortification spectra (jagged lines resembling battlements)

• Transient aphasia sometimes occurs
• Tingling, numbness or weakness of one side
• The patient feels nauseated

Headache follows the prodrome:

• Often begins locally and becomes generalized
• Nausea increases
• Vomiting follows
• Patient is irritable
• Patient prefers to be in a dark room
• Superficial temporal artery is engorged and pulsating

The attack lasts for several hours and then ceases. Sleep often follows.

Common migraine (migraine without aura):

• This is the usual variety of migraine
• Prodromal visual symptoms are vague
• There is recurrent headache accompanied by nausea and malaise

Hemiplegic migraine:

• Rare
• Is where classical migraine is accompanied by hemiplegia
• Recovery occurs within 24 hours

Ophthalmoplegic migraine:

• Rare
• Is a 3^rd nerve palsy occurring in a migraine attack
• Difficult to distinguish from other causes of a 3^rd nerve palsy without investigation

Basilar migraine:

The prodromal symptoms are:

• Circumoral tingling
• Numbness of the tongue
• Vertigo
• Diplopia
• Transient visual disturbance
• Complete blindness
• Syncope
• Dysarthria
• Ataxia

These occur either in isolation or progress to a migrainous headache

Differential diagnosis:

• Meningitis
• Subarachnoid haemorrhage
• TIA (note: headache is uncommon)
• Epilepsy

Management:

General measures include:

• Reassurance and relief of anxiety
• Avoidance of precipitating dietary factors

During an attack:

• Paracetamol (or another simple analgesic)
• Antiemetic if necessary (e.g. metoclopramide)
• 5HT₁ agonist (e.g. sumatriptan SC, PO Inh) is of value

Prophylaxis:

• 5HT antagonist (e.g. pizotifen 0.5mg ON PO for several days, increasing to 1.5mg ON PO)
• Propranolol 10mg PO TID, increasing to 40-80mg PO TID
• Amitripyline 10-30mg ON PO is sometimes helpful