MIGRAINES
Prevalence ˜12%; 90% pts w/FHx; begin early-late teens around puberty, decline in severity & frequency w/age, especially postmenopause; may present w/variety of sx as aura, but acephalgic migraine a dx of exclusion (r/o stroke, TIA, sz). When evaluating for migraine, rule out med overuse HA.
Presentation: Lateralized but can switch sides; mod-severe throbbing pain, worse w/activity, lasts hours-days; photophobia & phonophobia, N > V; nasal congestion or tearing; aura (motor, sensory, or visual sx).
Common triggers: Changes in homeostasis, sleep patterns, missed or delayed meals, specific foods (cheese, chocolate, red dye, wine, MSG), changes in weather, menstruation or hormonal shifts, stress.
Clinical features:
Migraine w/o aura: 4-72 h (untreated); uni/l, pulsating, mod-severe pain, ↑ by activity; N/V, photo/phonophobia, menstrual relationship common.
Migraine w/aura: Fully reversible visual, sensory, speech/language, motor, brainstem, or retinal disturbance; sx spreads gradually ≥5 min; lasts 5-60 min; HA or migraine sx follow w/in 60 min (Cephalalgia 2013;33(9):629.)
Rx: Nonpharmacological; relaxation techniques, biofeedback, etc.; 8-9 h uninterrupted sleep nightly w/consistent sleeping & awakening times; avoid long work hours or irregular shifts; limit caffeine to <240 mg/day, avoiding skipping meals, avoid smoking; exercise 5×/wk for 30 min; limit rescue/abortive med to 2×/wk; avoid known triggers (foods, alcohol, etc.); keep a detailed HA diary, clarify the efficacy of Rx, help identify triggers.
Acute treatment of attack (see specific meds in table below):
Mild-moderate: NSAIDs, antiemetics, simple analgesics, or their combination; consider triptans if prior poor response to the above.
Mod-severe: Triptans preferred, can combine w/NSAID and/or antiemetics; consider DHE. Consider corticosteroids for status migrainosus, severe & resistant or refractory migraines, higher baseline disability, & previous history of recurrent headaches; do not use >6×/yr (Curr Pain Headache Rep 2014;18:464). Give maximal recommended dose of triptan when possible. Avoid opiods; use seldom & only as last resort (initial use is assoc. w/longer length of stay, early return to ED, & progression to chronic migraine) (Cephalalgia 2014;pii:0333102414557703).
Considerations: Early intervention = maximum benefit; less effective 2-4 h after onset; relief should be w/in 2-4 h, depending on drug; 90% have relief after a second dose; any one triptan should be tried on three separate occasions before abandoned; failure of one does not mean another will not work; consider parenteral route for possible malabsorption; if on propranolol, should receive rizatriptan 5 mg & total ≤15 mg in 24 h; if HA worsens w/triptan, reduce the dose by 50%; if nausea, add metoclopramide 10 mg to oral regimen at home; adding NSAID to triptan can improve efficacy & prevent postdrome of lethargy & memory disturb (naproxen 500 mg); concurrent use w/serotonergic meds should be monitored for serotonin syndrome; concurrent use w/MAO inhibitors is contraindicated, except w/naratriptan & frovatriptan, both have longer half-lives; migraine w/aura is not a contraindication to triptan use. Coronary & vascular disease is a contraindication.
Common possible side effects of triptans: Lethargy, paresthesias, & muscle tightness & stiffness, especially neck & chest—explain to pts, as can raise anxiety & concerns for anaphylactic reactions & MI. Muscular sx typically pass w/in about 30 min.
Migraine prophylaxis: Consider starting a prophylactic med if HA-related disability ≥3 days/mo; duration >48 h; acute meds ineffective, contraindicated, or likely to be overused; attacks → profound disability, prolonged aura, or true migrainous infarction; attacks occur >2-4×/mo; pt preference (Headache 2005;45(Suppl 1):S34).
Chronic Migraine: Headache on ≥15 days/mo > 3 mo, which has features of migraine at least 8 days/mo. R/o other HA d/o including medication overuse HA, hemicrania continua, chronic tension HA. Rx: Treatment of comorbid psychiatric illness & nonpharmacological mgt is essential. Topiramate & botox injections shown beneficial in RCTs but other conventional prevention meds may also work (Nat Rev Neurol 2012;8:162).
MIGRAINE VARIANTS
Status migrainosus: >72 h; need to r/o 2° causes.
Estrogen-related migraine
Women of childbearing age. Usually occur right before & during menstruation or w/withdrawal of estrogen. Rx: Acute treatment, as for nonmenstrual migraines. Prevention: Extended duration OCP if already on OCP or if indication for OCP exist or prophylaxis as above. Short-term prevention: Long-acting triptan or NSAID 2-3°days before & continue during menses. Women w/migraine w/aura have increase risk of stroke (see Migraine and Stroke Risk below); use of OCP should be avoided or carefully considered.
Migraine with brainstem aura
Aura of visual, sensory, or speech/language sx associated w/dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia, or decreased consciousness; aura of 5-60 min, usually unilateral, followed by HA w/in 60 min, similar to vertebrobasilar stroke presentation; should prompt stroke w/u w/vessel imaging. If vascular w/u is neg, Rx is per migraine algorithm.
Hemiplegic migraine
Aura of typically uni/l motor weakness & visual, sensory, and/or speech/language sx; there are familial forms; it is rare & stroke should be r/o. Rx is per migraine algorithm except that triptans & DHE should be avoided (controversial); additional meds to consider include acetozolamide & lamotrigine (Lancet Neurol 2011;10:457).
