Migraine
NeuP2 Neurology MRCEM syllabus
| Headline | |
|---|---|
| Etiology | |
| Epidemiology | Strong genetic component. |
| Clinical presentation | ± aura. Headache: unilat, throbbing, worse with activity Accompanied by N&V, light + sound aversion, lasts hours to days GI upset more common in children |
| Pathogenesis | Neurogenic inflammation of trigeminal neurons innervating large vessels and meninges → dilation of meningeal blood vessels, peptide release → sensitisation of peripheral nociceptors |
| Diagnostic investigations | Clinical diagnosis. |
| Management | triptans PO/IM/SC, nasal spray as soon as headache starts + anti-emetic e.g. prochlorperazine (+diphenhydramine - ↓ risk dystonic rxn) ➥ can trial triptans as trial of treatment (not licensed age <18) ➥ Aspirin up to 900mg ➥ High-flow oxygen ➥ NSAID > paracet BUT advise re overuse (2-3x/wk) ➥ Don't forget the psychosocial ESPECIALLY in children |
| Ongoing management | Follow-up: In 2-8 weeks. Headache diaries, eye checks + lifestyle (regular exercise, snack before bed, avoid caffeine, fluid intake) ➥ ↑ stroke risk → risk venous thrombosis = avoid OCP (CI with aura) consider preventative treatment if migraines are having significant impact on QOL, acute treatment contraindicated or ineffective, or risk of medication overuse headache: - propanolol 80-160mg - topiramate (can start in primary care; CI pregnancy – MUST have highly effective contraception) - amitriptyline Menstrual migraine: frovatriptan, zolmitriptan |