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Dr David PB Watson
Hamilton Medical Group Aberdeen
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Theories of Migraine
Acute Treatment
Prevention
Case Studies
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A chronic disorder with episodic attacks
Complex changes in the brain
During attacks
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Headache
Several associated
symptoms
Functional disability
In-between attacks
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Enduring predisposition to future
attacks
Anticipatory anxiety
Cortical events
Meninges and other
peripheral structures
TNC
Trigeminal
ganglion
Brainstem
Neuropeptides
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.
Premonitory
Mood changes
Fatigue
Cognitive changes
Muscle pain
Food craving
Preheadache
Aura
Early Headache
Fully reversible Dull headache
Neurological changes:
Nasal congestion
Visual somatosensory
Muscle pain
Mild
Unilateral
Throbbing
Nausea
Photophobia
Phonophobia
Osmophobia
Moderate
Headache
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.
Advanced Headache
Postdrome
Severe
Fatigue
Cognitive changes
Muscle pain
Post headache
Time
Advanced Headache
Unilateral
Throbbing
Nausea
Photophobia
Phonophobia
Preheadache
Severe
Headache Phase
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.
Postheadache
Time
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The case for
the sensitive migraine
brain
Normal life events
trigger or are
associated with
attacks in those
predisposed
Dehydration
Sleep
disturbance
Hunger
Stress
Diet
Environmental
stimuli
Changes in oestrogen
level in women
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.
 Headache threshold variability
 Patient 4
 Patient 3
 Patient 2
 Patient 1
 Trigger
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Beware of using painkillers more than 2 days
a week
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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)
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Best evidence ASPIRIN 900 mg
IBUPROFEN 400 mg
In pregnancy PARACETAMOL 1000mg
Take early in headache
May be combined with anti-sickness
medicines such as Domperidone,
Metoclopramide and Prochloroperazine
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Migraleve = paracetamol, codeine, (yellow)
buclizine (pink)
MigraMax = aspirin and metoclopramide
Paramax = paracetamol and metoclopramide
Clotam Rapid = Tolfenamic Acid
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Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Sumatriptan
Zolmitriptan
Brain
Nerve
Blood
Vessel
Decreased pain
Decreased pain
transmission
Decreased pain
transmission
Decreased
Decreasain
BBbBion
pain
transmission
transmissioned
transmission p
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Early in the headache phase
Not during aura
Can repeat after 2hours if migraine recurs
No response, don’t repeat
Response idiosyncratic
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Tablet ( gastric absorption)
Melts (gastric absorption)
Nasal Spray ( Gastric and nasal absorption)
Injection ( subcutaneous)
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Most patients have few problems
Sensations of tingling, heat, heaviness,
pressure, tightness of throat or chest
Flushing
Dizziness
Feeling of weakness, fatigue
Nausea and vomiting
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Take early in headache phase
Rescue Treatment (include rectal)
Naproxen
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Consider if frequent debilitating migraine
Not a cure
Good response is works in 50 out of 100
patients to reduce headache frequency and
severity by half
Can be combined
Need adequate doses
 Headache threshold variability
 Patient 4
Patient 1 Preventer
 Patient 3
 Patient 2
 Patient 1
 Trigger
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B Blockers
Tricyclic Antidepressants
Anti Epileptics
Pizotifen
Venlafaxine
Candesartan
(Flunarazine)
(Methysergide)
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Propranolol 80-240 mg
Avoid in asthma
Side Effects (rarely a problem)
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Fatigue
Coldness of extremities
Sleep disturbance and nightmares
Gastro intestinal disturbance
Dizziness
Headache
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Amitriptyline 10 -125 mg
Nortriptyline 10-125 mg
Patient Information Leaflet = anti-depressant
Side effects
 Sedation
 Dry mouth
 Constipation
 Headache
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Sodium Valproate 600-1200 mg daily
 Weight gain
 Hair Loss
 Nausea, Diarrhoea
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Topiramate 50-150 mg daily
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Weight Loss
Sedation and slowed thinking
Irritability and Depression
Pins and Needles
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Start low and aim high
Combinations can be effective
Consider reducing/stopping in 6-12 months
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25 year old lady
Migraine with aura twice a month, always
with menstruation. Can vomit late in
headache. Menstrual migraine can be 2 days
Never misses work
Migraine can be present on waking
Aspirin 2 tabs partially helps some headaches
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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
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37 year old lady, 4 migraine without aura a
month, last 2 days each
Misses 3 days of work a month
Can vomit within 2 hours
Naratriptan helps some time
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Consider
 Take triptan early
 Faster acting triptan
 Nasal triptan
 Naproxen
 Rescue Rx suppositories