A Patient With Migraine
Photophobia. Examination revealed noneuro deficit, no local tenderness of the sinus or cervical spine. There was no scalp tenderness. She was admitted to the hospital and underwent routine blood tests which were normal except for the presence of mild maxillary sinusitis.
Diagnosis: Migraine without aura.
A headache is a common presentation both in outpatients clinic and as well as in the emergency department. Most of the acute onset headache presents in the emergency and the main concern is the possibility of subarachnoid haemorrhage although migraine may sometimes present in the emergency. Usually, patients with chronic intermittent headache present in the outpatient’s clinic and there is a long list of differential diagnosis.
Common causes of a headache
Subarachnoid haemorrhage: Severe, sudden, thunder clasp type headache, causes a momentary fainting attack. There may be a warning headache particularly in a case of expanding aneurysm. Features are
- Neck stiffness
- Positive Kernig’s sign
- Bilateral up going plantars
With this background, urgent admission and neuroimaging will be required. CT brain scan is the preferred investigation as it can detect the presence of blood much earlier than MCI scan which may be negative initially.
Migraine (with aura, without aura): Diagnostic features are:
• Unilateral pain
•Pulsating in nature
• Common in young females
• Nausea vomiting and light sensitivity
• Reversible brain stem and cortical dysfunction with aura
• Visual aura is classical with aura
• Male preponderance
• Usually nocturnal
• Usually unilateral
• Usually periodic with features of autonomic disturbance like and congested eyesAcute attack should be treated with sumatriptan 6 mg sc, maximum
The acute attack should be treated with sumatriptan 6 mg sc, maximum up to flow oxygen therapy should also be instituted during the acute attack.
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For preventive purpose:
Short term: Tapering dose of steroid for a period of 10-15 days may be methysergide with a maximum dose of 9 mg starting with 1 mg may be up to 6 months [restricted use up to 6 months Long term: Lithium with a starting dose 30 mg may be used. Verapamil drug which can be used
Long-term: Lithium with a starting dose 30 mg may be used. Verapamil drug which can be used up to 80 g twice daily.
• Bilateral • Non-pulsating • No aggravation by simple physical activity • No nausea, vomiting • A band like sensation over the head • Usually chronic It is a very common presentation in daily practice.
• Non-pulsating • No aggravation by simple physical activity • No nausea, vomiting • A band like sensation over the head • Usually chronic It is a very common presentation in daily practice.
• No aggravation by simple physical activity • No nausea, vomiting • A band like sensation over the head • Usually chronic It is a very common presentation in daily practice.
• No nausea, vomiting • A band like sensation over the head
• A band like sensation over the head
• Usually chronic
It is a very common presentation in daily practice. The acute attack should be treated with NSAID and sumatriptan. For the preventive purpose, amitriptyline may be used.
Headache due to be brain tumour:
• Progressively worse
• Associated with vomiting
• Increased with exertion, cough
• Other associated neurological signs
“Like cerebellar sign, facial weakness in case of acoustic neuroma”
Transdermal oestrogen 100 ml used from 2-3 days prior to menstruation may be of additional value.
Giant cell arteritis:
• Elderly male
• Scalp tenderness
• High ESR
• Visual problems
Not so common in India. However, diagnosis is important as steroid improves the condition and prevents visual loss. I have come across only 4 cases of cranial arteritis who responded to the steroid. Any patient presenting with proximal muscle weakness and pain along with a headache, one should strongly consider polymyalgia rheumatics along with giant cell arteritis (Common association).
Other causes of headaches — commonly encountered:
- Cervical spondylosis
- Acute glaucoma (this diagnosis will be missed if not thought of — features: a headache, eye pain and vomiting).
- Another common and challenging differential diagnosis is medication overuse headache (MOH). This typically complicates a migraine which is transformed into a chronic daily headache. Regular use of ergots leads to MOH.
This patient had features of a migraine without aura. CT brain was done to rule out subarachnoid haemorrhage. She responded to the usual line of management and discharged home on prophylactic medication.
Management of A migraine: Analgesics:
The first important thing is to relieve the symptoms of a headache, nausea and vomiting. Drugs commonly used are:
- Combination analgesic and antiemetic, paracetamol metoclopramide. Opiates should be avoided because of its abuse potential especially in the genesis of MOH.
This has revolutionised the treatment of a migraine since early 90’s. Of five types of triptans so far available sumatriptan is commonly used in India. It can be used orally or is a subcutaneous injection. Sumatriptan 50 mg or 100 mg is the drug of choice. It can also be
given by subcutaneous route.
Other triptans (naratriptan, zolmitriptan, almotriptan) are not generally available in India. They are almost equipotent.
Triptans should be used with caution in patients with a cardiac problem. Triptans are better than analgesics in an acute migraine. However daily use must be avoided as it may cause MOH. Although more effective than ergots, these are more expensive.
This is still a very popular drug in India. It is cheap and effective. It should be used with caution in patients with a cardiac problem. Abuse potentiality with resultant MOH is there.
Although there is a genetic predisposition for a migraine, certain exogenous factors like dietary factors and stress may trigger a migraine and manipulation of these factors may help in the management of a migraine. Such factors are: 1) Coffee, 2) Tea, 3) Cola, 4) Alcohol.
Treatment of Acute Affect: Specific treatment with triptans and doses:
|Almotriptan||12.5 mg upto 25 mg|
|Eletriptan||40 mg upto 80 mg|
|Frovatriptan||2.5 mg upto 5 mg|
|Naratriptan||2.5 mg upto 5 mg|
|Rizatriptan||5 mg upto 20 mg|
|Sumatriptan (oral)||50 mg upto 300 mg|
|Zolmitriptan||2.5 mg upto 10 mg|
Prevention of recurrence:
One-third of the patients with a migraine will have a recurrence. Use of prophylactic medication will reduce the incidence of recurrence. The drugs commonly used for this purposes are:
- Beta-blocker (Propranolol) – Drug of choice in the presence of co-morbid condition like hypertension.
- Amitriptyline (25 mg — 75 mg) — Particularly in patients with depression and insomnia. It can cause
- Sodium valproate (400 mg — 600 mg) thrice daily, can cause a liver problem.
- Pizotifen (0.5 mg — 3 mg) — can cause drowsiness, weight gain.
- Methysergide (1 mg — 6 mg) — it should be used with caution, causes retroperitoneal fibrosis in prolonged use.
- Flunarizine (5 mg — 15 mg) — Most commonly used the drug in India. Long-term use may cause weight gain, depression and Parkinsonism.
- Topiramate — It is also used to prevent migraine headaches. It works by affecting several chemicals in the brain that help to reduce seizure activity and prevent migraine headaches from occurring.
Other Facts of Management:
Lifestyle modification like avoidance of stress, sleep irregularity and relative hypoglycaemia but intake of regular fibre containing diet etc. may be helpful. International travel is a frequent trigger for a migraine and appropriate precautionary measures should be taken.
A migraine with aura is a risk factor (albeit minor) for cerebral stroke. So it is preferable to avoid oestrogen containing oral contraceptive pills (OCP) and other forms of contraceptive devices are preferable in patients with a migraine.
Certain foods may trigger migraine headaches, so try to avoid these. The most common are: wine, processed and fermented foods, pickle, marinated foods, much chocolate, nuts and dairy products, cured meats, chicken liver etc.
Avoid certain odours or perfumes, loud noises or bright lights, and smoking may also trigger a migraine. Drink plenty of water and place a cool cloth on your head and forehead.
Additional cases of Migraine
CASE: A 30-years-old lady •from Bangladesh attended the clinic with the history of 6-8 months of a headache. Of late, her vision in the left eye was deteriorating and she had episodic vomiting. Examination revealed normal BP, there was 61h nerve palsy on the left side. Fundoscopy revealed grade IV papilloedema in both eyes.
Raised intracranial tension probably due to space occupying lesion in the brain. She underwent urgent MRI Scan of the brain which revealed a left-sided big cerebellar tumour with evidence of gadolinium enhancement. She underwent operative intervention with symptomatic relief. However, her vision still remained poor on discharge. Biopsy revealed haemangioblastoma of the cerebellum.
Early morning headache, associated with effortless vomiting is a feature of SOL of the brain. In case of posterior fossa tumour, papilloedema appears early because of obstruction of CSF drainage.
CASE: A 28-years-old obese, mildly hypertensive lady had been complaining of a severe headache following a recent pregnancy. Initial investigations were all satisfactory. CT scan of the brain was normal. MRI angiogram of cerebral vessels did not reveal any an aneurysm. The ophthalmological examination which was initially missed during her r consultation revealed gross papilloedema both eyes. A diagnosis of benign intracranial hypertension was made and she responded to repeated lumbar puncture, diuretic and a short course of steroid therapy.
Diagnosis: benign intracranial hypertension in an obese hypertensive lady.
Causes of benign intracranial hypertension:
- Steroid in the long-term
- Vitamin A intoxication
- During pregnancy or postpartum period
This condition is frequently associated with obesity and hypertension Ophthalmoscopic examination is essential during a routine examination in a patient with a headache which can give useful clues to the diagnosis.
Case: A 36-years-old lady presented with a severe headache and unconsciousness. She was found to have subarachnoid haemorrhage and after a stormy course in the hospital was finally discharged from the hospital in a stable state. During the course of treatment, she was formed to have an arterio-venous malformation which bled to give rise to her current complication. In the past she was treated by many physicians for her chronic headache, CT scan on couple of occasion was normal and she recommends migraine prophylaxis without much help.
Diagnosis: cerebral bleed due to av malformation.
In case of a persistent headache with negative CT scan, one should suspect vascular anomalies like an aneurysm or AV and request for either CT or MRI angiogram of cerebral vessels or conventional digital subtraction angiography as plain CT scan may be elusive. Clinical judgment is important in this regard.
- A migraine is a common cause of an acute and chronic headache in clinical practice.
- In patients presenting with unilateral, throbbing, headache and vomiting—particularly in young females — migraine should be considered first.
- In an acute headache, CT brain scan is preferable to MRI scan, as it detects blood early.
- In acute attack triptans are the drug of choice, although ergots are also effective and cheap.
- Very frequent use of ergots can cause medication over a use headache.
- If the attack of a migraine is frequent, prophylactic medication should be used and the selection should depend upon other co-morbid condition.