Migraine

Migraine 1

Migraine

• Characterised by episodic headache, typically

unilateral, associated with vomiting and visual

disturbance.

• Headache may be bitemporal and generalised

without focal visual or neurological disturbance.

• Incidence 250/1,00,000, neurological disease. Migraine 2

SinusSinus

TreatmentTreatment

TensionTension

MigraineMigraine

The Headache Dilemma…The Headache Dilemma…

HOW COMMON IS MIGRAINE

o World- 15-20% of women World- 15-20% of women o 10-15% of men10-15% of meno In India 15-20% migraineIn India 15-20% migraineo Adults-female: male ratio is 2:1Adults-female: male ratio is 2:1o In childhood boys and girls are In childhood boys and girls are

affected equally until puberty when affected equally until puberty when predominance shifts to girlspredominance shifts to girls

Pathogenesis• ↓ cerebral blood flow at the onset of an attack in migraine

with aura. During phase of attack, dilatation of extracranial

arteries related to fluctuations in blood 5-ht levels.

• Genetic predisposition.

• Chocolate, cheese, alcohol may precipitate attack.

• Episodes ↑ perimenstrually, at weekends or in women

taking oral contraceptives.

• Stress & anxiety may initiate an attack.

Migraine 8

Trigeminal Nerve

Sensory nervedischarge

Directly

PainPain

Neruogenic Inflammation(CGRP,SP release)

PG + kinin release

Perivascular oedmea

AuraAuraSpreading depression

+ Hypoperfusion

Unknown abnormal neuronal discharge +

NSAIDs

5-HT1D Agonist5-HT2 Antagonist 5-HT1D Agonist

5-HT1D Agonist

5-HT1D Agonist

Dilatation of B.V

5HT2receptor act

Release of CGRP, substance P & Inflammatory Cytokines

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5 6

PATHOPHYSIOLOGYVascular theory-

o Intracerebral blood vessel constriction – Intracerebral blood vessel constriction – auraaura

o Intracranial/extra cranial blood vessel Intracranial/extra cranial blood vessel vasodilatation-headachevasodilatation-headache

Serotonin theory-

o Decreased 5-ht levels linked with migraineDecreased 5-ht levels linked with migraine

o Specific 5-ht receptors found in blood Specific 5-ht receptors found in blood vessels of brainvessels of brain

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2

Changes in nerve cell activity and blood flow may result in visual disturbance, numbness or tingling, and dizziness.

Electrical impulses spread to other regions of the brain.

Migraine originates deep within the brain

3Chemicals in the brain cause blood vessel dilation and inflammation of the surrounding tissue

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The inflammation irritates the trigeminal nerve, resulting in severe or throbbing pain

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CLASSIFICATION

o Migraine with auraMigraine with aura

o Migraine without auraMigraine without aura

o Complicated migraineComplicated migraine

PHASES OF ACUTE MIGRAINE

o ProdromeProdrome

o AuraAura

o HeadacheHeadache

o PostdromePostdrome

PRODROMEo Vague premonitory symptoms that Vague premonitory symptoms that

begin from 12 to 36 hrs before the begin from 12 to 36 hrs before the aura and headacheaura and headache

o Symptoms includeSymptoms include:-:- YawningYawning ExcitationExcitation DepressionDepression LethargyLethargy Craving or distaste for various foodsCraving or distaste for various foodso Duration- 15-20minDuration- 15-20min

AURAo Aura is a warning or signal before onset of Aura is a warning or signal before onset of

headacheheadache

o Symptoms includeSymptoms include

Flashing of lightsFlashing of lights

Zig zag linesZig zag lines

Difficulty in focussingDifficulty in focussing

o Duration:15-30 minDuration:15-30 min

HEADACHEo Headache is generally unilateral and Headache is generally unilateral and

is associated with symptoms like:is associated with symptoms like:o AnorexiaAnorexiao NauseaNauseao VomitingVomitingo PhotophobiaPhotophobiao PhonophobiaPhonophobiao TinnitusTinnitus

o Duration:4-72 hrsDuration:4-72 hrs

POSTDROMEFollowing headache, patient Following headache, patient

complains ofcomplains ofo FatigueFatigueo DepressionDepressiono Severe exhaustionSevere exhaustiono Some patients feel unusually Some patients feel unusually

freshfresh

o Duration: few hrs to 2 daysDuration: few hrs to 2 days

Clinical Features Starts after puberty, continues till late midlife.

Attack may occur from a few days to several months.

Attacks may last for hours to days.

Premonitory symptoms – zig-zag lines, flashing, coloured lights,

defects in visual field & dysphasias with headache.

Headache localized to frontal region & spreads to whole of one

side of head – pain severe & throbbing associated with vomiting,

photophobia, pallor.

Patient is shifted to a bed in darkened room.

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MIGRAINE MANAGMENT

Non pharmacological treatmento Identification of triggersIdentification of triggerso MeditationMeditationo Relax techniquesRelax techniqueso PsychotherapyPsychotherapy

Pharmacological treatmento Abortive treatmentAbortive treatmento Preventive treatmentPreventive treatment

ABORTIVE TREATMENT

Non specific treatment-

o AspirinAspirin

o ParacetamolParacetamol

o IbuprufenIbuprufen

o diclofenacdiclofenac

ABORTIVE THERAPYSpecific treatment-

Ergot alkaloidsErgot alkaloids:-ergotamine:-ergotamine

dihydroergotaminedihydroergotamine

TriptansTriptans:- sumatriptan:- sumatriptan

rizatriptanrizatriptan

Antinauseant drugsAntinauseant drugs:- metaclopramide:- metaclopramide

chlorpromazinechlorpromazine

Triptans work best in 1Triptans work best in 1stst couple of hrs of attack couple of hrs of attack

Ergotamine works at any time during the attackErgotamine works at any time during the attack

Management Avoid dietary and other precipitants.

Maintain a diary of attacks.

Stop oral contraceptives.

Soluble Aspirin (600-900 mg) or Paracetamol (1 Gm) with or

without Metoclopramide as antiemetic.

Ergotamine tartarate, 0.5-1.0 mg sublingually may abort

headache if taken as soon as visual symptoms are felt. No More

than 12 mg in a week. Excessive use may lead to vasospasm &

paradoxical headache. Contraindicated in pregnancy, IHD &

peripheral vascular disorders.Migraine 25

…Management• Serotonin agonist-triptans – Sumatriptan for acute attacks of

migraine (100 mg). No more than 300 mg per 24 hours or Inj.

Sumatriptan 6 mg SC. Not more than 2 injections per 24

hours. Highly efficacious.

• Prophylaxis if attacks occur weekly:

Propranolol : 40-80 mg 8 hrly. Pizotifen

: 1.5-3 mg at night.

• Amitriptyline : 25-100 mg at night.

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Migraine & Oral Contraceptives

C/I migraine if there is typical aura, focal

features or if it is severe and lasts for

more than 72 hrs despite treatment

with ergotamine.

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Acute Migraine Attack• It appears to begin in serotonergic (5-HT) and

noradrenergic neurons in the brain. These monoamines affect cerebral & extracerebral vasculature and cause release of vasoactive substances such as H, PGs, neuropeptides involved in pain, i.e. neurogenic inflammation can be inhibited by antimigraine drugs.

• Migraine aura of visual or sensory disturbance originates in occipital or sensory cortex.

• Throbbing headache is due to dilatation of vessels – sensitive arteries outside the brain.

Migraine 29

Triggering Factors Avoidance

• Stress – exertion, anxiety, excitement, fatigue, anger.

• Foods containing vasoactive amines – chocolate, cheese.

• Bright lights, loud noise.• Food Allergy.• Hypoglycemia.• Menstruation and oral contraceptives.

Migraine 30

Treatment – Stepped Approach

• Aspirin 600 mg oral dispersible (soluble) as early as possible.

• Alternatives are Paracetamol, Ibuprofen, Naproxen.

• Metoclopramide or Domperidone (dopamine agonists) – antiemetics that promote gastric emptying & enhance absorption of analgesic.

• Efficient use of analgesic & antiemetic is adequate for majority of attacks.

Migraine 31

Stepped Treatment

Severe migraine attacks should be treated with

triptans – Sumatriptan. Headache may return in

6-36h in 1/3rd patients. Use second dose.

Ergotamine 1-2 mg used if other treatments

failed, but not within 12h of the last dose.

Do not give triptans until 24h have elapsed after

stopping ergotamine.

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Triptans

Selectively stimulate 5-HT 1B/1D – receptors found

in cranial blood vessels – vasoconstriction.

-Sumatriptan.

-Rizatriptan.

-Almotriptan.

-Naratriptan.

-Zolmitriptan.

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SUMATRIPTAN

• Rapid oral absorption.• 84% presystemic elimination.• SC bioavailability 96%.• Oral 50-100 mg, maximum 300 mg in 24h,

Repeat 2h.• Intranasal 20 mg, maximum 40 mg in 24h,

Repeat 1h.• SC 6 mg, 12 mg in 24h, Repeat 1h.

Migraine 34

Sumatriptan - ADRs

• Malaise, fatigue, dizziness, vertigo, sedation.• N,V.• Feelings of chest pressure, tightness and pain.• Cardiac arrhythmias, MI.

Migraine 35

Sumatriptan – C/I

Prophylaxis of migraine

MI

IHD

Variant angina

Uncontrolled HT

Concomitant ergotamine

Within 2 wks after stopping MAOIs

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RIZATRIPTAN

• C/I: HT, IHD, Prinzmetal’s angina, Lactation,

Within 2 wks of MAOIs, Within 24 hrs of

treatment with another 5-HT agonist or

ergotamine.

Tab. Rizact 5 mg Rs 30/-

10 mg Rs 50/-

Migraine 37

ERGOTAMINE Partial agonist at α-adrenoceptors

(vasoconstrictor). Partial agonist at serotonergic receptors. Constricts all peripheral arteries. Effect persists for 24h, repeated doses cause

cumulative toxicity. Tablets 1 mg crushed before swallowing. Initially 1-2 mg, maximum 4 mg in 24h. Not more than 8 tablets in a week. Rectal suppositories of 2 mg preferred.

Migraine 38

…ERGOTAMINE CONTRAINDICATIONS: -

Vascular & Valvular disease. -Pregnancy. -Collagen diseases. -Prophylaxis.

ADRs: -Muscle cramps. -Stiffness. -Tiredness. -N,V,D.

ERGOTISM: Severe peripheral vasoconstriction, hypertension, gangrene of extremities, anginal pain.

Migraine 39

Drug Prophylaxis

• More than 2 attacks per month.

• Propranolol, Atenolol, Metoprolol.

• Verapamil, Flunarizine.

• Pizotifen, Cyproheptidine.

• Amytriptyline.

• Methysergide.

Migraine 40

THANK YOU

Migraine 41