Classified as with aura (10%) and without aura (90%)
History: Aura –visual, dysphasia, motor, sensory approx 30mins.
Unilateral throbbing pain and disability lasting 4-72 hours.
Chronicity, frequency, associated symptoms
- ?COCP use, menopause or related to menstrual cycle
- ?family history
- ?neck pain/disease, arterial disease, sinuses
- ?overuse of triptans for migraine
- ?sleep deprivations/stress
Neurological examination + BP
Treatment of Acute Migraines:
Trial of single drug for symptomatic relief:
Aspirin up to 1200mg stat (then up to 600mg 6hrly)
Paracetamol 1500mg ( then up to 1g 6hrly)
NSAIDS, preferably in soluble effervescent formulations
Combination preparations are less satisfactory but often used: paracetamol, aspirin, caffeine or aspirin/metoclopramide. Do NOToffer ergots or opioids for the acute treatment of migraine.
If vomiting trial of Diclofenac Suppositories, domperidone.
Add an oral or nasal triptan to paracetamol / NSAID (please note to avoid triptans if patient is high risk for CVD or pregnant).
Antiemetics improve drug absorption, reduce pain and may abort attacks, so often helpful even if no GI symptoms – use dopaminergic type e.g. metoclopramide or domperidone.
Preventative therapy: should decrease symptoms by 50%
Address stress and exercise, triggers including missed meals, sleep and caffeine excess.
Use drug treatment if symptoms sufficient to disrupt life and frequent enough to justify daily treatments.
First line: BBlocker e.g. propranolol 40-80mg daily as slow release, increase fortnightly by 40-80mg stages up to 160mg bd
Topimarate is an alternative but is teratogenic and can impair the effectiveness of hormonal contraceptives.
Amitryptiline 10mg nocte, increase to 25mg, and then by 25mg steps 2-4 weekly up to 100mg
Consider: Topiramate, Gabapentin, Sodium Valproate, Riboflavin
Continue prophylaxis for 6 months after successful control of migraine then withdraw; re-introduce as needed
New onset severe headache with or without focal neurological features may need admission (?SAH, SOL)
Refer to Neurology:
Ensure maximal analgesia, anti-emetics and triptans have all been used and there has been a trial of at least one preventative therapy before referral.
Be alert to Medication overuse causing symptoms (analgesia used on more than 15 days a month) particularly opiates, may need withdrawal
Consider referring those with atypical or complex migraine e.g. new onset aura without headache, onset at an unusual age (>55yrs) rapidly worsening, or uncommon aura phenomena (leg weakness, loss of consciousness, prolonged neuro deficits etc), migraine variants (cluster, hemicrania continua).
Additional info:Neurology recommend www.bash.org.uk under publications-headache guideline.
NICE guidelines September 2012 http://pathways.nice.org.uk/pathways/headaches/management-of-migraine-with-or-without-aura