dr david pb watson hamilton medical group aberdeen
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Dr David PB WatsonHamilton Medical Group Aberdeen
Theories of MigraineAcute TreatmentPreventionCase Studies
A chronic disorder with episodic attacks
Complex changes in the brain
During attacks – Headache– Several associated
symptoms– Functional disability
In-between attacks – Enduring predisposition to
future attacks– Anticipatory anxiety
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.
Cortical events
BrainstemNeuropeptides
Trigeminalganglion
Meninges and other peripheral structures
TNC
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.
Headache
Post headache TimePreheadache ModerateMild Severe
Premonitory
Mood changes FatigueCognitive changesMuscle painFood craving
Fully reversibleNeurological changes: Visual somatosensory
Aura
Dull headacheNasal congestionMuscle pain
Early Headache
UnilateralThrobbingNauseaPhotophobiaPhonophobiaOsmophobia
Advanced Headache
FatigueCognitive changesMuscle pain
Postdrome
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.
Headache Phase
Postheadache TimePreheadache Severe
UnilateralThrobbingNauseaPhotophobiaPhonophobia
Advanced Headache
The case for the sensitive migraine brain
Normal life events trigger or are associated with attacks in those predisposed
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.
Dehydration
Diet
Environmentalstimuli
Changes in oestrogenlevel in womenStress
Hunger
Sleep
disturbance
Beware of using painkillers more than 2 days a week
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)
Best evidence ASPIRIN 900 mg IBUPROFEN 400 mg In pregnancy PARACETAMOL
1000mgTake early in headacheMay be combined with anti-sickness
medicines such as Domperidone, Metoclopramide and Prochloroperazine
Migraleve = paracetamol, codeine, (yellow) buclizine (pink)
MigraMax = aspirin and metoclopramide
Paramax = paracetamol and metoclopramide
Clotam Rapid = Tolfenamic Acid
AlmotriptanEletriptanFrovatriptanNaratriptanRizatriptanSumatriptanZolmitriptan
Decreased pain transmissionDecreased pain
transmissionDecreased pain transmissionDecreasain transmissioned p
BBbBionDecreased pain transmission
Brain
Nerve
Blood Vessel
Early in the headache phaseNot during auraCan repeat after 2hours if migraine
recursNo response, don’t repeatResponse idiosyncratic
Tablet ( gastric absorption)Melts (gastric absorption)Nasal Spray ( Gastric and nasal
absorption) Injection ( subcutaneous)
Most patients have few problems
Sensations of tingling, heat, heaviness, pressure, tightness of throat or chest
FlushingDizzinessFeeling of weakness, fatigueNausea and vomiting
Take early in headache phaseRescue Treatment (include rectal)Naproxen
Consider if frequent debilitating migraine
Not a cureGood response is works in 50 out of
100 patients to reduce headache frequency and severity by half
Can be combinedNeed adequate doses
Patient 1 Preventer
B BlockersTricyclic Antidepressants Anti EpilepticsPizotifenVenlafaxineCandesartan (Flunarazine) (Methysergide)
Propranolol 80-240 mgAvoid in asthmaSide Effects (rarely a problem)
Fatigue Coldness of extremities Sleep disturbance and nightmares Gastro intestinal disturbance Dizziness Headache
Amitriptyline 10 -125 mgNortriptyline 10-125 mgPatient Information Leaflet = anti-
depressantSide effects
Sedation Dry mouth Constipation Headache
Sodium Valproate 600-1200 mg daily Weight gain Hair Loss Nausea, Diarrhoea
Topiramate 50-150 mg daily Weight Loss Sedation and slowed thinking Irritability and Depression Pins and Needles
Start low and aim highCombinations can be effectiveConsider reducing/stopping in 6-12
months
25 year old ladyMigraine with aura twice a month,
always with menstruation. Can vomit late in headache. Menstrual migraine can be 2 days
Never misses workMigraine can be present on wakingAspirin 2 tabs partially helps some
headaches
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
37 year old lady, 4 migraine without aura a month, last 2 days each
Misses 3 days of work a monthCan vomit within 2 hoursNaratriptan helps some time
Consider Take triptan early Faster acting triptan Nasal triptan Naproxen Rescue Rx suppositories
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