Migraine

Exam Cram

• Migraine is primary headache disorder of unknown aetiology

• Presentation: headache lasting hours till 36hrs with evolving, positive neurological signs, e.g. visual changes, arm weakness

• Diagnosis: clinical, normal investigations

• Acute Management: 1. supportive, 2. chlorpromazine 

Outline

Background

• Unknown aetiology: cerebral vasospasm, familial component

• Aura describes the focal neurology and this can occur without a headache

Assessment

History

• Headache: unilateral, lasting up to 48hrs

• Evolving neurology- visual changes or limb weakness

• Common triggers: lack of sleep, cheese, red wine, hormonal fluctuation during menopause

Examination

• Normal observations but high symptom burden

• Focal neurology

Investigations

• Normal in migraine, rule out differentials 

• FBC, EUC, LFT, CRP

• CT-H, CT-Venogram

Diagnosis

Diagnostic criteria: clinical

Differentials: 

• Tension headache- milder headache without neurology, chronic duration

• TIA/ Stroke- acute onset focal neurology, not evolving, headache rare symptom

• Cluster headache- < 30s severe episodic headache with eye watering

• Brain Cancer- insidious focal neurology, seizures & rarely headaches lasting > 72hrs

• Medication overuse headache- significant use of NSAIDs and paracetamol

Management

Acute

• Avoid triggers, sleep and mental health hygiene, 

• Paracetamol, NSAIDs

Long Term (relapse prevention)

• Amitriptyline, propranolol or topiramate

• Stop COCP in individuals with migraine with aura due to stroke risk

Med Reg Notes

Hemiplegic Migraine

• Headache

• Unilateral weakness

• Evolving symptoms

• Previous similar symptoms

• CT-Head normal

• Stroke during a migraine is rare

• Prognosis: make a full recovery

Migraine and Risk of Stroke 

As of 2024, Migraine with Aura increases the risk of stroke subtely but migraine without aura doesn't increase the risk of stroke. An important differential of a hemiplegic migraine is stroke. Migrainous infarction is a stroke during a migraine, this is very rare. 

References and Resources

1. https://www.stroke.org.uk/stroke/managing-risk/migraines-and-stroke

Page written in 2024.