Migraine

Migraine - Chronic
Rahul Soman, M. Pharm

 

Definition  

A primary episodic headache disorder characterized by various combinations of neurological, gastrointestinal, and autonomic changes . Migraines may have common (without aura), classic (with aura), or complex (basilar, hemiplegic, ophthalmoplegic, abdominal) presentations.

 

Medical History  

* Dietary intake finding

* Alcohol intake - finding

* Menstruation finding

* Hormonal Contraceptive use

* Menopause [Menopause - Chronic]

* Estrogen/Progestin Combination use

* Antihypertensive use

* Exercise history finding

* Whiplash injury to neck

* Blunt head trauma

* Smoking

* Cocaine abuse

* Environmental finding

* Family history of Migraine

 

Findings  

* Headache

* Nausea

* Mood disorder

* Vomiting

* Light intolerance

* Blurred vision

* Tachyarrhythmia

* Visual obscuration

* Visual field defect

* Pain in eye

* Noise intolerance

* Abdominal pain

* Abdominal distension, gaseous

* Aphasia

* Carotid artery finding

* Fatigue

* Paresthesia

* Scalp tenderness

* Weight gain

* Hyperventilation

* Edema

* Engorgement of vein

* Altered mental status

* Ataxia

* Chest pain

* Pallor

* Nuchal rigidity

* Myalgia

* Vertigo

* Syncope

* Hypesthesia

* Hemiplegia

* Nasal congestion

* Diarrhea

* Seizure

* Homonymous hemianopia

* Third cranial nerve weakness

* Diplopia

* Dysarthria

* Neck pain

* Increased body temperature

 

Tests  

 

Headache  

* Imaging by body site, Entire brain: Neuroimaging may aid in differential diagnosis of some patients by ruling out specific intracranial abnormalities , but is not universally recommended in all patients with all headache types .

 

Suspected subarachnoid hemorrhage in patients with a negative or equivocal head CT scan  

* Cerebrospinal fluid examination: Findings consistent with subarachnoid hemorrhage include elevated opening pressure, elevated RBC count that does not diminish in successive tubes, and xanthochromia .

 

Meningitis  

* Cerebrospinal fluid examination

 

Suspected giant cell (temporal) arteritis  

* Erythrocyte sedimentation rate measurement: Erythrocyte sedimentation rate is elevated in most, but not all, patients with giant cell arteritis; a normal result does not exclude disease .

 

Differential Diagnosis  

* Subarachnoid hemorrhage

* Thromboembolic stroke

* Transient ischemic attack - Acute

* Intracranial hemorrhage

* Bacterial meningitis - Acute

* Viral meningitis - Acute

* Viral encephalitis - Acute

* Temporal arteritis

* Intracranial tumor

* Carotid artery dissection

* Vertebral artery dissection

* Cluster headache - Acute

* Abscess of brain - Acute

* Hydrocephalus

* Pseudotumor cerebri - Acute

* Trigeminal neuralgia - Acute

* Sinusitis - Acute

* Tension-type headache

* Temporomandibular joint-pain-dysfunction syndrome

* Optic neuritis

* Postconcussion syndrome

* Amaurosis fugax

* Low pressure headache

* Vasculitis

* Pheochromocytoma - Acute

* Glaucoma - Acute

 

Treatment  

 

Drug Therapy  

 

Prevention of migraine  

 

PROPRANOLOL HYDROCHLORIDE  

Adults: 80 to 240 mg/day orally

 

TIMOLOL MALEATE  

Adults: 20 to 30 mg/day orally

 

AMITRIPTYLINE HYDROCHLORIDE  

Adults: 30 to 150 mg/day orally

 

DIVALPROEX SODIUM  

Adults: 500 to 1500 mg/day orally

 

VALPROATE SODIUM  

Adults: 800 to 1500 mg/day orally

 

TOPIRAMATE

Adults: 100 mg/day orally in 2 divided doses; recommended titration rate is 25 mg in the evening for 1 week, 25 mg twice daily for 1 week, 25 mg in the morning and 50 mg in the evening for 1 week, and then 50 mg twice daily

 

Procedural Therapy  

 

Headache  

* Biofeedback, thermal: Thermal biofeedback plus relaxation, alone, or in combination with prophylactic drug therapy for headache may be effective in some patients .

 

Headache  

* Cognitive - behavior therapy: Cognitive-behavioral therapy, alone, or in combination with prophylactic drug therapy for headache may be effective in some patients .

 

Headache  

* Electromyographic biofeedback: Electromyographic biofeedback, alone, or in combination with prophylactic drug therapy for headache may be effective in some patients .

 

Non-Procedural Therapy  

 

Migraine  

* Risk Factor Modification

* Self-Massage

* Progressive Relaxation

* Decreased Environmental Stimulation