 Dr David PB Watson  Hamilton Medical Group Aberdeen

 Theories of Migraine  Acute Treatment  Prevention  Case 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 Brainstem Neuropeptides Trigeminal ganglion 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 Time PreheadacheModerateMildSevere Premonitory Mood changes Fatigue Cognitive changes Muscle pain Food craving Fully reversible Neurological changes: Visual somatosensory Aura Dull headache Nasal congestion Muscle pain Early Headache Unilateral Throbbing Nausea Photophobia Phonophobia Osmophobia Advanced Headache Fatigue Cognitive changes Muscle 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 Time PreheadacheSevere Unilateral Throbbing Nausea Photophobia Phonophobia 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 Environmental stimuli Changes in oestrogen level in women Stress Hunger Sleep disturbance

 Headache threshold variability  Trigger  Patient 3  Patient 2  Patient 1  Patient 4

 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 1000mg  Take early in headache  May 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

 Almotriptan  Eletriptan  Frovatriptan  Naratriptan  Rizatriptan  Sumatriptan  Zolmitriptan Decreased pain transmission Decreasain transmissioned p BBbBionDecreased pain transmission Brain Nerve Blood Vessel

 Early in the headache phase  Not during aura  Can repeat after 2hours if migraine recurs  No response, don’t repeat  Response 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  Flushing  Dizziness  Feeling of weakness, fatigue  Nausea and vomiting

 Take early in headache phase  Rescue Treatment (include rectal)  Naproxen

 Consider if frequent debilitating migraine  Not a cure  Good response is works in 50 out of 100 patients to reduce headache frequency and severity by half  Can be combined  Need adequate doses

 Headache threshold variability  Trigger  Patient 3  Patient 2  Patient 1  Patient 4 Patient 1 Preventer

 B Blockers  Tricyclic Antidepressants  Anti Epileptics  Pizotifen  Venlafaxine  Candesartan  (Flunarazine)  (Methysergide)

 Propranolol mg  Avoid in asthma  Side Effects (rarely a problem)  Fatigue  Coldness of extremities  Sleep disturbance and nightmares  Gastro intestinal disturbance  Dizziness  Headache

 Amitriptyline mg  Nortriptyline mg  Patient Information Leaflet = anti-depressant  Side effects  Sedation  Dry mouth  Constipation  Headache

 Sodium Valproate mg daily  Weight gain  Hair Loss  Nausea, Diarrhoea  Topiramate mg daily  Weight Loss  Sedation and slowed thinking  Irritability and Depression  Pins and Needles

 Start low and aim high  Combinations can be effective  Consider reducing/stopping in 6-12 months

 25 year old lady  Migraine with aura twice a month, always with menstruation. Can vomit late in headache. Menstrual migraine can be 2 days  Never misses work  Migraine can be present on waking  Aspirin 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 month  Can vomit within 2 hours  Naratriptan helps some time

 Consider  Take triptan early  Faster acting triptan  Nasal triptan  Naproxen  Rescue Rx suppositories