MIGRAINE

Periodic severe headache, usually unilateral, which may  occur with or without an aura (neurological warning signs)
and associated with nausea and/or vomiting

Causes

The cause is unknown but thought to be linked to:

  • Familial factors
  • Craniovascular disorders, which can be precipitated by: stress, anxiety, menstruation, flashing lights, hunger,
    lack of sleep, oestrogens (in COC), perfumes, tyramine containing foods e.g. red wine, cheese, chocolate

Clinical features

  • Warning signs (aura): visual or sensory sympotms (flashing lights) preceeding the start of the headache
  • Migraine with warning signs is called migraine with aura. They are not always present
  • Moderate to severe episodic unilateral headache throbbing (pulsating)
  • Nausea and vomiting, sensitivity to light and sound

Differential diagnosis

  • Any cause of headache
  • Conversion disorder (hysteria)

Investigations

  • No specific investigations needed except if another cause is suspected

Management

Treatment of acute episode

  • Paracetamol 1 g every 6 hours
  • Or Ibuprofen 400 mg every 6-8 hours
  • Or Acetylsalicilic acid 300-900 mg every 4-6 hours (max 4 gr daily)

If severe and/or not responding to the above treatment

  • Diclofenac 75 mg IM
    • Plus metoclopramide 10 mg IM /IV for the nausea and vomiting
  • Or ergotamine 2 mg sublingual, then 1-2 mg hourly to a max of 6 mg in 24 hours
  • Or Sumatriptan 50 mg, repeat after 2 hours if necessary, max 300 mg in 24 hours

Prophylaxis: in case of >3 attacks/month and/or functional impairment

  • Amitriptyline 10-75 mg nocte or
  • Propranolol 40-80 mg every 12 hours

Prevention

  • Avoid precipitating factors