Neurosurgery notes/Functional/Craniofacial pain/Migraine

Migraine

View Details
logo
Parent item
Craniofacial pain

General

  • Migraine attacks usually occur in individuals predisposed to the condition, and may be activated by factors such as bright light, stress, diet changes, trauma, administration of radiologic contrast media (especially angiography) and vasodilators.

Classification

  • Based on the 1962 ad hoc committee on headache (H/A). See also index under Headache, e.g. for: crash migraine (thunderclap headache), post-myelogram headache...
  • Common migraine
    • Episodic H/A with N/V and photophobia, without aura or neurologic deficit.
  • Classic migraine
    • Common migraine + aura
    • May have H/A with occasional focal neurologic deficit(s) that resolve completely in ≤ 24 hrs
      • Over half of the transient neurologic disturbances are visual, and usually consist of positive phenomena (spark photopsia, stars, complex geometric patterns, fortification spectra) which may leave negative phenomena (scotoma, hemianopia, monocular or binocular visual loss…) in their wake
      • The second most common symptoms are somatosensory involving the hand and lower face
      • Less frequently, deficits may consist of aphasia, hemiparesis, or unilateral clumsiness.
    • A slow march-like progression of deficit is characteristic.
    • The risk of stroke is probably increased in patients with migraine
  • Complicated migraine
    • Occasional attacks of classic migraine with minimal or no associated H/A, and complete resolution of neurologic deficit in ≤ 30 days.
  • Migraine equivalent
    • Neurologic symptoms (N/V, visual aura, etc.) without H/A (acephalgic migraine).
    • Seen mostly in children.
    • Usually develops into typical migraine with age.
    • Aura may be shortened by opening and swallowing contents of a 10mg nifedipine capsule.
  • Hemiplegic migraine
    • H/A typically precedes hemiplegia which may persist even after H/A resolves.
  • Basilar artery migraine
    • Essentially restricted to adolescence.
    • Recurrent episodes lasting minutes to hours of transient neurologic deficits in distribution of vertebrobasilar system.
    • Deficits include:
      • Vertigo (most common)
      • Gait ataxia
      • Visual disturbance (scotomata, bilateral blindness),
      • Dysarthria
      • Followed by severe H/A and occasionally nausea and vomiting.
    • Family history of migraine is present in 86%.

Summary

Disease
Presentation
Treatment
Common migraine
- NO AURA OR DEFICIT
- Pain > 4 h
- Most common type
- Includes acute pain relief and prevention
- Avoid triggers
Medications:
a. Paracetamol
b. Anti-inflammatory
c. Triptans
d. Ergotamine
e. Antiepileptics (topiramate, valproate) and similar (gabapentin, pregabalin)
f. Beta-blockers (propranolol, atenolol, timolol)
g. Calcium channel blockers (verapamil)
h. Antidepressants (amitriptyline)
Other treatments:
a. Alternative medicine (acupuncture, biofeedback, massage)
b. Cefaly (FDA approved device causing transcutaneous supraorbital nerve stimulation)
Classic migraine
- AURA LASTING <24 h (transient focal neurological symptom, most common visual).
(If aura lasts for more than 24 h, exclude ischemic lesion) Typical duration is <30 min
- Pain > 4 h
Same as above
Acephalgic migraine (may be called migraine equivalents)
- AURA WITHOUT HEADACHE (for example gastrointestinal symptoms, dysarthria etc. → exclude TIA / seizures)
- Females, children and young adults
Same as above
  • Migraines are considered neurovascular disorders that may last up to 72 hours and may be accompanied by nausea, vomiting, irritability, photophobia, or sensitivity to sound/smell.
  • Possibly there are four stages of migraine: prodrome (hours to days before), aura (immediately before), headache, postdrome (after).
  • Status migrainosus: pain >72 hours.