Migraine Diagnosis and treatment of the attack David Kernick St Thomas Health Centre Exeter.
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Transcript of Migraine Diagnosis and treatment of the attack David Kernick St Thomas Health Centre Exeter.
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MigraineDiagnosis and treatment of
the attack
David Kernick
St Thomas Health Centre
Exeter
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Classifying headache
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IHS Headache classification Primary Secondary
• Migraine
• Tension type
• Cluster
• Traumatic
• Vascular
• Non-vascular
• Substance induced
• Infection
• Metabolic
• Facial structures
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What do people think when they present with headache?
• I need glasses (<1% headache due to undiagnosed refractive errors)
• Its my blood pressure
• I have a tumour (1 in 1000 risk)
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Medication overuse headacheMedication overuse headacheH
eada
che
inte
nsit
yH
eada
che
inte
nsit
y
Migraine attacksMigraine attacks
Frequent ‘daily’ headachesFrequent ‘daily’ headaches
Withdrawal of all analgesiaWithdrawal of all analgesia
Return of episodic Return of episodic headacheheadache
Increased frequency of headache, Increased frequency of headache,
associated with increased associated with increased frequency of analgesia use.frequency of analgesia use.
Daily headache with spikes of more severe pain
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Is it migraine?
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Simple Diagnostic aid
• Migraine – have to lie down
• Tension headache – can keep going
• Cluster Headache – have to bang head
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Formal Migraine
• 4-72 hours
• Two of : unilateral, pulsating, moderate or severe pain, aggregation by physical activity.
• At least one of: nausea/vomiting, photophobia, phonophobia.
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Other diagnostic pointers for migraine
• I feel nauseated
• I don’t like light or sound
• Movement makes things worse
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Migraine
Background
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Impact of migraine
• In top 20 of WHO disability index
• 1000,000 people loose work or school each day
• Over £2 billion cost p.a. in absenteeism
Steiner 2003
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What is migraine?
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Migraineurs brains are differentProblems with change
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Thalamus +Mid Brain structures
Medication overuse headache
Tension type headache
AURA
CERVICALNUCLEI
MIGRAINECENTRE
HypothalamusCLUSTER
Headache model
Migraine: aura - activation migraine centre – modulation – Inflammation at brain surface
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What is happening in Migraine?
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Migraine and the neck
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The Migraine attack
• Prodrome
• Aura (movement, sensation, +,-)
• Headache
• Postdrome
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Aura without pain
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The management of acute migraine
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Some thoughts about medication
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Drug treatment
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Licensed or unlicensed?Generic or proprietary?
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Benefit v disadvantages
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Placebo effect
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Is a drug worth paying for?
NICE
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Migraine treatmentAcute
• Paracetamol (3)/Aspirin (3)/
Domperidone (Motilium 3)
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Migraine treatmentAcute
• Paracetamol/Asp/Domperidone
• Rectal NSAI/Domperidone
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Migraine treatmentAcute
• Paracetamol/Asp/Domperidone
• Rectal NSAI/Domperidone
• Triptan
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The Triptans
• Work on the migraine pathway
• Tablets, melts, nasal spray, injection.
• Side effects
• Failure response is not a class effect
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Triptan Half Life
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Triptans in the elderly
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For the migraine attack
• Motilium (10mg) – 2 tablets for nausea
• Paracetamol (500mg) – 3 tablets for pain
• Soluble Asprin (300 mg) – 3 tablets for inflammation
• Imigran (50mg) migraine specific – 1 or 2
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Getting the best out of you GP
• Emphasise the impact
• Help with diagnosis
• Help with triggers
• Reassure that you don’t expect a scan
• Direct to information
• Ask to be referred
• Help yourself
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MigraineDiagnosis and treatment of
the attack
David Kernick
St Thomas Health Centre
Exeter
You Tube Migraine channel or David Kernick Channel
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Migraine treatment - Preventative
• Beta blocker ++ (L)• Pizotifen + - (L)• Amitriptyline + • Sodium valproate + +• Topiramate ++ (L)• Calcium antagonists + -• Lisinopril, Montelukast + -• Methylsergide +++ (L)
Evidence
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Migraine treatment - Preventative
• Feverfew
• Butterbur
• Magnesium
• Riboflavin
• Coenzyme Q10
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Migraine treatment - Preventative
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THE BEST THING YOU CAN DO FOR YOUR MIGRAINE IS TO GIVE UP FAGS, BOOZE AND FRIED FOOD
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The Treatment of Migraine
David Kernick
St Thomas Health Centre
Exeter