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Updated: Dec 30 2021

Migraine Headache

  • Snapshot
    • A 31-year-old female presents with a headache that is throbbing and affecting the right-side of her head. She also reports nausea and had one episode of vomiting. Her symptoms began approximately 8 hours ago, where she began to see a bright light that progressively expanded, making it difficult for her to see. Sitting in a quiet dark room improves her symptoms. Medical history is insignificant. She denies alcohol, smoking, or illicit drug use.
  • Introduction
    • Episodic primary headache disorder
      • likely secondary to activation of the trigeminovascular system
      • cortical spreading depression may explain aura
  • Epidemiology
    • Affects 12% of the general population
    • More common in females
    • Migraine without aura is more common
    • Not uncommon to have a family history
    • Risk factors
      • Precipitating factors include
        • emotional stress
        • weather
        • sleep disturbances
        • odors
        • lights
        • females hormones
        • alcohol
        • smoke
        • food
  • Presentation
    • Symptoms
      • pulsating/throbbing quality
      • length usually 4-72 hours long
      • unilateral (usually)
        • do not exclude migraine if headache is bilateral
      • nausea/vomiting
      • debilitating
      • aura (~25% of cases)
        • there is complete reversability of symptoms
        • positive symptoms
          • visual - more common (e.g., bright lines, bright shapes)
          • auditory (e.g., tinnitus)
          • somatosensory (e.g., parasthesias)
        • negative symptoms
          • e.g., loss of vision
      • photophobia
      • phonophobia
      • focal neurological deficits that subside when headache ends in hemiplegic migraine
  • Differential
    • Tension headache
    • Medication overuse headache
    • Meningitis
    • Subarachnoid hemorrhage
  • diagnosis
    • Clinical diagnosis
  • Treatment
    • Acute (Abortive) TherapyPreventive (Prophylactic) Therapy
      Simple analgesicsNSAID sacetaminophenTriptancan cause vasospasm (stroke and MI) in particular when combined with DHE)Dihydroergotamine (DHE)overuse can cause ergotismsymptomsmiosis, psychiatric changes, burning pain in the skin, chest pain, seizures, bradycardia, and hypertensionProchloperazine
      can cause acute dystonic reactions such as oculogyric crisisMetoclopramideSecond-line treatmentsvalproic acid
      β-blockersTricyclic antidepressantsTopiramateValproate
  • Complications
    • Status migranosus
1 of 0
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