Migraine Headache

What is migraine headache?

Migraine headache affects of 23% to 26% of Canadian women, and 7.8% to 10% of Canadian men. Migraine headaches, are painful and throbbing headaches that last from 4 to 72 hours.

There are two types of migraine headache:

Migraine without aura:

  1. Headache attacks lasting 4-72 hours
  2. Headache has at least two of the following characteristics:
    1. unilateral location
    2. pulsating quality
    3. moderate or severe pain intensity
    4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
  3. during headache, at least one of the following is present:
    1. nausea and / or vomiting
    2. photophobia and phonophobia

Migraine with aura:

  1. Aura consisting of at least one of the following, but no motor weakness:
    1. fully reversible visual symptoms including positive features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision)
    2. fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)
    3. fully reversible dysphasic speech disturbance
  2. At least two of the following:
    1. homonymous visual symptoms and/or unilateral sensory symptoms
    2. at least one aura symptom develops gradually over ≥ 5 minutes and/or different aura symptoms occur in succession over ≥ 5 minutes
    3. each symptom lasts ≥ 5 and ≤ 60 minutes

What are some common causes of headache?

Metabolic/Mental/Medical:

  • High blood pressure
  • Hypoglycemia
  • Anxiety
  • Depression
  • Anemia
  • Diabetes
  • DKA
  • Workplace problems

Infections/Inflammations:

  • Meningitis
  • Encephalitis
  • Brain tumor
  • Intracranial hemorrhage
  • Sinusitis
  • Neck muscle spasm and pain

Drugs:

  • Alcohol abuse
  • Stimulant drugs such as cocain, crack, amphetamines
  • Opioids

Structural:

  • Brain mass
  • Brain trauma
  • Neck muscle spasm

How does migraine headache present?

  • The main symptom of migraine headache is a throbbing headache on one side of head
  • Nausea and vomiting can be experienced by some people

What information your doctor might need to collect?

  • Onset
  • Length of headache
  • Triggers
  • Headache description
  • Underlying health problems
  • Past history of head trauma
  • History of weight loss, low energy, personality changes, …

Is there any laboratory work up for migraine?

Although there is no specific test for diagnosis of migraine headache, you physician might request some blood work ups to exclude other causes of headaches. The following tests might be requested as initial assessments and investigation:

  1. CBC to rule our anemia
  2. Electrolytes to rule out dietary imbalances
  3. Thyroid tests
  4. Liver enzymes

What diagnostic tests might be requested?

A head CT or MRI might be requested along the way to exclude the malignant causes of headaches such as brain tumors, bleeding and changes to ventricle size.

How to manage migraine headache?

Treatment of acute attacks:

  1. Mild-moderate attacks:
    1. Acetaminophen:
      1. 1000 mg four time daily
    2. NSAIDs:
      1. Iboprofen 400 mg every 4 hour
      2. naproxen 500 mg twice daily
  2. Moderate-severe attacks:
    1. Triptans
      1. Sumatriptan
        1. tablets 50 mg, 100 mg: 1 tablet at onset, may repeat in 2 hours, not to exceed 2 tablets per day
        2. nasal spray 20 mg
        3. injection 6 mg
      2. Zolmitriptan
        1. tablets 2.5 mg i-tab with headache and repeat q2 hr total 10 mg
        2. nasal spray 5 mg
      3. Rizatriptan tablets 10 mg
        1. 5 to 10 mg orally, can be repeated in 2 hours, not to exceed 30 mg per day
      4. Almotriptan tablets 12.5 mg
    2. NSAIDs
      1. Iboprofen 400 mg every 4 hour
      2. naproxen 500 mg twice daily
  3. Refractory migraine:
    1. Triptan with NSAID or
    2. Dihydroergotamine
    3. Dexamethasone 10-25 mg IV one time in acute cases

Treatment of migraine refractory to triptans:

  • Tramadol or Codeine
    • limit the use to no more than 9 days per month (headache society guidelines)
    • Close and regular monitoring of patients is required to prevent abuse and diversion

 

For treatment of nausea:

  • Metoclopramide 10 mg every 6 hours
  • Domperidone 10 mg every 6 hours

Prevention

Prevention with lifestyle and behavior change:

  • Identify the triggers and prevent them. Common triggers could be:
    • Food
    • Stress
    • Poor sleep
    • Emotional instability
    • Tiredness

Prevention with Medications:

  •  Beta-blockers
    • Propranolol: Start at 20 mg to 40 mg BIDup to maximum of 160 mg daily
    • Nadolol: start at 20-40 mg OD up to 160 mg daily
    • Metoprolol: start at 50 mg BID up to maximum of 200 mg daily
  • Tricyclic Strategy
    • Start at 10 mg daily and increase slowly
    • Good in patients with insomnia
  • Gabapentin
  • Magnesium
  • Coenzyme Q10
  • Divalproex
  • Venlafaxine
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