migraine (vk)
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Migraine
Migraine 1
Migraine
• Characterised by episodic headache, typically
unilateral, associated with vomiting and visual
disturbance.
• Headache may be bitemporal and generalised
without focal visual or neurological disturbance.
• Incidence 250/1,00,000, neurological disease. Migraine 2
SinusSinus
TreatmentTreatment
TensionTension
MigraineMigraine
The Headache Dilemma…The Headache Dilemma…
HOW COMMON IS MIGRAINE
o World- 15-20% of women World- 15-20% of women o 10-15% of men10-15% of meno In India 15-20% migraineIn India 15-20% migraineo Adults-female: male ratio is 2:1Adults-female: male ratio is 2:1o In childhood boys and girls are In childhood boys and girls are
affected equally until puberty when affected equally until puberty when predominance shifts to girlspredominance shifts to girls
Pathogenesis• ↓ cerebral blood flow at the onset of an attack in migraine
with aura. During phase of attack, dilatation of extracranial
arteries related to fluctuations in blood 5-ht levels.
• Genetic predisposition.
• Chocolate, cheese, alcohol may precipitate attack.
• Episodes ↑ perimenstrually, at weekends or in women
taking oral contraceptives.
• Stress & anxiety may initiate an attack.
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Trigeminal Nerve
Sensory nervedischarge
Directly
PainPain
Neruogenic Inflammation(CGRP,SP release)
PG + kinin release
Perivascular oedmea
AuraAuraSpreading depression
+ Hypoperfusion
Unknown abnormal neuronal discharge +
NSAIDs
5-HT1D Agonist5-HT2 Antagonist 5-HT1D Agonist
5-HT1D Agonist
5-HT1D Agonist
Dilatation of B.V
5HT2receptor act
Release of CGRP, substance P & Inflammatory Cytokines
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PATHOPHYSIOLOGYVascular theory-
o Intracerebral blood vessel constriction – Intracerebral blood vessel constriction – auraaura
o Intracranial/extra cranial blood vessel Intracranial/extra cranial blood vessel vasodilatation-headachevasodilatation-headache
Serotonin theory-
o Decreased 5-ht levels linked with migraineDecreased 5-ht levels linked with migraine
o Specific 5-ht receptors found in blood Specific 5-ht receptors found in blood vessels of brainvessels of brain
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Changes in nerve cell activity and blood flow may result in visual disturbance, numbness or tingling, and dizziness.
Electrical impulses spread to other regions of the brain.
Migraine originates deep within the brain
3Chemicals in the brain cause blood vessel dilation and inflammation of the surrounding tissue
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The inflammation irritates the trigeminal nerve, resulting in severe or throbbing pain
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CLASSIFICATION
o Migraine with auraMigraine with aura
o Migraine without auraMigraine without aura
o Complicated migraineComplicated migraine
PHASES OF ACUTE MIGRAINE
o ProdromeProdrome
o AuraAura
o HeadacheHeadache
o PostdromePostdrome
PRODROMEo Vague premonitory symptoms that Vague premonitory symptoms that
begin from 12 to 36 hrs before the begin from 12 to 36 hrs before the aura and headacheaura and headache
o Symptoms includeSymptoms include:-:- YawningYawning ExcitationExcitation DepressionDepression LethargyLethargy Craving or distaste for various foodsCraving or distaste for various foodso Duration- 15-20minDuration- 15-20min
AURAo Aura is a warning or signal before onset of Aura is a warning or signal before onset of
headacheheadache
o Symptoms includeSymptoms include
Flashing of lightsFlashing of lights
Zig zag linesZig zag lines
Difficulty in focussingDifficulty in focussing
o Duration:15-30 minDuration:15-30 min
HEADACHEo Headache is generally unilateral and Headache is generally unilateral and
is associated with symptoms like:is associated with symptoms like:o AnorexiaAnorexiao NauseaNauseao VomitingVomitingo PhotophobiaPhotophobiao PhonophobiaPhonophobiao TinnitusTinnitus
o Duration:4-72 hrsDuration:4-72 hrs
POSTDROMEFollowing headache, patient Following headache, patient
complains ofcomplains ofo FatigueFatigueo DepressionDepressiono Severe exhaustionSevere exhaustiono Some patients feel unusually Some patients feel unusually
freshfresh
o Duration: few hrs to 2 daysDuration: few hrs to 2 days
Clinical Features Starts after puberty, continues till late midlife.
Attack may occur from a few days to several months.
Attacks may last for hours to days.
Premonitory symptoms – zig-zag lines, flashing, coloured lights,
defects in visual field & dysphasias with headache.
Headache localized to frontal region & spreads to whole of one
side of head – pain severe & throbbing associated with vomiting,
photophobia, pallor.
Patient is shifted to a bed in darkened room.
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MIGRAINE MANAGMENT
Non pharmacological treatmento Identification of triggersIdentification of triggerso MeditationMeditationo Relax techniquesRelax techniqueso PsychotherapyPsychotherapy
Pharmacological treatmento Abortive treatmentAbortive treatmento Preventive treatmentPreventive treatment
ABORTIVE TREATMENT
Non specific treatment-
o AspirinAspirin
o ParacetamolParacetamol
o IbuprufenIbuprufen
o diclofenacdiclofenac
ABORTIVE THERAPYSpecific treatment-
Ergot alkaloidsErgot alkaloids:-ergotamine:-ergotamine
dihydroergotaminedihydroergotamine
TriptansTriptans:- sumatriptan:- sumatriptan
rizatriptanrizatriptan
Antinauseant drugsAntinauseant drugs:- metaclopramide:- metaclopramide
chlorpromazinechlorpromazine
Triptans work best in 1Triptans work best in 1stst couple of hrs of attack couple of hrs of attack
Ergotamine works at any time during the attackErgotamine works at any time during the attack
Management Avoid dietary and other precipitants.
Maintain a diary of attacks.
Stop oral contraceptives.
Soluble Aspirin (600-900 mg) or Paracetamol (1 Gm) with or
without Metoclopramide as antiemetic.
Ergotamine tartarate, 0.5-1.0 mg sublingually may abort
headache if taken as soon as visual symptoms are felt. No More
than 12 mg in a week. Excessive use may lead to vasospasm &
paradoxical headache. Contraindicated in pregnancy, IHD &
peripheral vascular disorders.Migraine 25
…Management• Serotonin agonist-triptans – Sumatriptan for acute attacks of
migraine (100 mg). No more than 300 mg per 24 hours or Inj.
Sumatriptan 6 mg SC. Not more than 2 injections per 24
hours. Highly efficacious.
• Prophylaxis if attacks occur weekly:
Propranolol : 40-80 mg 8 hrly. Pizotifen
: 1.5-3 mg at night.
• Amitriptyline : 25-100 mg at night.
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Migraine & Oral Contraceptives
C/I migraine if there is typical aura, focal
features or if it is severe and lasts for
more than 72 hrs despite treatment
with ergotamine.
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Acute Migraine Attack• It appears to begin in serotonergic (5-HT) and
noradrenergic neurons in the brain. These monoamines affect cerebral & extracerebral vasculature and cause release of vasoactive substances such as H, PGs, neuropeptides involved in pain, i.e. neurogenic inflammation can be inhibited by antimigraine drugs.
• Migraine aura of visual or sensory disturbance originates in occipital or sensory cortex.
• Throbbing headache is due to dilatation of vessels – sensitive arteries outside the brain.
Migraine 29
Triggering Factors Avoidance
• Stress – exertion, anxiety, excitement, fatigue, anger.
• Foods containing vasoactive amines – chocolate, cheese.
• Bright lights, loud noise.• Food Allergy.• Hypoglycemia.• Menstruation and oral contraceptives.
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Treatment – Stepped Approach
• Aspirin 600 mg oral dispersible (soluble) as early as possible.
• Alternatives are Paracetamol, Ibuprofen, Naproxen.
• Metoclopramide or Domperidone (dopamine agonists) – antiemetics that promote gastric emptying & enhance absorption of analgesic.
• Efficient use of analgesic & antiemetic is adequate for majority of attacks.
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Stepped Treatment
Severe migraine attacks should be treated with
triptans – Sumatriptan. Headache may return in
6-36h in 1/3rd patients. Use second dose.
Ergotamine 1-2 mg used if other treatments
failed, but not within 12h of the last dose.
Do not give triptans until 24h have elapsed after
stopping ergotamine.
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Triptans
Selectively stimulate 5-HT 1B/1D – receptors found
in cranial blood vessels – vasoconstriction.
-Sumatriptan.
-Rizatriptan.
-Almotriptan.
-Naratriptan.
-Zolmitriptan.
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SUMATRIPTAN
• Rapid oral absorption.• 84% presystemic elimination.• SC bioavailability 96%.• Oral 50-100 mg, maximum 300 mg in 24h,
Repeat 2h.• Intranasal 20 mg, maximum 40 mg in 24h,
Repeat 1h.• SC 6 mg, 12 mg in 24h, Repeat 1h.
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Sumatriptan - ADRs
• Malaise, fatigue, dizziness, vertigo, sedation.• N,V.• Feelings of chest pressure, tightness and pain.• Cardiac arrhythmias, MI.
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Sumatriptan – C/I
Prophylaxis of migraine
MI
IHD
Variant angina
Uncontrolled HT
Concomitant ergotamine
Within 2 wks after stopping MAOIs
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RIZATRIPTAN
• C/I: HT, IHD, Prinzmetal’s angina, Lactation,
Within 2 wks of MAOIs, Within 24 hrs of
treatment with another 5-HT agonist or
ergotamine.
Tab. Rizact 5 mg Rs 30/-
10 mg Rs 50/-
Migraine 37
ERGOTAMINE Partial agonist at α-adrenoceptors
(vasoconstrictor). Partial agonist at serotonergic receptors. Constricts all peripheral arteries. Effect persists for 24h, repeated doses cause
cumulative toxicity. Tablets 1 mg crushed before swallowing. Initially 1-2 mg, maximum 4 mg in 24h. Not more than 8 tablets in a week. Rectal suppositories of 2 mg preferred.
Migraine 38
…ERGOTAMINE CONTRAINDICATIONS: -
Vascular & Valvular disease. -Pregnancy. -Collagen diseases. -Prophylaxis.
ADRs: -Muscle cramps. -Stiffness. -Tiredness. -N,V,D.
ERGOTISM: Severe peripheral vasoconstriction, hypertension, gangrene of extremities, anginal pain.
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Drug Prophylaxis
• More than 2 attacks per month.
• Propranolol, Atenolol, Metoprolol.
• Verapamil, Flunarizine.
• Pizotifen, Cyproheptidine.
• Amytriptyline.
• Methysergide.
Migraine 40
THANK YOU
Migraine 41