Migraine Headache: Difference between revisions
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== Differential Diagnosis == | == Differential Diagnosis == | ||
<br> | |||
In younger patients, several unusual disorders can mimic migraine with aura:<ref name="Merck Manual" /> | |||
*Dissection of the carotid or vertebral artery | |||
*Antiphospholipid antibody syndrome | |||
*Cerebral vasculitis | |||
*Moyamoya disease | |||
*CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) | |||
*MELAS (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes) syndrome | |||
In older patients, migraine with aura can be mistaken for a transient ischemic attack, especially when the aura occurs without headache.<ref name="Merck Manual" /><br> | |||
'''Other Primary Headaches''':<ref name="Merck Manual" /> | |||
*Cluster headache | |||
*Tension-type headache | |||
*Chronic paroxysmal hemicrania | |||
*Hemicrania continua | |||
'''Secondary Headaches:<ref name="Merck Manual" />''' | |||
Extracranial Disorders: | |||
*Carotid or vertebral artery dissection | |||
*Cervical spine disorders | |||
*CSF leak with low-pressure headache | |||
*Dental disorders (infection, temporomandibluar joint dysfunction) | |||
*Glaucoma | |||
*Sinusitis | |||
Intracranial Disorders: | |||
*Brain tumors and mass lesions | |||
*Chiari type I malformation | |||
*Hemorrhage (intracerebral, subdural, subarachnoid) | |||
*Idiopathic intracranial hypertension | |||
*Infections (eg, cerebritis, encephalitis, meningitis) | |||
*Obstructive hydrocephalus | |||
*Vascular disorders (eg, moyamoya disease, vascular malformations, vasculitis, venous sinus thrombosis) | |||
Systemic Disorders: | |||
*Accelerated hypertension | |||
*Bacteremia | |||
*Fever | |||
*Hypercapnia | |||
*Hypoxia (including altitude sickness) | |||
*Viremia | |||
Drugs and Toxins | |||
*Analgesic rebound | |||
*Caffeine withdrawal | |||
*Hormones (eg, estrogen) | |||
*Nitrates | |||
*Proton pump inhibitors<br> | |||
== Case Reports == | == Case Reports == |
Revision as of 21:25, 5 March 2010
Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.
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Definition/Description[edit | edit source]
Migraine is a chronic, episodic primary headache. Migraine is thought to be a neurovascular pain syndrome with altered central neuronal processing (activation of brainstem nuclei, cortical hyperexcitability, and spreading cortical depression) and involvement of the trigeminovascular system (triggering neuropeptide release, which produces painful inflammation in cranial vessels and the dura mater).[1]
Symptoms typically last 4 to 72 hours and may be severe. Pain is often but not always unilateral, throbbing, worse with exertion, and accompanied by autonomic symptoms (eg, nausea; sensitivity to light, sound, or odors). Fortification spectra and other transient focal neurologic deficits occur in a few patients, usually just before the headache, also known as aura.[1] Diagnosis of migraine can usually be made by history alone. Treatment includes lifestyle changes (diet, exercise, sleeping habits), medications including NSAIDs, analgesics, serotonin receptor agonists, beta blockers, calcium channel blockers, and antiemetics.[1][2]
Prevalence[edit | edit source]
Migraine headaches are the second most common type of primary headache. An estimated 28 million people in the United States (about 12% of the population) will experience migraine headaches at some point.[2] Lifetime prevalence is 18% for women and 6% for men in the US. It most commonly begins during puberty or young adulthood, waxing and waning in frequency and severity over the ensuing years and usually diminishing after age 50.[1] In 90% of migraineurs, the first attack generally develops before the age of 40 years. In women the frequency of headaches is highest during their reproductive years, when estrogen levels are higher, and decreases to some extent after menopause. About 45% of cases of migraine emerge during childhood or adolescence. Migraine with aura is more likely to develop at an earlier age than migraine without aura.[2]
Characteristics/Clinical Presentation[edit | edit source]
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Associated Co-morbidities[edit | edit source]
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Medications[edit | edit source]
According to Clinical Neurology (6th ed)[3], the following medications are generally used:
1. Acute Treatment:
Simple Analgesics
- Aspirin
- Naproxen Sodium
- Ibuprofen
- Acetominophen
Comments: May cause gastric pain or bleeding and rebound headache if used frequently.
Ergot Preparations
- Ergotamine/caffeine (Cafergot)
Comments: May cause nausea and vomiting (N/V); contraindicated by pregnancy or coronary or peripheral vascular disease (PVD)
- Dihydroergotamine
Comments: Use with metoclopramide (antiemetic)
Narcotic analgesics
- Codeine/aspirin
- Codeine/aspirin/acetominophen
- Meperidine
- Butorphanol
5-HT agonists (Serotonin Receptor Agonists)
- Sumariptan (Imitrex)
- Rizatriptan (Maxalt)
- Zolmitriptan (Zomig)
- Naratriptan (Amerge)
- Almotriptan (Axert)
- Frovatriptan (Frova)
- Eletriptan (Relpax)
Comments:10% incidence N/V; contraindicated by pregnancy or coronary or PVD, and with monoamine oxidase inhibitors (MAOI)
Other Agents
- Caffeine/butalbital/aspirin (Fiorinal)
- Prochlorperazine
Comments: Can cause hypotension and drug-induced dystonia
2. Prophylactic Treatment
Antiinflammatory agents:
- Aspirin
- Naproxen Sodium
Comments: May cause gastric pain or bleeding
Tricyclic Antidepressants
- Amitriptylline
- Nortriptyline
- Protriptyline
- Doxepin
Comments: May cause dry mouth, urinary retention, and sedation; contraindicated in glaucoma or prostatism
Beta Blockers
- Nadolol
- Atenolol
- Timolol
- Metoprolol
Comments: Listed in descending order of efficacy; symptomatic bradycardia may occur at high doses; contraindicated in asthma and congestive heart failure; not to be used with calcium blockers
Ergot Alkaloids
- Methergine
Comments: Occurrence of retroperitoneal fibrosis with urethral obstruction and mediastinal fibrosis, although uncommon, should be monitored withe creatinine, ultrasonography, or intravenous urograms, and chest x-rays every 6 months; a drug holiday every 6 months is prudent
Cyproheptadine Comments: Drowsiness common early in treatment
Anticonvulsants
- Phenytoin
- Valproic acid
- Topiramate
- Gabapentin
Calcium Channel Antagonists
- Verapamil
- Nicardipine
- Flunarizine
Comments: Contraindicated by severe left ventricular dysfunction, hypotension, sick sinus syndrome without artificial pacemaker, or second- or third-degree AV nodal block; constipation is most common side effect; not for use with beta blockers
3. Other Agents
- Prochlorperazine
- Hydroxyzine
- Metoclopramide
Comments: Adjunct to treatment; improves enteric drug absorption and reduces nausea; dystonia and akathisia may occur and respond to IV benedryl
Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]
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Causes[edit | edit source]
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Systemic Involvement[edit | edit source]
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Medical Management (current best evidence)[edit | edit source]
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Physical Therapy Management (current best evidence)[edit | edit source]
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Alternative/Holistic Management (current best evidence)[edit | edit source]
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Differential Diagnosis[edit | edit source]
In younger patients, several unusual disorders can mimic migraine with aura:[1]
- Dissection of the carotid or vertebral artery
- Antiphospholipid antibody syndrome
- Cerebral vasculitis
- Moyamoya disease
- CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
- MELAS (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes) syndrome
In older patients, migraine with aura can be mistaken for a transient ischemic attack, especially when the aura occurs without headache.[1]
Other Primary Headaches:[1]
- Cluster headache
- Tension-type headache
- Chronic paroxysmal hemicrania
- Hemicrania continua
Secondary Headaches:[1]
Extracranial Disorders:
- Carotid or vertebral artery dissection
- Cervical spine disorders
- CSF leak with low-pressure headache
- Dental disorders (infection, temporomandibluar joint dysfunction)
- Glaucoma
- Sinusitis
Intracranial Disorders:
- Brain tumors and mass lesions
- Chiari type I malformation
- Hemorrhage (intracerebral, subdural, subarachnoid)
- Idiopathic intracranial hypertension
- Infections (eg, cerebritis, encephalitis, meningitis)
- Obstructive hydrocephalus
- Vascular disorders (eg, moyamoya disease, vascular malformations, vasculitis, venous sinus thrombosis)
Systemic Disorders:
- Accelerated hypertension
- Bacteremia
- Fever
- Hypercapnia
- Hypoxia (including altitude sickness)
- Viremia
Drugs and Toxins
- Analgesic rebound
- Caffeine withdrawal
- Hormones (eg, estrogen)
- Nitrates
- Proton pump inhibitors
Case Reports[edit | edit source]
add links to case studies here (case studies should be added on new pages using the case study template)
Resources
[edit | edit source]
add appropriate resources here
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Beers MH, Porter RS, Jones TV, Kaplan JL, Berkwits M. The Merck Manual of Diagnosis and Therapy 18th ed. Whitehouse Station:Merck Research Laboratories; 2006: 1847-1849
- ↑ 2.0 2.1 2.2 Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist 3rd ed. St. Louis: Saunders Elsevier; 2009: 1551-1559.
- ↑ Aminoff MJ, Greenberg DA, Simon RP. Clinical Neurology 6th ed. New York: Lange Medical Books/McGraw-Hill; 2005: 85-90.