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Migraine (Epidemiology (In 90% onset is before 40 years, If onset > 50…
Migraine
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Clinical Presentation
Migraine without aura
Two of - unilateral, pulsing, moderate/severe pain in head, aggravated by routine physical activity
During headache at least one of - nausea and/or vomiting during headache, photophobia and phonophobia
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Migraine with aura
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Unilateral, pulsatile headache
There may be a prodrome that precedes the headache by hours/days - yawning, cravings and mood/sleep changes
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Differential Diagnosis
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Tension headache, cluster headache, medication over-use headache
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Pathophysiology
Cortical spreading depression - self-propagating wave of neuronal and glial depolarisation that spreads across the cerebral cortex is thought to cause the aura
Neurogenic inflammation leads to vasodilation and plasma protein extravasation - leading to pain that propagates all over cerebral cortex
Changes in brainstem blood flow lead to an unstable trigeminal nerve nucleus and nuclei in the basal thalamus
Treatment
Acute - Don't offer ergots or opioids, TRIPTANS, NSAIDS, +/- antiemetic
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Prevention
If more than 2 attacks a month, or acute treatment required more than 2x a week
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Diagnosis
Always examine - eyes (for papilloedema and other eye issues using fundoscopy), BP, head & neck (scalp, neck muscles and temporal arteries)
Exclude other causes
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Indications for neuroimaging (CT/MRI) - worst/severe headache (SAH), change in pattern of migraine, abnormal neurological exam, onset > 50 years, epilepsy, posteriorly located headache
Lumbar puncture indications - SAH (bad headache), severe rapid onset headache, progressive headaches, unresponsive headaches, NEUROIMAGING SHOULD PRECEDE
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Definition
Recurrent throbbing headache often preceded by an aura and associated with nausea, vomiting and visual changes
A migraine aura may affect the patients eyesight with visual phenomena such as fortification spectra, shimmering or scotomas, but may also result in pins and needles, dysphasia and rarely weakness of limbs and motor function