QuestionSBA
QuestionChoice
The headaches are having a significant impact on this patient’s quality of life so continuing to only manage the acute attacks with simple analgesia is not adequate treatment. Prophylaxis of future attacks should be offered for this patient.
33719
b
Continue with paracetamol as required
QuestionChoice
Topiramate is contraindicated in pregnancy or in patients trying to conceive.
33720
c
Topiramate
QuestionChoice
Verapamil is used as prophylaxis for cluster headaches. These presents as multiple short-lived headaches in a short period of time and usually involve tearing or redness of the eye on the affected side. The patient here has a clear history of migraines.
33722
e
Verapamil
QuestionChoice
Carbamazepine is offered to patients with trigeminal neuralgia and not with migraines. Trigeminal neuralgia would presents with electric shock like painful episodes occurring across one cheek.
33721
d
Carbamazepine
QuestionChoice
This patient is presenting with recurrent migraines. A migraine is a primary headache disorder that typically presents with a unilateral throbbing pain, worsened by light and noise. Patients will often describe needing to go to sleep or rest in a dark room to help the headache, which interferes with carrying out daily activities. Management includes trigger avoidance, and treatment of acute episodes with an oral triptan or simple analgesia like paracetamol/NSAIDs.

In patients where the headaches are having a significant impact on their daily function, as in this patient, prophylaxis should be offered. NICE recommends prophylaxis of attacks with propranolol, topiramate or amitriptyline. Topiramate is contraindicated in pregnancy or in those trying to conceive, so propranolol is the most appropriate option here.
33718
a
Propranolol
QuestionComment
If you got this wrong - drops out 

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# Summary

Migraine is a common neurological disorder characterised by recurrent, unilateral, throbbing headaches often preceded by an aura such as visual or sensory symptoms. Migraines can last between 4-72 hours and often result in photophobia and phonophobia. Key signs and symptoms include a unilateral headache, a pulsating character, impairment or worsened by daily activities, and presence of nausea,  vomiting or photophobia. Diagnosis is often based on clinical history, focusing on the presence of an aura. Management strategies include avoidance of triggers, prophylaxis with medications such as Propranolol, Topiramate or Amitriptyline, and managing acute attacks with oral triptans alongside Paracetamol or an NSAID.

# Definition

Migraine is a primary headache disorder characterised by intense episodes of debilitating headaches, usually unilateral and pulsating in nature. Symptoms may be preceded by an 'aura' which manifests as visual disturbances or sensory changes. The pain usually lasts from 4-72 hours and can be accompanied by nausea, vomiting, photophobia, and phonophobia.

# Epidemiology

Migraines are one of the most prevalent neurological disorders worldwide, affecting roughly 12% of the global population. It is more common in women, with a male to female ratio of approximately 1:3, likely related to hormonal influences. The peak incidence occurs between the ages of 30-39.

# Aetiology

The exact cause of migraines is not fully understood, but it is likely a combination of genetic and environmental factors. 

The triggering factors are variable and can include certain foods, changes in weather, stress, hormonal changes, and certain medications such as oral contraceptives.

# Signs and Symptoms

- Aura (usually visual or sensory symptoms preceding the headache)
- Unilateral throbbing headache
- Photophobia and phonophobia
- Nausea and/or vomiting

The International Headache Society criteria for migraine without aura:

| Criteria | Description                                                  |
| -------- | ------------------------------------------------------------ |
| A        | At least five attacks fulfilling criteria B-D                |
| B        | Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) |
| C        | Headache has at least two of the following four characteristics: <br>1. Unilateral location <br>2. Pulsating quality <br>3. Moderate to severe pain intensity <br>4. Aggravation by or causing avoidance of routine physical activity |
| D        | During headache, at least one of the following: <br>1. Nausea and/or vomiting <br>2. Photophobia and phonophobia |
| E        | Not better accounted for by another ICHD-3 diagnosis         |

# Differential Diagnosis

Migraines must be differentiated from other conditions that present with severe headache. Some of these include:

- Tension-type headache: Bilateral, band-like pressure or tightness, not worsened with physical activity, no associated nausea or vomiting.
- Cluster headache: Severe, unilateral, orbital, supraorbital and/or temporal pain lasting 15-180 minutes, occurring up to 8 times a day, associated with autonomic symptoms like ptosis, miosis, lacrimation.
- Subarachnoid hemorrhage: Sudden-onset severe headache, often described as "the worst headache of my life", associated with nausea, vomiting, and possible loss of consciousness.
- Giant cell arteritis: New headache in a person over 50 years, scalp tenderness, jaw claudication, visual disturbances, elevated ESR and CRP.

# Investigations

Diagnosis is primarily clinical, based on the history and examination. 

A headache diary is important to help identify triggers and response to treatment.

If secondary causes of headaches are suspected, further investigations may be warranted, such as neuroimaging (MRI or CT) or blood tests (ESR, CRP for giant cell arteritis).

# Acute Management

- **Avoidance of triggers**: 
  - Identify and avoid potential triggers like certain foods, stress, and poor sleep.
- **Medications for acute attacks**: 
  - **Triptans** (e.g., Sumatriptan) – avoid in patients with ischaemic heart disease.
  - **Paracetamol** or an **NSAID** (e.g., Ibuprofen) can be used in combination with triptans.
  - **Anti-emetics** (e.g., Metoclopramide)
- **Special considerations**:
  - Female patients with migraine with aura should avoid the **combined oral contraceptive pill** due to increased risk of ischaemic stroke.

# Prophylaxis

- Medications:
  - **Propranolol** (contraindicated in asthma).
  - **Topiramate**.
  - **Amitriptyline**.
  - **Candesartan**.
- Injections:
	- Greater Occipital Nerve Block
	- Botulinum Toxin Injection 
- **Newer treatments**:
  - **Rimegepant** (per NICE guidance, May 2023):
    - Used for preventing episodic migraine.
    - Suitable when at least 3 preventive treatments have failed.
    - Indicated for adults with 4-15 migraine attacks per month.

Regular use of acute migraine medications (e.g., triptans, NSAIDs) more than 10-15 days per month can lead to **medication overuse headache (MOH)**.

Patients should be counseled on limiting the use of acute treatments to prevent MOH.

## References

[Click here for NICE Clinical Knowledge Summaries on Migraines](https://cks.nice.org.uk/topics/migraine/)
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A 21-year-old female patient presents to the GP with a three-month history of recurrent headaches. The headache starts as a throbbing pain on one side of her head and worsens with bright lights and noise. She typically takes paracetamol, lays down in a dark room, and sleeps, which helps the headaches. She does not notice any symptoms preceding the headache, and physical examination shows no abnormalities. The headaches have caused her to have several days off of university. She is currently trying to conceive.

What is the most appropriate treatment for this patient?
a