QuestionSBA
QuestionChoice
Opiates should be avoided in migraine headache
32942
e
Co-codamol 30/500mg
QuestionChoice
This is the correct answer. First line treatment for migraines include: 1. Simple analgesia. 2. An anti-emetic if required. 3. Triptans (usually prescribed if moderate to severe symptoms)
32938
a
Ibuprofen 400mg
QuestionChoice
Whilst nausea is common with migraine, and prochlorperazine is a correct treatment, this will not directly relieve the migraine
32939
b
Prochlorperazine 3mg
QuestionChoice
Propranolol is used for migraine prophylaxis, with a target dose of 80mg twice daily
32941
d
Propranolol 80mg
QuestionChoice
Aspirin is an option in migraine but the dose is usually 900mg. Please don't despair and worry that you have to memorise drug doses! This choice was left in to teach you that an option for migraine is 900mg Aspirin which is one of the rare instances where a larger dose than 300mg is used
32940
c
Aspirin 300mg
QuestionComment
question was not clear if asking for acute management or prophylaxis
7682
QuestionComment
also GP is unlikely to prescribe ibuprofen - would recommend buying over the counter 
7683
User
subscriber
Dermis Cystic
QuestionComment
It says pain relief during acute episodes
8808
User
subscriber
Yellow Zebras
User
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Dermis Cystic
QuestionComment
i thought exercise was a trigger for migraines?
21215
QuestionComment
I agree, if it is worse when she doesn't do exercise in my opinion that exlcudes migraine as a diagnosis 
58612
User
subscriber
SJS
User
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Amnesia Syndrome
QuestionComment
Why not asprin?
54494
User
subscriber
Sulman
QuestionComment
GPs would not prescribe ibruprofen, so I went up the pain ladder to a medication they may prescribe to relieve pain: FML 
62176
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subscriber
j.g.73
Concept
Chapter
# 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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First line treatment for migraines include: 1. Simple analgesia. 2. An anti-emetic if required. 3. Triptans (usually prescribed if moderate to severe symptoms)
A 23-year-old woman visits her GP due to headaches. They are unilateral, severe (8/10), last several hours and are associated with nausea. She has noticed that they are worst when she does not do any exercise.

What medication should the GP prescribe for pain relief during acute episodes?
a