2 min read - Migraine

A 21 years old boy presented with recurrent headache. Headache is severe that he can't do his studies during the episodes. It lasts for about a day, and is associated with nausea and vomiting. He gets pain two to three times a week.

What are the possibilities?

  • In young patients, commonest causes for headache are
    • Sinusitis
    • Tension headache
    • Migraine
After browsing internet about the symptoms, he himself made the diagnosis of migraine. He took panadiene regularly but the response was poor. Finally he decided to see a doctor to get treatment for his migraine.

He was started on flunnerizine by the GP for migraine. Initially the response was good. But about a month later he was brought to hospital by his friends after collapsing while playing a cricket match. He was getting tonic clonic convulsions.

Seizure was managed with IV diazepam. Urgent CT brain revealed a large space occupying lesion.

Lesson

Migraine is common. It's an easy diagnoses to make. But, it's easy to overlook serious pathologies unless you take a proper history and do a good examination.

Never ever diagnose migraine because the patients say they have it!

What specific features in the history and examination would you have looked for?
  • Always exclude sinister pathologies.
    • Early morning headache - Consider space occupying lesions
    • Features of raised intracranial pressure
      • eg: increased pain with straining
    • Impaired vision or visual fields
    • Impaired hearing, tinnitus, vertigo
      • Specifically look for corneal reflex - That is the first thing to disappear in a CP angle tumor.
    • Papilloedema
    • Nasal block or epistaxis
      • It could be sinusitis
      • But you should never miss a nasopharyngeal tumor
    • Cognitive decline/ deteriorating school performance
    • Any focal neurological deficit
    • BLOOD PRESSURE
    • WITHOUT A DETAILED NEUROLOGICAL EXAMINATION IS PERFORMED YOU WILL NEVER PICK ANY OF THIS.
    •  Think and list down the other features which you will look for.

Typical history of migraine is like

  • Moderate to severe headache
  • Mostly unilateral, but can be bilateral also
  • Lasts for 4-72 hours
  • Associated with nausea and vomiting. In some headache gets better after vomiting.
  • Can have photophobia and phonophobia.
  • Can have an aura.
Read about variants of migraine.

What are the principles of treatment?
  • Treating acute pain
    • Paracetamol
    • Panadiene
    • NSAIDS - ibuprofen/ diclofenac
    • Always combine with antiemetics
    • Triptans in the form of tablets as well as nasal sprays are available in Sri Lanka albeit a bit expensive. They are very effective for some patients.
  • Preventive treatment
    • Avoid the things which precipitates headache! Patients knows what makes it worse.
    • Should be given for those who have frequent episodes which interfere with their day to day activities.
    • There's no point prescribing a drug to be taken daily, if the episodes occur once a month.
    • Available drugs
      • Flunnerizine - 5-10mg daily
        • Causes weight gain
      • Topiramate 25-50mg once or twice a day
        • Helps weight loss
      • Propranolol - 20-40mg bd/tds
        • Effective and cheap
        • Many do not respond
        • Never forget that it can cause erectile dysfunction



Comments

  1. Tharanga JothirathnaJuly 9, 2019 at 12:06 AM

    What about prochlorperazine in acute event and also for prophylaxis. I have migraine, I use diclofenac, omeprazole and 10mg of stematil when ever I get migraine (previously used to get dilcofenac and omeprazole only) which gives better relief. and also stematil can prevent migraine too. I have fist hand experiences.

    ReplyDelete

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