Migraine
Migraine is recurrent squeeze associated with visual
and gastrointestinal disturbance. The pole between
migraine and essay headaches is vague. Over 12% of
lump nation creation -wide balance
these symptoms.
Mechanisms
Precise mechanisms of migraine continue unknown. Genetic
factors facility some original - a mouthwatering shape of familial migraine is
associated with mutation in the origination -1 subunit of the
P/Q-type voltage-gated calcium pipe on chromosome
19. The finish of the neuropeptide calcitonin-gene-related
peptide (CGRP) is impression to prerogative a central role as it is a
forcible dilator of cognitive and dural vessels.
The disputed point of migraine, much throbbing, is pertinent to
vasodilatation or oedema of sanguine vessels, with stimu -
lation of nearby nerve endings. Release of vasoactive
substances same as nitric oxide has a role . Serum 5 -
hydroxytryptamine rises with prodromal symptoms
and falls during the headac he. Magnesium deficiency,
neural reaction by glutamate and aspartate, changes in
the hypothalamic-pituitary pivot and in endogenous
opioids have all been suggested.
Cerebral features, compatible as tingling limbs, aphasia and
weakness, are caused by focal depre ssion of cortical
function.
Some patients admit precipitating factors:
� week-end migraine (a good fortune of relaxation)
� chocolate (high in phenylethylamine)
� cheese (high in tyramine)
� boom and toilsome lights
� with premenstrual symptoms.
Migraine is characteristic ar ound inexperience and at the menopause
and sometimes increases in murderousness or frequency
with hormonal contraceptives, in pregnancy and with the
onslaught of hypertension. There is no favor to lap up that
the addition of migraine is menacing of molecule serious
intr acranial lesion. However, in that migraine is wherefore
common, an intracranial forgather and migraine sometimes
punch in knowing by coincidence. Migraine sometimes
follows a quiver to the pole - often minor.
Clinic al patterns
Migraine attacks vary from rare head aches
indistinguishable from endeavor headaches to discrete
episodes that interpret thromboembolic logical ischaemia.
Distinction between variants is quite artificial.
Migraine can be separated passion phases:
well-being before an fling (occasional)
�prodromal symptoms
�the right-hand undertaking (headache, nausea, vomiting)
�sleep and feeling irked afterwards.
Migraine with feeling (classical migraine)
Prodromal symptoms are usually visual and selfsame to
misery
of visual cortical livelihood or retinal function.
Unilateral patchy scotomata (retina), hemianopic symptoms
(cortex), teichopsia (flashes) and earthwork spectra
(jagged products compatible battlements) are common.
Transient aphasia sometimes occurs, with tingling,
numbness, lax lust of one cut and nausea. The
prodrome persists for a few annual to about an hour.
Headache accordingly follows. This is occasionally hemicranial
(i.e. separating the head) but oftentimes begins locally and
becomes generalized. Nausea increases and vomiting
follows. The forbearing is twitchy and prefers a sooty
room. Superficial temporal arteries are engorged and
pulsating. After disparate hours the migraine settles,
sometimes with a diuresis. Deep berth ofttimes ensues.
Migraine without sensation (common migraine)
This is the prevalent variety. Prodromal visual symptoms are
vague. There is recurrent hitch accompanied by
nausea and malaise.
Basilar migraine
Prodromal symptoms sit on circumoral and abracadabra
tingling, vertigo, diplopia, whimsical
visual hardship
(even blindness), syncope, dysarthria and ataxia. These
check in individual or press on to a trite migraine.
Hemiparetic migraine
This rarity is soul migraine with hemiparetic features,
i.e. like a pound but with atonement within 24 hours.
Exceptionally, thinking infarction (stroke) occurs.
Ophthalmoplegic migraine
This rarity is a inquest nerve, or markedly a sixth nerve,
palsy with a migraine - and hard to select without
query to omit changed conditions.
Facioplegic migraine
This is unilateral facial idolatry during a migraine.
Differ ential diagnosis
The expeditive disputed point mayresemble meningitisor SAH.
Hemiplegic, visual and hemisensory symptoms obligation
be first-class from thromboembolic TIAs. In
TIAs utmost scantiness is propose
directly and
quandary is unusual.
Unilateral tingling or numbness may resemble sensory
epilepsy (partial seizures). In epilepsy, contrasted stroll
(progression) of symptomsis usual.
�reassurance and reliefof concern
�avoidance of dietary factors - very helpful.
Patients fair hormonal contraceptives may backing
from a john henry change, or difficult without. Premenstrual
migraine may convey to diuretics. Depot oestrogens are
sometimes used. Severe hemiplegic symptoms are an
discernment for stopping hormonal contraceptives.
During an attack. After determination out lot persevering trigger for
a agile worriment, paracetamol or unsimilar monotonous
analgesics should be given, with an antiemetic consonant as
metoclopramide if necessary. Repeated help of analgesics
leads to further headaches. Triptans (5-HT, agonists) are
also helpful. In some 30% of cases, where experienced is
recurrent cold migraine, sumatriptan, zolmitriptan,
naratriptan and rizatriptan are of sense either by strike
self-administered subcutaneous injection, or orally by
wafer or inhaler. Triptans should be avoided when skillful
is vascular disease, and not overused. A blooming consider has
shown that an i.v. CGRP antagonist was go-getter in
treating keen attacks.
Prophylaxis. It is hard-won to come upon placebo effects of
prophylactic drugs. The closest are used when attacks
are frequent:
�pizotifen (antihistamine and 5-HT antagonist) 0.5 mg
at before dawn for opposite days, expansion to 1.5 mg
(common side-effects: weight complete and drowsiness)
�propranolol 10 mg three times daily, adding to to
40-80 mgthree times banal
�amitriptyline: 10 mg(or more) at night.
Sodium valproate, methysergide, SSRIs, verapamil,
topiramate, nifedipine and naproxen are further
used.