Precipitating factors in migraine
- Hormonal: often premenstrual or related to oral contraceptive (fluctuations in oestrogen).
Clinical history with - occasional positive family history
- travel sickness or migraine variants (abdominal pains) in childhood
- onset in childhood, adolescence, early adult life or menopause Distinguish from: - partial (focal) epilepsy (in hemiplegic or hemisensory migraine)
- aneurysm compressing III cranial nerve (in ophthalmoplegic migraine)
- transient ischaemic attack (in hemiplegic or hemisensory migraine)
- arteriovenous malformation - gives well localised but chronic headache
(i) Identification and avoidance of precipitating factors
(ii) Prophylaxis: use only for frequent and severe attacks Pizotifen (5HT2 receptor blocker)
Propranolol (beta adrenergic receptor blocker)
Methysergide (5HT2 receptor blocker) - use with caution in view of side effects, e.g.
retroperitoneal fibrosis. In resistant cases, use calcium antagonists, antidepressants and anticonvulsants.
(iii) Treatment of an acute attack:
Simple analgesics (e.g. aspirin) with metoclopramide to enhance reduced absorbtion during an attack.
Sumatriptan (a selective 5HT[ agonist) - effectively reverses dilatation in extracranial vessels. Given orally or subcutaneously. Ergotamine - widespread action on 5HT receptors reversing dilatation. Give orally or by inhalation, injection or by suppository. Methylprednisolone i.m. or i.v. will halt the attack when prolonged (status migrainosus).
CLUSTER HEADACHES (Histamine cephalgia or migrainous neuralgia)
Cluster headaches occur less frequently than migraine, and more often in men than women, with onset in middle age.
Characteristics: Severe unilateral pain around one eye, associated with conjunctival injection, lacrimation, rhinorrhea and occasionally a transient Horner's syndrome. Duration: 10 minutes to 2 hours.
Frequency: Once to many times per day, often wakening from sleep at night. 'Clusters' of attacks separated by weeks or even many months. Alcohol may precipitate the attacks. Mechanism: Serum histamine levels rise during the attacks, hence 'histamine cephalgia'. Treatment: Antihistamines give disappointing results. Ergotamine and sumatriptan may give relief. Use prednisolone 30 mgs daily in refractory cases. For prevention, use 68 methysergide, calcium channel blockers or lithium carbonate.
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