Migraine: Aura, Triggers, Evaluation, and Treatment

00:01 Let's talk a little bit about auras.

00:03 Auras is the first thing that happens often before the headache for many migraineurs and they can look very different from patient to patient.

00:10 The most common aura is a visual aura.

00:13 And typically patients will describe a scotoma, a dark spot in their vision or multiple dark spots in their vision.

00:21 Occasionally, they will have positive symptoms Scintillating scotomas, and that's a dark spot with a bright wavy line around it.

00:29 Or photopsia, those are flashes of light that can occur in someone's vision or a fortification spectra.

00:35 As you can see in the image here, this is a complex bright light that occurs over top of what someone should be seeing and would be very prominent.

00:46 Abnormal perceptions such as macropsia, things appearing too big, or micropsia, things appearing too small, are also seen described by patients variably during that visual aura which typically lasts about 30 minutes prior to the headache.

01:01 Other auras can also be seen.

01:02 They're less common, but can be seen.

01:05 The key with an aura is it is typically the same thing every time.

01:09 So cheiro-aural paresthesias, sensory ataxia, abnormal smells and tastes.

01:14 Patients can describe these either during the prodrome period or in the aura phase.

01:19 We can also see non-visual association cortical syndromes.

01:22 Auras that are unrelated to vision or sensory perception of praxia/agnosia, speech and language disturbances, déjà vu, and trancelike nightmares or sort of delirious states.

01:36 These latter auras are uncommon.

01:38 And typically would prompt evaluation with imaging and supposed to the standard visual aura which would not necessitate additional imaging to look for an underlying cause.

01:49 What are some of the triggers for migraine? Many migraineurs will live with their migraine lifelong.

01:54 And so avoiding triggers is critical for treatment.

01:57 And we need to evaluate these in patients when taking a good history.

02:01 Bright lights, pungent aromas or specific aromas for certain patients.

02:06 Sleep deprivation is one of the most common and we see it a lot.

02:11 A psycho-emotional stressors, any stressor really both emotional, physical, mental stressors can set off a migraine attack.

02:19 Analgesic rebound, so patients who have required analgesic medicines and then stop the medicine, there can be a rebound migraine or cluster of migraines in patients who have stopped those medicines.

02:30 Chocolate in many patients, caffeine, red wine, alcohol, a number of triggers.

02:35 Not all of these are seen in every patient and a good history will elucidate those triggers for individual patients that can be avoided.

02:43 How do we evaluate patients with migraine or tension-type headache? Well, this is really a clinical diagnosis.

02:49 And we've gone through the clinical criteria that are important to establish, and a good history is really the first step in evaluating these patients.

02:58 Does not require imaging.

02:59 So sometimes imaging is done particularly with patients who have acephalgic migraines or basilar migraine or familial hemiplegic migraine, or rare auras.

03:07 But imaging is not required to make this diagnosis.

03:10 It may be worthwhile to get imaging a series of circumstances.

03:14 So if patients have rapidly increasing headache, that's a red flag and we'd want imaging.

03:19 If there's new onset focality, a new focal neurologic deficit.

03:23 This indicates a mass lesion or some other brain pathology until proven otherwise, which would require imaging.

03:30 Headache that causes awakening from sleep is suggestive of a high-pressure headache.

03:34 Again, that's not a headache that is there when the patient wakes up, that could be any number of things.

03:39 But a headache that wakes the patient out of sleep usually early in the morning 3, 4 or 5am requires imaging for evaluation of a cause of a high-pressure headache.

03:49 Thunderclap headaches and incoordination or problems with coordination require evaluation of the posterior fossa and posterior fossa abnormalities or obstruction of CSF flow can cause headache is one of the early symptoms.

04:02 And so incoordination or ataxias would require additional imaging.

04:07 How do we treat migraine or tension-type headaches? Well, we really think about two things for managing patients.

04:14 One is to terminate the migraine, stop it and its track.

04:17 When this headache starts, how do we stop it? And everybody needs something to stop their headache.

04:22 In many patients, we will also consider migraine prophylaxis and this is for people typically who have headaches occurring more than twice a month or that's interfering significantly with their life.

04:32 And this is a discussion with a clinician about the benefit of the treatment and the risk and morbidity to the patient.

04:40 Migraine termination.

04:42 What are the things that we think about? And what's a typical approach for thinking through abortive treatments for migraine things that stopped the migraine once it started? Well typically I start with Tylenol or ibuprofen or just taking a nap.

04:56 Those are good conservative abortive treatments for patients who have mild headaches or mild episodes of migraine.

05:02 When those fail we think about adding antiemetics and nonsteroidal anti-inflammatory.

05:07 The nonsteroidals are typically a little bit more potent than Tylenol, and antiemetics can be very successful as migraine abortive treatments.

05:15 Both in their therapeutic qualities as well as many of them are sedating and sleep can be restorative and resolve migraine for many patients.

05:25 When that's ineffective, we typically move to triptans.

05:28 Triptans are approved for abortive treatment for migraine, these are vasoconstricting agents.

05:33 So one of the early things that happens during that aura is vasodilation as a result of activation of the trigeminal vascular circulation and system and triptans cause vasoconstriction.

05:47 Aborting the migraine preventing that vasodilation that triggers the onset of pain during an aura and so we give triptans during the aura.

05:56 In addition, we can try a number of other acute interventions for migraine, particularly for patients presenting to a clinic or the emergency department or acute care, migraine cocktail steroids, other antiemetics, Benadryl, non steroidal, anti-inflammatories and when those fail we think about second line abortive treatments.

06:14 IV valproate acid, IV magnesium, Thorazine and some patients require inpatient hospitalization for dihydroergotamine which is an Ergo it's a vasoconstrictive agent, a little more potent in the triptans and is typically given on the inpatient setting in a hospital.

06:31 Additional 2nd-line medications include calcitonin gene-rleated peptide (or CGRP) antagonists and the selective serotonin 1F receptor agonist, lasmiditan.

06:45 So let's look at some of those abortive treatments and talk about their features.

06:49 Triptans are the medicine to remember when we're talking about a abortive treatment for migraine.

06:54 There are short acting triptans like suma-, sumatriptan or rizatriptan.

06:59 Long-acting triptans as you can see here, frovatriptan.

07:04 And they're used to the highest dose.

07:06 So we typically find the dose that is the highest dose needed to manage the patient's acute migraine and we can repeat one dose within 2 hours, but no more than two doses in 24 hours.

07:17 They are vasoconstricting agents and we worry about the potential cardiovascular side effects, particularly in patients who have a premorbid diagnosis of cardiovascular disease.

07:28 They're also combination agents, sumatriptan and naproxen can be particularly effective.

07:32 But that combination of a triptan and a nonsteroidal anti-inflammatory are often used either as a combination pill are given together.

07:39 DHE is the inpatient dihydroergotamine we discussed.

07:43 There are also other Ergo derivatives that have been used in the past but you rarely see these currently nonsteroidals can be particularly effective especially naproxen that's when I particularly like to use.

07:56 And there are new agents that are being developed in the nonsteroidal category as well.

08:01 And then antiemetics are critical and we often combine a nonsteroidal or a triptan with an antiemetic.

08:07 You see several of these listed here that can be effective not only in treating the migraine but in promoting sedation which can be helpful for these patients.

08:16 CGRP antagonists are newer 2nd-line medications which can also be used for prophylactic therapy.

08:24 They may be considered if triptans are ineffective or contraindicated due to underlying cardiovascular disease.

08:32 Similarly, lasmiditan lacks vasoconstrictor activity, and can be used when cardiovascular risk factors are present. For patients who have severe exacerbations, multiple migraine attacks without resolution or return to baseline which would be status migrainosus or very severe attacks, we'd consider IV interventions, IV, magnesium, IV valproate acid, IV compazine, corticosteroids or dihydroergotamine.

09:01 Either alone or some of these in combination to abort that migraine once it started and some migraine attacks can be quite debilitating for patients and require multiple interventions.