Let's talk a little
bit about auras.
Auras is the first thing that happens often
before the headache for many migraineurs
and they can look very different
from patient to patient.
The most common aura
is a visual aura.
And typically patients
will describe a scotoma,
a dark spot in their vision or
multiple dark spots in their vision.
they will have positive symptoms
and that's a dark spot with
a bright wavy line around it.
Or photopsia, those are flashes of
light that can occur in someone's vision
or a fortification spectra.
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.
Abnormal perceptions such as
macropsia, things appearing too big,
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.
Other auras can also be seen.
They're less common,
but can be seen.
The key with an aura is it is
typically the same thing every time.
So cheiro-aural paresthesias,
sensory ataxia, abnormal smells and tastes.
Patients can describe these either during
the prodrome period or in the aura phase.
We can also see non-visual
association cortical syndromes.
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.
These latter auras are uncommon.
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.
What are some of the
triggers for migraine?
Many migraineurs will live
with their migraine lifelong.
And so avoiding triggers
is critical for treatment.
And we need to evaluate these in
patients when taking a good history.
Bright lights, pungent aromas or
specific aromas for certain patients.
Sleep deprivation is one of the
most common and we see it a lot.
A psycho-emotional stressors, any
stressor really both emotional, physical,
mental stressors can set
off a migraine attack.
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.
Chocolate in many patients, caffeine,
red wine, alcohol, a number of triggers.
Not all of these are seen in
every patient and a good history
will elucidate those triggers for
individual patients that can be avoided.
How do we evaluate patients with
migraine or tension-type headache?
Well, this is really
a clinical diagnosis.
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.
Does not require imaging.
So sometimes imaging is done particularly
with patients who have acephalgic migraines
or basilar migraine or familial
hemiplegic migraine, or rare auras.
But imaging is not required
to make this diagnosis.
It may be worthwhile to get
imaging a series of circumstances.
So if patients have rapidly
that's a red flag and
we'd want imaging.
If there's new onset focality,
a new focal neurologic deficit.
This indicates a mass lesion
or some other brain pathology
until proven otherwise,
which would require imaging.
Headache that causes awakening from sleep
is suggestive of a high-pressure headache.
Again, that's not a headache that
is there when the patient wakes up,
that could be any
number of things.
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.
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.
And so incoordination or ataxias
would require additional imaging.
How do we treat migraine
or tension-type headaches?
Well, we really think about two
things for managing patients.
One is to terminate the
migraine, stop it and its track.
When this headache
starts, how do we stop it?
And everybody needs something
to stop their headache.
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.
And this is a discussion with a clinician
about the benefit of the treatment
and the risk and
morbidity to the patient.
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.
Those are good conservative
abortive treatments for patients
who have mild headaches or
mild episodes of migraine.
When those fail we think
about adding antiemetics
The nonsteroidals are typically a
little bit more potent than Tylenol,
and antiemetics can be very successful
as migraine abortive treatments.
Both in their therapeutic qualities
as well as many of them are sedating
and sleep can be restorative and
resolve migraine for many patients.
When that's ineffective,
we typically move to triptans.
Triptans are approved for
abortive treatment for migraine,
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
Aborting the migraine
preventing that vasodilation
that triggers the onset
of pain during an aura
and so we give triptans
during the aura.
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,
Benadryl, non steroidal,
and when those fail we think about
second line abortive treatments.
IV valproate acid,
IV magnesium, Thorazine
and some patients require inpatient
hospitalization for dihydroergotamine
which is an Ergo it's a
a little more potent in the
triptans and is typically given
on the inpatient
setting in a hospital.
So let's look at some of
those abortive treatments
and talk about their features.
Triptans are the
medicine to remember
when we're talking about a
abortive treatment for migraine.
There are short acting triptans like
suma-, sumatriptan or rizatriptan.
Long-acting triptans as you can see
And they're used to
the highest dose.
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.
They are vasoconstricting agents
and we worry about the potential
cardiovascular side effects,
particularly in patients
who have a premorbid
They're also combination agents,
sumatriptan and naproxen can
be particularly effective.
But that combination of a triptan
and a nonsteroidal anti-inflammatory
are often used either as a
combination pill are given together.
DHE is the inpatient
dihydroergotamine we discussed.
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.
And there are new agents
that are being developed
in the nonsteroidal
category as well.
And then antiemetics
and we often combine a nonsteroidal
or a triptan with an antiemetic.
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.
For patients who have
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,
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