dr david pb watson hamilton medical group aberdeen
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Dr David PB WatsonHamilton Medical Group Aberdeen
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Theories of MigraineAcute TreatmentPreventionCase Studies
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A chronic disorder with episodic attacks
Complex changes in the brain
During attacks – Headache– Several associated
symptoms– Functional disability
In-between attacks – Enduring predisposition to
future attacks– Anticipatory anxiety
TGS = trigeminal system; TNC = trigeminal nucleus candalis.Bigal ME et al. Neurology. 2008;71:848–855; Brandes JL. Headache. 2008;48:430–441; Coppola G et al. Cephalalgia. 2007;27:1429–1439; Goadsby PJ et al. N Engl J Med. 2002;346:257–270; Haut SR et al. Lancet Neurol. 2006;5:148–157; Lovati C et al. Headache. 2008;48:272–277; Pietrobon D. Neuroscientist. 2005;11:373–386.
Cortical events
BrainstemNeuropeptides
Trigeminalganglion
Meninges and other peripheral structures
TNC
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Cady R et al. Headache. 2002;42:204–216.Linde M. Acta Neurol Scand. 2006;114:71–83.Linde M. Cephalgia. 2006; 26; 712–721.
Headache
Post headache TimePreheadache ModerateMild Severe
Premonitory
Mood changes FatigueCognitive changesMuscle painFood craving
Fully reversibleNeurological changes: Visual somatosensory
Aura
Dull headacheNasal congestionMuscle pain
Early Headache
UnilateralThrobbingNauseaPhotophobiaPhonophobiaOsmophobia
Advanced Headache
FatigueCognitive changesMuscle pain
Postdrome
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Cady R et al. Headache. 2002;42:204–216. Linde M. Acta Neurol Scand. 2006;114:71–83.Linde M. Cephalgia. 2006; 26; 712–721.
Headache Phase
Postheadache TimePreheadache Severe
UnilateralThrobbingNauseaPhotophobiaPhonophobia
Advanced Headache
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The case for the sensitive migraine brain
Normal life events trigger or are associated with attacks in those predisposed
CNS = central nervous system.Coppola G et al. Cephalalgia. 2007;27:1429–1439; Kelman L. Cephalalgia. 2007; 27:394–402; Pietrobon D et al. Nat Rev Neurosci. 2003;4:386–398.
Dehydration
Diet
Environmentalstimuli
Changes in oestrogenlevel in womenStress
Hunger
Sleep
disturbance
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Beware of using painkillers more than 2 days a week
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Medicines taken during a headache to reduce or put the pain away and to help sickness
Painkillers Anti-sickness medications Migraine specific medicines
Triptans Ergotamine (Cafergot, Migril includes
cyclizine and caffeine)
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Best evidence ASPIRIN 900 mg IBUPROFEN 400 mg In pregnancy PARACETAMOL
1000mgTake early in headacheMay be combined with anti-sickness
medicines such as Domperidone, Metoclopramide and Prochloroperazine
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Migraleve = paracetamol, codeine, (yellow) buclizine (pink)
MigraMax = aspirin and metoclopramide
Paramax = paracetamol and metoclopramide
Clotam Rapid = Tolfenamic Acid
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AlmotriptanEletriptanFrovatriptanNaratriptanRizatriptanSumatriptanZolmitriptan
Decreased pain transmissionDecreased pain
transmissionDecreased pain transmissionDecreasain transmissioned p
BBbBionDecreased pain transmission
Brain
Nerve
Blood Vessel
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Early in the headache phaseNot during auraCan repeat after 2hours if migraine
recursNo response, don’t repeatResponse idiosyncratic
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Tablet ( gastric absorption)Melts (gastric absorption)Nasal Spray ( Gastric and nasal
absorption) Injection ( subcutaneous)
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Most patients have few problems
Sensations of tingling, heat, heaviness, pressure, tightness of throat or chest
FlushingDizzinessFeeling of weakness, fatigueNausea and vomiting
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Take early in headache phaseRescue Treatment (include rectal)Naproxen
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Consider if frequent debilitating migraine
Not a cureGood response is works in 50 out of
100 patients to reduce headache frequency and severity by half
Can be combinedNeed adequate doses
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Patient 1 Preventer
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B BlockersTricyclic Antidepressants Anti EpilepticsPizotifenVenlafaxineCandesartan (Flunarazine) (Methysergide)
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Propranolol 80-240 mgAvoid in asthmaSide Effects (rarely a problem)
Fatigue Coldness of extremities Sleep disturbance and nightmares Gastro intestinal disturbance Dizziness Headache
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Amitriptyline 10 -125 mgNortriptyline 10-125 mgPatient Information Leaflet = anti-
depressantSide effects
Sedation Dry mouth Constipation Headache
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Sodium Valproate 600-1200 mg daily Weight gain Hair Loss Nausea, Diarrhoea
Topiramate 50-150 mg daily Weight Loss Sedation and slowed thinking Irritability and Depression Pins and Needles
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Start low and aim highCombinations can be effectiveConsider reducing/stopping in 6-12
months
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25 year old ladyMigraine with aura twice a month,
always with menstruation. Can vomit late in headache. Menstrual migraine can be 2 days
Never misses workMigraine can be present on wakingAspirin 2 tabs partially helps some
headaches
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Consider Dose. Aspirin 900 mg helps day time
migraine Timing. Taken early in headache works
better Nausea/vomiting . Required triptan for
menstrual migraine Rescue = triptan
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37 year old lady, 4 migraine without aura a month, last 2 days each
Misses 3 days of work a monthCan vomit within 2 hoursNaratriptan helps some time
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Consider Take triptan early Faster acting triptan Nasal triptan Naproxen Rescue Rx suppositories