migraine%20headache
MIGRAINE HEADACHE
Migraine headache without aura has at least 5 attacks of any 2 symptoms of unilateral headache that is throbbing or pulsating in nature, moderate to severe in pain and activity aggravates pain. It is accompanied with either nausea and vomiting or photophobia &/or phonophobia. The symptoms last for 4-72 hours without signs of secondary headache.
Migraine headache with aura has at least 2 attacks with any of the fully reversible symptoms of flickering lights, spots or lines &/or vision loss, sensory symptoms of pins & needles &/or numbness and dysphasic speech disturbance but without motor weakness. Accompanied by at least 2 of the following symptoms of homonymous visual symptoms &/or unilateral sensory symptoms or at least 1 aura symptoms develop gradually over ≥5 minutes &/or different aura symptoms that occur in succession over ≥5 minutes.

Lifestyle Modification

Predisposing Factors Recognition and Trigger Avoidance

  • Patient should be educated about the many influences that can lead to a migraine attack
  • Identify and differentiate between predisposing and precipitating or trigger factors
    • Some predisposing factors cannot always be avoided but can be treated
    • Factors triggering an acute attack in one patient may not trigger an attack in another patient
  • Predisposing factors: Stress, depression, anxiety, menstruation, menopause, head or neck trauma
  • Trigger factors:
    • Environmental triggers: Weather changes, bright lights, loud noise, motion, high altitude, odors (eg fumes or perfumes)
    • Lifestyle triggers: Disturbance in sleep patterns, long distance travel, poor diet, skipping meals, smoking, stress, physical strain, fatigue
    • Hormonal triggers: Menopause, puberty, menstruation
    • Medication triggers: Glyceryl trinitrate, oral contraceptives, hormone therapy
    • Dietary triggers: Caffeine, chocolate, aspartame, alcohol, monosodium glutamate, tyramine-containing food and nitrate-containing food
  • Most patients benefit from adequate hydration, regular eating patterns and sleep schedules, regular aerobic exercise and stress reduction
  • Patients also prefer to stay in a dark and quiet room during the attacks 

Patient Education

  • Individuals need to understand that migraine headache is a physiological disorder with genetic predisposition or a primary brain disorder with no structural lesion in the brain
    • Patients are predisposed to blood vessel and inflammatory responses in the brain which cause pain
  • Patients need to be educated about controlling acute attacks and preventive therapy
  • Patients should be made aware of the potential for medication-induced headache (manifested as chronic daily headache) which can be caused by the overuse of analgesics and acute migraine drugs
    • If treating acute headache >2x/week, the patient should consider prophylaxis treatment to prevent medication-induced headache
  • When creating a management plan, involve the patient in the decision-making process
  • Discuss therapeutic options including risks versus benefits and medication-induced headache
  • Patient should be encouraged to keep a headache diary
    • Record frequency, duration and severity of each headache attack
    • Take note of any resulting disability
    • Treatment used for headache and its effects (include adverse reactions to the medication)

Rescue Medication

  • Clinical consideration: Self-administered rescue medication for patients who have severe migraine which do not respond to other treatments
  • May consist of opioid or Butalbital-containing combination that patient may use at home
    • Enables the patient to administer pain relief without the need for physician clinic or emergency department visit
  • Patient must be educated on the appropriate use of rescue medication
  • There should be an adequate trial of preventive therapy because clinical benefit manifests after 2-3 months


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