Migraine✅

These questions are used to determine your score, which then is matched to a level of disability.

• How many days in the last 3 months did you miss work or school because of your headaches?
• How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school.)
• On how many days in the last 3 months did you not do household work because of your headaches?
• How many days in the last three months was your productivity in household work reduced by half or more because of your headaches? (Do not include days you counted in question 3 where you did not do household work.)
• How many days in the last 3 months did you miss family, social or leisure activities because of your headaches?

Once you have answered these questions, add up the total number of days to determine your level of disability.

What your Physician will need to know about your headache:

• A. On how many days in the last 3 months did you have a headache? (If a headache lasted more than 1 day, count each day.)
• B. On a scale of 0 - 10, on average how painful were these headaches? (where 0 = no pain at all and 10 = pain as bad as it can be.)

⚡ Acute Migraine Management

🧠 Core idea: treat early, use adequate doses, avoid opioids, and assess for medication-overuse headache if acute treatments are being used frequently.

🧠 NICE Acute Treatment Pearls

• Offer combination treatment with an oral triptan plus an NSAID, or an oral triptan plus paracetamol.
• Consider an antiemetic even if the patient does not feel nauseated, because gastric stasis can reduce absorption during migraine.
• If one triptan fails, try another triptan or another route before concluding triptans do not work.
• Use nasal or subcutaneous triptan if vomiting, severe nausea or rapid escalation prevents oral treatment.
• Avoid opioids for migraine.
• Watch for medication-overuse headache: triptans/opioids/combination analgesics on ≥10 days/month, or paracetamol/NSAIDs on ≥15 days/month.

🛡️ Migraine Prevention — When to Consider

• Frequent, severe or disabling migraine despite good acute treatment.
• Acute medication is needed too often or medication-overuse headache is developing.
• Attacks cause significant absence from work/school or impaired quality of life.
• Contraindication, intolerance or poor response to acute treatments.
• Discuss benefits, side effects, pregnancy plans, comorbidities and patient preference before starting.

🛡️ Preventive Treatment Options

🚩 Red Flags — Do Not Assume Simple Migraine

• Thunderclap headache or maximal intensity at onset.
• New headache with fever, meningism, rash or reduced consciousness.
• New neurological deficit that persists or does not fit usual aura.
• New headache after age 50, cancer, immunosuppression or pregnancy/postpartum.
• Headache triggered by cough, exertion or sex.
• Progressive worsening pattern or papilloedema.

📌 Clinical Pearls

• Acute treatment works best when taken early, while pain is still mild or moderate.
• Triptans are for migraine pain, not for non-specific daily headache.
• Preventives usually need 6–8 weeks at a tolerated therapeutic dose before judging benefit.
• A useful response is often defined as around 50% reduction in migraine frequency or severity.
• Review contraception and pregnancy plans before prescribing topiramate, candesartan or newer specialist therapies.

References

• SIGN Migraine Guidance
• NHS Migraine Management

Cases - Migraine

• Case 1 - Migraine Without Aura (“Common Migraine”) 💥: A 28-year-old woman presents with unilateral, throbbing headaches lasting 12 hours, associated with photophobia, phonophobia, and nausea. Attacks occur around menstruation. Diagnosis: Migraine without aura. Management: Acute: NSAID + triptan; Preventive: consider propranolol if frequent; menstrual migraine may benefit from perimenstrual triptan or hormonal therapy.
• Case 2 - Migraine With Aura (“Classic Migraine”) 🌈: A 35-year-old man reports visual zig-zag lines (scintillating scotoma) followed by unilateral headache with nausea and photophobia. Aura lasts 20 minutes and resolves before headache onset. Diagnosis: Migraine with aura. Management: Avoid vasoconstrictors if vascular risk factors; triptans for acute therapy; topiramate for prevention if frequent.
• Case 3 - Hemiplegic Migraine 🧠: A 19-year-old woman develops transient right arm weakness and dysphasia for 30 minutes, followed by severe left-sided headache. Brain imaging normal. Family history of similar attacks. Diagnosis: Familial hemiplegic migraine. Management: Avoid triptans/ergots; preventive therapy with verapamil or acetazolamide; genetic counselling.
• Case 4 - Status Migrainosus ⏳: A 40-year-old woman presents with continuous severe unilateral headache lasting >72 hours, unresponsive to her usual triptan. She has vomiting and photophobia. Diagnosis: Status migrainosus. Management: Hospital admission; IV fluids, antiemetics, IV NSAID or dihydroergotamine; exclude secondary causes.
• Case 5 - Chronic Migraine (Medication Overuse Headache) 💊: A 45-year-old man with longstanding migraine now has daily headaches. He takes OTC analgesics most days. Headaches are less severe but constant. Diagnosis: Chronic migraine with medication overuse headache. Management: Withdraw overused analgesics; introduce preventive therapy (e.g., topiramate, propranolol, botulinum toxin A if refractory); lifestyle measures.

Teaching Commentary 🧠

Migraine is a neurovascular disorder characterised by recurrent disabling headaches, often with aura. Key subtypes: - Without aura (commonest, unilateral throbbing, N/V, photophobia). - With aura (transient neurological symptoms, often visual). - Hemiplegic migraine (motor aura, mimics stroke). - Status migrainosus (prolonged, severe, emergency). - Chronic migraine (≥15 headache days/month, often with medication overuse). Management is stepwise: trigger avoidance → acute therapy (NSAIDs, triptans, antiemetics) → preventive therapy if frequent/severe (beta-blockers, topiramate, valproate, CGRP mAbs). Always consider red flags (first or worst headache, neuro deficits, papilloedema).