What is it?

Neurological (not muscular) disorder involving vasodilatation in brain.

 

Diagnostic tool – ‘Migraine ID’  

1. Stopped activities at least once in past 3 months

2. Nausea/squeemish

3. Does light bother you

 

Useful guideline (includes self care patient leaflet)

 

Diagnosis is clinical. Be cautious requesting MRI – incidental findings that create anxiety and cost (follow up imaging) – but needed if suspect secondary cause

 

Management of acute attack

Key is treat early – when first feel headache

Paracetamol 1g + NSAID (eg naproxen – longer duration)

Can start with triptan also if above not effective

 

Triptans 

– effective but can be side effects due to vasoconstriction effects eg. tight neck/chest

– must not use if known vascular disease (IHD, CVD)

– eletriptan useful if triptan wears off too soon

– naratriptan slower onset, may be more tolerable

 

Gepants – ‘Rimegepant’

– no vasoconstriction so useful alternative – $30 per tablet

 

Nausea and delayed gastric emptying reduces absorption – metoclopramide can be used (or ondansetron wafer)

 

Medication overuse – risk if using acute treatments > 15 days/month or triptans > 10 days/month

 

Stubborn migraine attack – if all above fail can resort to short course of opiates or steroids

 

Preventives

Amitriptyline very low dose – 5mg-10mg at 6pm

Candesartan – tends to be well tolerated and more effective in men

Propranolol

Topiramate – side effects can be problematic and risk of teratogenicity

Onabotulinum toxin A – if > 15 days/month of headache (any type) – works on neurophysiology not muscle

CGRP monoclonal antibody – SC injection 6 monthly – not immunosuppressive