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Headache and Migraine

We used to call migraines and things vascular. It’s really neurologic. The vascular involvement is secondary. We call it neurogenic inflammation that involves the blood vessels. Having said that, tension-type headaches can overlap vascular or migraines. They can again occur episodically from stress or fatigue. There is a very strong family history and among children, actually boys have it more commonly. This is interesting because our adult colleagues will tell you that women have migraine much more commonly, and they are right as well. So there is a change-over in gender prevalence. It is a young person’s headache. You don’t diagnose migraines in somebody who is having excruciating headaches and they are 68-years-old. You should be thinking giant cell arteritis.

Common symptoms of migraine; it is very frequently unilateral and it begins as a dull ache that becomes throbbing and possibly incapacitating. There may be visual or sensory auras. Anorexia, nausea and vomiting are common. Photophobia, the classic migraineur, you say, "What do you do?" and they will tell you that they go lie down in a quiet dark place. There may be mood changes. This is a picture from a young boy with migraine who described his aura as "Everything looks slanted." He actually drew this picture. Other auras may resemble like Alice in Wonderland. You can get micropsia, macropsia, distorted images. So those can be part of the migraine’s aura. This is a graphic that you don’t need to really know too much, the only point I am trying to show here is that migraine predominates in this age group.

Types of migraines; now in the old days people used to confuse the hell out of you by talking about classic migraine, common migraine. The Headache Society is actually our friend. They made it simpler. They just call it migraine with aura or migraine without aura, so much more straightforward. Then there are hemiplegic migraines where the patient presents like they just had a stroke. And you do have to take them seriously and evaluate them closely. They may be ophthalmoplegic migraines. One of the interesting things is that in hemiplegic migraines it’s truly an aura.

Vascular migraine, can present with brain stem-related syndromes and you can have cortical blindness. Again, the symptoms tend to resolve as the headache begins. Acute confusion. I told you about this earlier. You could mistake it for certain types of epilepsy, that is the non-convulsive status, but your classic differential when you are looking at a kid like this - a teenager - in the emergency department, you have to think about the seizure disorder but you should be sending a tox screen.

So what are the headaches that you really worry about? Well, the headaches that awaken the patient, or morning headaches with vomiting, headaches accompanied by seizures. It could be an AVM that ruptured. Also I also get a little panicky if I see a new patient who come advertised as migraines but their aura is un-variable. They always have the same symptoms, the same hemicranial. You don’t know that they don’t have an AVM. So it could be due to a lesion. Similarly, in the exam, if there is mental confusion, lethargy, presence of papilledema, you have to look at every eye patient’s eye grams carefully. Nuchal rigidity, blood pressure changes, those are all things that point to some significant medical issues.

So treatment of migraine; here we have abortive treatment which is where somebody actively has the headache and you need to treat them. Non-steroidal antiinflammatories certainly have a role. Indomethacin is powerful. On patients with a lot of nausea, indomethacin suppositories can be acutely used with great benefit.

Let’s talk a little bit about prophylaxis. What about the kid that is missing school two days out of the week? We really need to lower his incidence. So there are drugs for prophylaxis that are not good at treating the acute headache but are calculated to lower the incidence and to make them milder. That includes beta-blockers.

I want to tell you a little bit about the triptans. Sumatriptan is the most popular one. Everyone has heard of Imitrex. By the way, don’t memorized doses because they are not going to ask you how to dose these.