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Toronto Notes 2019 Headache Table 22. Prophylactic Management of Migraine Headaches
Neurology N45
Class Drug Evidence
Beta-blockers Propranolol A Timolol A Metoprolol B
TCA Amitriptyline A Nortriptyline C
CCBs Flunarizine A Verapamil B AED Valproate A Topiramate + folic acid A
supplement
Contraindications
Asthma, DM (mask hypoglycemia) CHF
Heart disease, glaucoma Avoid in elderly
Depression, obesity
Heart disease
Liver, renal, pancreatic disease Renal disease
Side Effects
Fatigue Depression Light-headedness
Sedation
Dry mouth Weight gain Light-headedness
Weight gain, depression, PD (rare)
Weight gain (4.5-9 kg), constipation
Weight gain, tremor, alopecia, teratogenic: neural tube defect
Paresthesia, weight loss, cognitive: memory loss, difficulty concentrating, renal stone (rare)
Temporal Arteritis
>60 yr Temporal
Variable; can be severe Jaw claudication
Polymyalgia rheumatica Visual loss
Temporal artery changes: Firm, nodular, incompressible Tender
Prednisone
See Rheumatology, RH20
Vasculitis (GCA)
Table 23. Headaches – Selected Serious but Rare Secondary Types
Age of Onset
Location
Onset/Course
SAH: thunderclap onset Severity
Provoking
Associated Sx
Physical Signs Management Etiology
IIH = idiopathic intracranial HTN
Meningeal Irritation
Any age
Generalized Meningitis: hours-days Gradual; worse in AM Severe
Head movement
Neck stiffness
Photophobia
Focal deficits (e.g. CN palsies)
Kernig’s sign Brudzinski’s sign Meningismus
CT/MRI with gadolinium LP, antibiotics for bacterial meningitis
Meningitis, SAH
Increased ICP
Any age Any location
Variable Severe
Lying down Valsalva Head low Exertion
N/V
Focal neurolgical symptoms Decreased level of consciousness
Focal neurolgical symptoms Papilledema
CT/MRI and treatment to reduce pressure
See Neurosurgery, NS6
Tumour, IIH, malignant HTN
Migraine Headaches
Definition (Common Migraine)
The oral contraceptive pill is contraindicated with complicated migraine due to risk of stroke
Migraine auras can mimic other causes of transient neurological deficits (e.g. TIAs and seizures)
“Menstrual Migraine” Subtype
Migraine headache that is associated with the onset of menstruation – usually 2 d before to 3 d after the onset of menstrual bleeding
If patient presents to ED with severe migraine and N/V – consider treating with IV anti- emetics (chlorpromazine, prochlorperazine)
• ≥5attacksfulfillingeachofthefollowingcriteria ■ 4-72 h duration
■ 2 of the following: unilateral, pulsating, moderate-severe (interferes with daily activity), aggravated
by routine physical activity
■ 1 of the following: nausea/vomiting, photophobia/phonophobia/osmophobia
Epidemiology
• 18%females,6%males;frequencydecreaseswithage(especiallyatmenopause)
Etiology and Pathophysiology
• theoriesofmigraineetiology
■ depolarizing wave of “cortical spreading depression” across the cerebral cortex that may cause an
aura (e.g. visual symptoms due to wave through occipital cortex) and also activate trigeminal nerve
afferent fibres
■ possible association with vasoconstriction/dilation
• significant genetic contribution
• triggers:stress,sleepexcess/deprivation,drugs(estrogen,nitroglycerin),hormonalchanges,caffeine
withdrawal, chocolate, tyramines (e.g. red wine), nitrites (e.g. processed meats)