MIGRAINE

Presented by Group J
 GROUP J
M. Umair Mansha Muqaddas Haider
102 108

M. Umar Saleem Nafeesa Arif

103 109

M. Usama Naqash Ahmad

104 110

M. Usama Solehria Nimra Rao

106 111

M. Waseem Akram Noor-Ul-Huda

107 112
 DEFINITION
The word migraine was derived from the
Latin word “hemicrania” meaning
“half skull”.

A migraine is a headache that can cause

severe throbbing pain or a pulsing
sensation, usually unilaterally and it’s
often accompanied by nausea,
vomiting and extreme sensitivity
to light & sound.
 FEATURES

Unilateral Run in Nausea Vomiting Symptoms

Families worsened by
Physical
Activity

Sensitivity to Pulsating 2-72 hours

light, sound, or
smell
 TYPES

Common Classical
Migraine Migraine
(Without (With Aura)
Aura)
 TYPES
• Common • Classical
Migraine Migraine
(Without Aura) (With Aura)

❖ ≥ 5 Attacks lasting ❖ Aura occurs

4-72 hours (symptoms that
❖ During headache, occur before a
there is; migraine)
• Nausea/Vomiting ❖ Aura lasts less
• Photophobia/ than 60 minutes
Phonophobia ❖ Headache follows
• Unilateral pain in less than 60
minutes
• Pulsating pain
 PATHOPHYSIOLOGY
Vascular Events
▪ During Aura Intracerebral blood vessels
vasoconstriction
▪ During Headache Intracranial/extracranial
blood vessels vasodilation
Serotonin Role
• Serotonin level linked to migraine
• Specific serotonin receptors found in blood
vessels of Brain

Present Understanding
Neurovascular process in which neural events results
in activation (vasodilation) of blood vessels which in
turn cause pain and further nerve activation.
PATHOPHYSIOLOGY
TRIGGERS OF MIGRAINE

WINE C H O C OLAT E NUTS CHEESE

PROCESSED SLEEP
M E AL S D ISTUR BA N C E S TRAVEL STRESS

M E N O PAU S E WEATHER ODORS BRIGHT

C H AN G E S L IG H T
PHASES OF MIGRAINE
▪ Prodrome
▪ Aura
▪ Headache
▪ Postdrome
PHASES OF MIGRAINE
 Prodrome
• Symptoms that begin from 12 to
36 hours before the aura and
headache
• Symptoms include
✓Yawning
✓Excitation
✓Depression
✓Lethargy
✓Craving or distaste for various
foods
 AURA
• Aura is a warning or signal before
onset of headache
• Symptoms
✓Flashing of light
✓Zig-zag lines
✓Difficulty in focusing
 HEADACHE
• Headache is generally unilateral
and is associated with symtoms
like:
✓Anorexia
✓Nausea
✓Vomiting
✓Photophobia
✓Phonophobia
✓Tinnitus
MANAGEMENT
OF MIGRAINE
Non-Pharmacological
➢Avoidance of triggers
➢Relaxation Techniques
➢Meditation
➢Psychotherapy
➢Regular Sleeping habits
➢Retiring to a darkened
room
Pharmacological
ACUTE TREATMENT
❑ Help manage the pain
❑ Work best if taken at first
signs of attack.
NON-SPECIFIC
TREATMENT
 NSAIDs
➢ PGE2 and PGl2 reduce the threshold to
stimulation of nociceptors, causing
peripheral sensitization
➢ CGRP release from the terminals of the
trigeminal sensory neurons is
modulated by PGE2
➢ Blockade of cyclooxygenase (COX) and
hence reduced synthesis of PG
 NSAIDs
DRUG DOSE ROUTE
Naproxen 500-700 mg Oral

Diclofenac 50-100 mg Oral/IM

Aspirin 500-650 mg Oral

Ibuprofen 200-300 mg Oral

 ANTIEMETICS
Antiemetics/Caffeine-in
combination with NSAIDs
➢ Metoclopramide effective for nausea and
vomiting associated with certain types of
headaches.
➢ D2 antagonistic action might be
responsible for relieve of migraine
➢ Caffeine block the adenosine
receptor vasoconstricting action.

DRUGS
❖ Metoclopramide (IV)
❖ Prochlorperazine (IV/IM)
 SPECIFIC
TREATMENT
 TRIPTANS
▪ Agonists at 5-HT1B & 5-HT1D
receptors
▪ For mild symptoms that do not
respond to Analgesics.
▪ For moderate and severe
symptoms of migraine
TRIPTANS
 TRIPTANS
Adverse Effects
➢ Coronary artery vasospasm Angina
➢ Transient Myocardial Ischemia
➢ Myocardial Infarction
➢ Blood Pressure
➢ Burning or Pain at the site of injection
➢ Paresthesia
➢ Dizziness-given orally
➢ Malaise
 TRIPTANS

Contraindication
➢Coronary artery disease
➢History of stroke or
transient ischemic attacks
➢Cerebrovascular Disease
➢Peripheral vascular disease
 TRIPTANS
Drugs
▪ Sumatriptan (SC, IV, Oral) [Prototype Drug]

▪ Zolmitriptan (Nasal Spray)

▪ Almotriptan (Oral)
▪ Eletriptan (Oral)
▪ Frovatriptan (Oral)
▪ Naratriptan (Oral)
▪ Rizatriptan (Oral)
 Ergot Alkaloids
▪ MOA is same as that of Triptans
▪ Agonists at 5-HT1B & 5-HT1D
receptors
▪ But Ergot alkaloids also act on
dopaminergic and adrenergic
receptors
▪ The vasoconstrictive activity of
ergot alkaloids is more &
long-lasting as compared to
Triptans
 Ergot Alkaloids

Adverse Effects
▪ Nausea
▪ Vomiting
▪ Coronary vasospasm
▪ Blood Pressure
 Ergot Alkaloids
Contraindication
➢ In pregnancy
➢ Peripheral vascular disease
➢ Coronary artery disease
➢ Hypertension
➢ Impaired hepatic or renal function

Drugs
▪ Ergotamine (Sublingual, Oral)
▪ Dihydroergotamine (IV,IM,SC,Intranasal)
[used in severe cases of Migraine]
PROPHYLAXIS
 Preventive Treatment
Indications
➢ Two or more attacks per month that
significantly interfere with the patient's
daily routine activity
➢ An unsatisfactory response to acute
therapy
➢ Contraindication to acute treatments
and adverse effects (AEs) related to
them.
➢ Uncommon migraine conditions,
including hemiplegic migraine, migraine
with prolonged aura or migrainous
infarction.
Migraine Prophylaxis
Drugs
➢ Beta Blockers
➢ Calcium channel blockers
➢ Anticonvulsants
➢ Tricyclic antidepressants
 Beta Blockers
▪ Gold standard in Migraine Prophylaxis
▪ Established Efficacy and Safety in
Migraine Prophylaxis
▪ Preferred if hypertension and anxiety
co-exist.

Mechanism Of Action
▪ Vasoconstriction
▪ Anxiolytic Action
▪ Decreased Sympathetic Activity

Drugs
Propranolol, Nadolol, Atenolol, Metoprolol
 Calcium Channel Blockers

Blockage of L-type calcium channels

causes Dural vasodilation which is
responsible for its anti-migraine action.

Drugs
▪ Verapamil
 Anti-Depressants
▪ Antidepressants inhibit cortical
spreading depression (CSD) and
enhance anti-nociception.
▪ Especially used for migraine
prophylaxis in patients with comorbid
depression.

Drugs
➢ Amitriptyline
➢ Nortriptyline
 Anticonvulsants
These drugs are also used
in Migraine prophylaxis.

Drugs
▪ Divalproex
HEADACHE
 Drugs for Tension
Headache
▪ NSAIDs
▪ Acetaminophen
▪ Aspirin
▪ Butalbital (used with
aspirin/acetaminophen with
caffeine)

❖Aspirin/Acetaminophen is often
used with caffeine
 Drugs for Cluster
Headache
• Inhalation of 100%
oxygen and triptans
(especially sumatriptan)
are used as first-line
abortive strategies for
cluster headache.
Thank You