Migraine Headache

In partial fulfillment of Nursing 505B

by
Melissa A. Makhoul

April 3, 2017
 Objectives
 Provide an overview of Migraine Headache including its characteristics
and pathophysiology.

 Review the general principles and clinical evidence for treatment of

Migraine Headache.

 Present a research article related to the management of Migraine

Headache.
Characteristics of Migraine Headache.

Throbbing head pain of moderate to severe intensity

that may be unilateral (60%) or bilateral (40%).

It affects over 10% of the population worldwide

About 65% are women in their late teens, 20s or 30s.

It usually develops in the morning after arising.

(Lehne, 2016).
 Characteristics (cont’).
Pain increases gradually and lasts 4 to 72 hours (median
is 24 hours).

Associated with N/V, neck pain and sensitivity to light

and sound.

Physical activity intensifies the pain.

Migraine has two forms (1) migraine with aura and (2)
migraine without aura.

(Lehne, 2016).
 Characteristics (cont’).

Precipitating factors include anxiety, fatigue, stress,

menstruation, alcohol, weather changes and
tyramine-containing food.

A family history of the disease is typical.

(Lehne, 2016).
 Pathophysiology.
• Migraine Headache is a neurovascular disorder that involves
dilation and inflammation of intracranial blood vessels.
• Headache generation begins with neural events that trigger
vasodilation.
• Vasodilation then leads to pain, which leads to further neural
activation, thereby amplifying pain-generating signals.
• Neurons of the trigeminal vascular systems are key
components.

(Lehne, 2016).
 Pathophysiology (cont’).
Available data suggests that two compounds play important role:

1. Some data implicate Calcitonin gene-related peptide (CGRP)

as a cause of migraine [promote migraine]:
• Plasma levels rise during a migraine attack.

2. Other data support a protective role of Serotonin (5-HT)

[suppress migraine]:
• Plasma levels drop by 50% during a migraine attack.

(Lehne, 2016).
 Overview of Treatment.
• Non specific analgesics
(aspirin like-drugs).
• Opioid analgesics (for severe
Abortive
therapy. migraine).
• Migraine-specific agents
(Triptans; serotonin receptor
agonists).

• Beta Blockers (propranolol,

timolol).
Migraine • Antiepileptics (topiramate).
Preventive • Tricyclic antidepressants
treatment. treatment. (Amitriptyline).
• Estrogen gel or patch(for
menstrually associated
migraine).
• Eliminate triggers.
• Adequate hydration.
Lifestyle • Physical activity.
changes. • Adapt good sleep pattern.
• Quit smoking, decrease
caffeine/alcohol intake. (Lehne, 2016; AHS, 2016).
 Non-Pharmacological interventions in the
treatment of Chronic Migraine (Preventive).

Botulinum toxin A
Acupuncture. injection (BOTOX).

They are used when adequate pain relief is not achieved by

conventional treatments.

(Naderinabi et.al, 2017)

 Acupuncture
Procedure:
• An acupuncturist will place needles at specific pressure points, usually along a
person’s back or neck where they can slow pain transmission.
• Treatment takes about an hour.
• Patients are advised to undergo at least six sessions (usually once a week).
• Long-term effectiveness beyond one year is uncertain and requires further
research.

 ("Acupuncture and Migraine

| American Migraine
Foundation", 2018)
 Acupuncture

How does it work?

• Not completely clear how it eases pain or decreases migraine:
 Provides pain relief by stimulating muscles and releasing the body’s natural
pain killers called endorphins.
 Reduces inflammation.
 Reduces plasma levels of CGRP and substance P.
 Modulates extracranial and intracranial blood flow.
 Affects serotonin (5-hydroxytriptamine) levels in the brain.

("Migraines", 2018)
 Acupuncture.
Possible side effects:
– Soreness, bleeding or bruising at needle sites.
– Injury to internal organs if needles are pushed in too deeply.
– Risk of infections.
– Feeling of heaviness.
– Numbness or tingling.

("Acupuncture for migraines", 2018)

 Botulinum toxin A injection.
What is botulinum?
• Botulism is the paralysis of muscles caused by high doses of botulinum toxin by the
bacteria Clostridium botulinum.
• Clinical practice found that it can be used in areas of medicine such as post-stroke
spasticity, dystonia and others.
• In the mid-1990s a number of people reported improvement in headaches in
patients receiving botulinum toxin for other reasons. 
• In 2010, Botox has been Approved by the Food and Drug Administration (FDA) to
prevent chronic migraine.

("Botox - The Migraine Trust", 2018)

 Botulinum toxin A injection.
How does it work?
• Still unclear.
• It is believed that botulinum toxin inhibits pain in chronic migraine by:
– Inhibiting the release of Acetylcholine at the neuromuscular junction causing
muscle relaxation.
– Inhibiting the release of neurotransmitters and neuropeptides involved in the
mechanism of pain.

Indication:
• For patients with chronic migraine occurring on 15 or more days each month
lasting 4 or more hours each day in people 18 years or older.

(Naderinabi et.al, 2017)

 Botulinum toxin A injection.
Procedure:
• The injections take about 15 minutes.
• BOTOX® is injected into shallow muscles, not too deeply beneath the skin.
• Each treatment involves 31 injections in 7 key areas of the head and neck.

• Major effects appear five to six weeks after the intramuscular injection.
• Injection cycles should be repeated every three months.
(Naderinabi et.al, 2017)
 Botulinum toxin A injection.
Side effects:
• Allergic reactions.
• Rash, itching.
• Headache.
• Muscle stiffness.
• Injection site reactions (bruising, bleeding, pain, redness, swelling, infection).
• Ptosis, inflammation of cornea, double vision, eye dryness, eyelid swelling and
bruising, decreased blinking.
•  Can spread to other body areas beyond where it was injected (trouble breathing,
talking or swallowing, loss of bladder control, chest pain, severe muscle
weakness…).
There is now increasing evidence documenting the
therapeutic effects of these two methods.

A randomized controlled study was performed with an

aim to compare the effects of acupuncture with
botulinum toxin-A injection and pharmacological
treatment in controlling chronic migraine.
 Statement of purpose
 IV= Treatment; with 3 independent categories (mutually exclusive).
 DV (s) = pain severity, medication usage, number of pain days in a month,
number of days per month which medication is needed, adverse effects.
• Population of interest
 Patients with chronic migraine.
 Research design
• Randomized controlled trial:
 IV (treatment) manipulated by administering a treatment to some and
administering some other treatment to others.
 Group A: Acupuncture; Group B: Botulinum toxin A; Group C: Sodium Valproate
500 mg/day.
 Control group: Group C.
 Participants were randomly allocated to these 3 groups.
 Prospective since the researcher institutes the interventions and subsequently
determines its effects.
• Randomization procedure
Randomly
Screen for
Get informed
Collect
eligibility to
assigned for
consent.
baseline
the study.
condition.
data.

Ad
mi
nis
ter
int
er
ve
nti
on
/c
on
tro
l
co
nd
iti
on
.

Collect outcome data.

 Data collection.
 Structured data
 Survey with closed ended questions “Checklist”.
 Visual analog scale to measure subjective experience of pain.
 Data was collected at 4 points in time T0, T1, T2 and T3 after treatment.
 The designed checklist was filled by a physician who was blinded to the type of
treatment.
Statistical Analysis.
 Results.
(1) VAS score significantly decreased from baseline to T3 in three groups with group
A (acupuncture) greater reduction.
(2) Number of days per month with migraine, missed out days due to headache and
number of times a patient needs medication significantly decreased in three
groups at T1, T2 and T3 with group A greater reduction.
(3) Fewer side effects were observed in group A patients.
(4) Significant reduction in proportion of patients on medication during a three-
time follow up with a dramatic increase for medications in Botox group at T3.
 Conclusion and limitations.
• This clinical trial demonstrates that acupuncture, botulinum toxin-A injection and
pharmacological treatment have beneficial effects on chronic migraine.
• Acupuncture may be the preferred method because of more effectiveness and
fewer side effects.
• Investigators only evaluated the VAS score and other measures such as quality of
life or disability have not been assessed.
• Repetitions of such kind of study considering these measures is recommended.
 References.
• Acute Migraine Treatment (2016). American Headache Society.
https://americanheadachesociety.org/wp-content/uploads/2016/07/NAP_for_Web_-_Acute_Treatment_o
f_Migraine.pdf
• Acupuncture and Migraine | American Migraine Foundation. (2018). American Migraine Foundation.
Retrieved 28 March 2018, from
https://americanmigrainefoundation.org/understanding-migraine/acupuncture-and-migraine-finding-a-co
mbination-that-sticks/
• Acupuncture for migraines. (2018). Migraine.com. Retrieved 28 March 2018, from
https://migraine.com/complimentary-and-alternative-therapies/acupuncture/
• a, G., & Botox, B. (2018). Common Side Effects of Botox (Botulinum Toxin Type A) Drug Center -
RxList. RxList. Retrieved 28 March 2018, from
https://www.rxlist.com/botox-side-effects-drug-center.htm#relatedresources
• Botox - The Migraine Trust. (2018). The Migraine Trust. Retrieved 28 March 2018, from
https://www.migrainetrust.org/living-with-migraine/treatments/botox/
• Migraines. (2018). Acupuncture.org.uk. Retrieved 28 March 2018, from
https://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/migraines.html
• Naderinabi, B., Saberi, A., Hashemi, M., Haghighi, M., Biazar, G., Abolhasan Gharehdaghi, F., … Chavoshi, T.
(2017). Acupuncture and botulinum toxin A injection in the treatment of chronic migraine: A randomized
controlled study. Caspian Journal of Internal Medicine, 8(3), 196–204.
http://doi.org/10.22088/cjim.8.3.196
• Richard Lehne (2016). Pharmacology for Nursing Care. 9th edition. Saunders-Elsevier.
Thank you