Information Sheet for Candidates

Your next patient in the emergency department is a 36 year old

lady, Jane, who woke up this morning feeling dizzy, almost like
loosing her balance when she tried to get out of bed. She felt
rather nauseated.
She also experienced some light spots and some flashing in her
right eye followed by a severe right sided headache.
She cant stand looking into light and noises exacerbate the
headache.
Your task is to:
Take a focused history
Examine the patient
Explain your diagnosis to the patient
Manage the condition

HISTORY:
Jane has had similar episodes of headaches for about 12 years since the birth of her first child. Her mother
used to get them as well.
No other medical conditions, 3 children, non smoker, no alcohol, no allergy.
SHx: She works as a secretary in a law firm. Happily married, no financial or emotional problems.
FHx:Her mother has migraines, otherwise unremarkable
EXAMINATION:
Jane looks rather washed out and uncomfortable but the physical examination is unremarkable.
DIAGNOSIS:
MIGRAINE
The cause is unknown but seems to be related to a functional disturbance of the cranial circulation with
prodromal symptoms (flashes of light, hemianopia, paraesthesias) due to vasoconstriction of intracerebral
vessels whilst the head pain is due to dilation of scalp arteries (extracerebral). It affects about 10% of our
population, runs in families, usually females!
It is important to identify possible TRIGGER FACTORS like:
FOOD:
- cheese
- oranges
- tomatoes
- red wine
- caffeine
- chocolate
DRUGS:
- vasodilators
- oestrogens
- nitrates
- indomethacin
- OCP
FATIGUE / TIREDNESS / EXHAUSTION
STRESS
EXERCISE
HORMONAL CHANGES (PUBERTY, MENSIS, CLIMACTERIUM, PREGNANCY)
NOISE / LIGHT
Diagnostic criteria:
1. Migraine without aura:
A - at least 5 attacks that fulfil B, C, D and E
B - headache lasting for 4 to 72 hours
C - at least two of these characteristics
unilateral
throbbing
moderate to severe intensity
aggravated by physical activity
D - nausea, vomiting, photophobia, phonophobia
E - no evidence of other disease

2. Migraine with aura:

A) at least 2 attacks that fulfil B and C
B) at least 3 of the following 4:
one or more completely reversible aura symptoms
the aura develops over >4 minutes
duration of aura <60 minutes
headache follows within one hour
C. no evidence of other disease
INVESTIGATIONS:
None! CT scan sometimes ordered because of patient anxiety about tumors or bleeds!
THERAPY: 1. abortive

2. preventive!!!

Identification and avoidance of trigger factors (see above!!!!)

Reassurance, rest in a dark and quiet room
Avoid movement, reading , TV or noises
Antiemetics (Stemetil/Prochlorperazine, Maxalon/Metoclopramide)
Simple analgesics (aspirin, paracetamol, mersyndol), avoid codeine (addiction)
NSAIDs (naproxen)
Phenothiazines/Chlorpromazine, Prochlorperazine (Stemetil)
Haloperidol
Triptans (Imigran), binds to serotonin receptors in the cranial blood vessels, leading to cerebral
vasoconstriction (contraindicated within 24 hours of ergotamine!)
Ergot derivates (ergotamine, dihydroergotamine), in combination with caffeine (Cafergot)
Non pharmacological therapy like acupuncture, behavioural therapy (improves communication
between patient and doctor, as well as patient participation in treatment process), life style changes,
relaxation Rx, stress Mx, biofeedback, feverfew, Vit. B122, coenzyme Q10 and magnesium.

PROPHYLAXIS:
1) Clonidine
2) Beta blockers (propranolol) (CI asthma, bradycardia)
3) Methysergide (preventer!)(only for 6 months, vasospastic syndromes, retroperitoneal fibrosis)
4) Cyproheptadine (drowsiness, weight gain)
5) Pizotifen malate (sandomigran, serotonin antagonist) (preventer!) (drowsiness, weight gain)
6) tricylic antidepressants (impaired alertness, anticholinergic, autonomic side effects)
7) Ca channel blockers (nifedipine, verapamil),(only in severe cases and for limited time)
The migraine prodrome comprises the symptoms (eg, yawning; food cravings; changes in sleep,
appetite, or mood) that precede the headache phase by hours or days. Aura precedes the headache
phase by minutes and it may or may not persist during it. Aura is more often visual (eg, scotomata or
positive visual phenomena such as teichopsia, photopsia, or dysmorphopsia). Sensory aura is less
common; it is characterized by paresthesias in the upper extremity and perioral area (ie, cheiro-oral

paresthesias). Motor and language deficits are less common. The migraine prodrome does not occur in
all patients, and a history of aura is present in only about 20% of cases.