Migraine

PLAB 2 CaseBank
1

Who you are:
You are a FY2 in GP surgery.

Who the patient is:
Emily White aged, 30, presented with headache.

What you should do:
Talk to the patient; take history, assess her and discuss the plan of management with the patient.

P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: On one side of my head. (+ve finding)
D: When did it start? (onset)
P: I have had it for the last 2 months.
D: What were you doing when you had this pain?
P: I was watching TV, but it happens all the time.
D: Is it continuous or comes and goes?
P: It comes in attacks lasting about 4 hours. (+ve finding)
D: What type of pain is it? (character)
P: Throbbing. (+ve finding)
D: Does the pain go anywhere? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: After resting it feels better.
D: Is there anything that makes the pain worse?
P: Noise. (+ve finding)
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and 10 being the most severe pain you have ever experienced? (score)
P: 7.
D: Apart from the headache, is there anything else? (concern)
P: No.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Would you consider this the worst headache of your life? (SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing your hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
D: Do you have any warning symptoms before the headache like flashing of light or noise? (AURA)
P: No.

+FLAWS
P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraines and kidney disease?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: You mentioned that you have had this pain for the last 2 months, how is this affecting your life?
P: Whenever I have this pain, it prevents me from carrying out my normal activities.
D: I am sorry to hear that, how are you coping?
P: It’s difficult doctor.
D: How’s your mood?
P: it’s fine, thanks.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine.
D: Do you do physical exercise?
P: I don’t get time to be honest

Don’t forget ICE

Examination
General physical and neurological examination.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you have a throbbing headache on one side of your head and it’s severe enough to affect your daily activity, so I suspect you are suffering from migraines.

Management
There’s currently no cure for migraines, although a number of treatments are available
to help ease the symptoms.
Refer you to a neurologist for further assessment and treatment if

  • a diagnosis is unclear.
  • you experience migraines on 15 days or more a month (chronic migraine).
  • treatment is not helping to control your symptoms.

Senior.
General advice:

  • Identifying and avoiding triggers is one of the best ways of preventing migraines.
    Recognising the things that trigger an attack and trying to avoid them.
  • Migraine diary: to help with the diagnosis, it can be useful to keep a diary of your migraine attacks for a few weeks.

Note down details including:

  • The date
  • Time
  • What you were doing when the migraine began
  • How long the attack lasted
  • What symptoms you experienced
  • What medicines you took

Medications:

  1. Painkillers
  • Many people who have migraines find that over-the-counter painkillers, such as
    paracetamol, aspirin and ibuprofen, can help to reduce their symptoms.
  • They tend to be most effective if taken at the first signs of a migraine attack, as this gives them time to absorb into your bloodstream and ease your symptoms.
  • Tablets you dissolve in a glass of water (soluble painkillers) are a good alternative because they’re absorbed quickly by your body.
  • Aspirin and ibuprofen are also not recommended for adults who have a history of stomach problems, such as stomach ulcers, liver problems or kidney problems.
  • Taking any form of painkiller frequently can make migraines worse. This is sometimes called a medication overuse headache or painkiller headache, in this case we may recommend that you stop using them.
  • If you find you cannot manage your migraines using over-the- counter medicines, we may prescribe something stronger or recommend using painkillers along with triptans.
  1. Triptans
  • Triptan medicines are a specific painkiller for migraine headaches. They’re thought to
    work by reversing the changes in the brain that may cause migraine headaches.
  • They cause the blood vessels around the brain to narrow (contract). This reverses the widening of blood vessels that’s believed to be part of the migraine process.
  • Triptans are available as tablets, injections and nasal sprays.
  • Common side effects of triptans include warm sensations tightness – tingling - flushing - feelings of heaviness in the face, limbs or chest. However, these side effects are usually mild and improve on their own.
  1. Anti-sickness medicines
  • These can successfully treat migraines in some people even if you do not experience feeling or being sick.
  • They can be taken alongside painkillers and triptans.
  • As with painkillers, anti-sickness medicines work better if taken as soon as your migraine symptoms begin.
  • They usually come in the form of a tablet but are also available as a suppository.
  • Side effects of anti-emetics include drowsiness and diarrhoea.
  1. Combination medicines
  • These medicines contain both painkillers and anti-sickness medicines.
  • It can also be very effective to combine a triptan with another painkiller, such as ibuprofen.
  • Many people find combination medicines convenient.
  • It may be better to take painkillers and anti-sickness medicines separately. This allows you to easily control the doses of each.

During an attack:

  • Sleeping or lying in a darkened room is the best thing to do when having a migraine
    attack.
  • Eating something helps, or they start to feel better once they have been sick.

Other treatment (to prevent migraines)

  1. Acupuncture
  • If medicines are unsuitable or do not help to prevent migraines, you can try acupuncture.
  • A course of up to 10 sessions over a 5- to 8-week period may be beneficial.
  1. Transcranial magnetic stimulation
  • TMS involves holding a small electrical device to your head that delivers magnetic pulses through your skin.
  • It can also be used in combination with the medicines mentioned above without interfering with them.
  • But TMS is not a cure for migraines and does not work for everyone.
  • Potential long-term effects of the treatment, these include: slight dizziness - drowsiness and tiredness.

Headache specialists in specialist centres may prescribe:

  1. Topiramate
  • Prevents migraines and is usually taken every day in tablet form.
  • Not given in kidney or liver problems or pregnancy.
  • Can reduce the effectiveness of hormonal contraceptives.
  • Side effects of topiramate can include: decreased appetite - feeling sick.
  1. Propranolol
  • Effectively prevents migraines. It’s usually taken every day in tablet form.
  • Not suitable for people with asthma, chronic obstructive pulmonary disease (COPD) and some heart problems.
  • Side effects of propranolol can include: cold hands and feet - pins and needles -problems sleeping.
  1. Amitriptyline
  • Helps prevent migraines. It’s usually taken every day in tablet form.
  • Can make you feel sleepy, so it’s best to take it in the evening or before you go to bed.
  • Other side effects include: constipation – dizziness - a dry mouth It may take up to 6 weeks before you begin to feel the full benefit of the medicine.
  1. Botulinum toxin type A
  • Prevents headaches in some adults with long-term migraines.
  • Should be given by injection to between 31 and 39 sites around the head and back of the neck.
  • A new course of treatment can be given every 12 weeks.
  • Treatment for pregnant and breastfeeding women
  • Medicines should be limited as much as possible when you’re pregnant or
    breastfeeding.

Preventing menstrual-related migraines

  • Menstrual-related migraines usually occur from 2 days before the start of your period to 3 days after.
  • As these migraines are relatively predictable, it may be possible to prevent them
    using either non-hormonal or hormonal treatments.
  • Non-hormonal treatments as (NSAIDs) or triptans. These medicines are taken as tablets 2 to 4 times a day from either the start of your period or 2 days before, until the last day of bleeding.
  • Hormonal treatments as contraceptives.

Specialist

  • If the treatments above are not effectively controlling your migraines, we may refer you to a specialist migraine clinic for further investigation and treatment.
  • In addition to the medicines mentioned above, a specialist may recommend other treatments, such as transcranial magnetic stimulation.

Follow-up appointment once you have finished your first course of treatment with triptans. This is so you can discuss their effectiveness and whether you had any side effects.

Safety-netting for any weakness or slurred speech + Meningitis and SAH symptoms.

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