Atherosclerosis & Migraine- Risk factor, Signs and symptoms & Treatment

Migraine
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Atherosclerosis

  • Intimal proliferation of smooth muscle cells and lipid deposition
  • Forms a lesion known as a plaque – can cause vessel luminal stenosis
  • Plaque can rupture causing localised thrombus formation and vessel occlusion

Risks

  • Age – commoner with increasing age
  • Men > Women especially pre menopausal.
  • Serum cholesterol LDL-C is bad HDL-C is good
  • Smoking – endothelial damage ? carbon monoxide
  • Hypertension, Diabetes mellitus
  • Family history, Oral contraceptive
  • Obesity, Gout, Type A personality
  • Diagonal ear crease, Corneal arcus
  • Hyper homocystinaemia, Hypertriglyceridaemia
  • High fibrinogen levels

Pathophysiology

  • Limit flow by causing a flow defect and ischaemia
  • Plaque rupture and vessel occlusion and infarction

Commonly affected vessels

  • Internal carotid, Vertebral, basilar and Middle cerebral artery
  • Proximal coronary arteries
  • Abdominal aorta and iliac, femoral and popliteal arteries
  • Thoracic aorta, femoral and popliteal arteries

Management

  • Dietary modifications
  • Smoking cessation
  • Exercise
  • Aspirin 75 mg od ( or Aspirin 81 mg OD US)
  • Simvastatin 40 mg od to achieve a Cholesterol < 5 mmol/l
  • Nitrates
  • Beta blockers – reduce myocardial oxygen demand
  • Calcium channel blockers – vasodilated coronary arteries
  • Nicorandil – potassium channel blocker
  • Angioplasty
  • Stenting
  • Surgically bypass the obstruction.

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Migraine

Background

Pathophysiology

  • Severe headaches, usually episodic but can be chronic.
  • Neurogenic inflammation leads to vasodilation and altered pain sensation.
  • Often improves with age.

Triggers

Triggers include CHOCOLATES and:

CHeese

Oral contraception.

Caffeine or its withdrawal.

AlcohOL

Anxiety

Travel

Exercise

Sleep deprivation.

50% have no trigger.

Signs and symptoms

POUNDing headache:

  • Photo- or phonophobia.
  • Lasts 4-72 hOurs.
  • Unilateral. However, can be bilateral.
  • Nausea and vomiting.
  • Debilitating. Worse with activity and patient will want to be still.
  • 15-30 minutes pre ± during headache.
  • Visual: sparkles, flashing lights, scotoma
  • Sensory: numbness and tingling (e.g. moving up arm) may also occur.
  • Motor symptoms: dysarthria, ataxia, ophthalmoplegia, hemiparesis.
  • Others: dysphasia, ANS symptoms (lacrimation, conjunctival injection).
  • Some experience aura alone.
  • Some experience a prodrome over hours to days, in which they may feel sleepy, moody, or hungry.
  • Neck pain or stiffness can occur, though may also suggest meningism.

Risk factors

  • Female gender. Often premenstrual.
  • Combined contraceptive pill.
  • Obesity
  • Patent foramen ovale.
  • A small number are part of a familial syndrome, including familial hemiplegic migraine, which presents with fever, severe auras, and reduced consciousness.

Diagnosis

Clinical diagnosis. International Headache Society criteria:

  • ≥2 headaches with aura.
  • Or ≥5 headaches lasting 4-72 hours AND any 1 of {nausea/vomiting or phono/photophobia} AND any 2 of {unilateral location,  pulsating quality, moderate or severe intensity, worse on moving, or limiting activity}.

Management

Acute treatment

Home treatment:

  • {NSAID or paracetamol PO} and/or {triptan PO, or IN if age 12-17}.
  • Adding metoclopromide PO to NSAID or paracetamol may help even in absence of nausea and vomiting.
  • Non-oral options if vomiting: triptan SQ/IN, diclofenac PR, domperidone PR.

Emergency department treatment of severe migraines:

  • Parenteral options: triptan SQ, antiemetic IV (metoclopromide, prochlorperazine), or ketorolac IV.
  • Add dexamethasone IV to reduce headache recurrence within 72h.

Prevention

Avoid triggers:

  • Migraine diary may help identify.
  • Regular meals, good sleep, avoid dehydration.
  • Stress reduction: CBT, relaxation therapy.

Indications for medical prophylaxis:

  • Frequent disability e.g. ≥2 episodes per month causing 3 days disability.
  • Standard acute treatment not effective.

Therapeutic options:

  • 1st line options: propranolol, amitriptyline, or topiramate. All similarly effective in adults, while in kids propranolol has the best evidence.
  • Acupuncture may be effective.
  • Botulinum toxin type A for refractory, chronic migraine.
  • Verapamil for hemiplegic migraine.

Complications

  • Chronic migraine: ≥15 headache days per month, of which ≥8 are migrainous, for ≥3 months.
  • Status migrainosus: >72 hour migraine.
  • Migrainous infarction: infarct during migraine. Higher risk if on combined pill and has migraine with aura, so use POP instead.
  • Depression, anxiety.

Treatment

Drugs

Sumatriptan, almotriptan, eletriptan, rizatriptan.

Mechanism

5-HT1 agonist vasoconstrictors.

Contraindications and interactions

  • CVD: IHD, HTN, coronary spasm.
  • Drugs: lithium, SSRIs, ergot.

Side effects

Rare but serious:

  • Arrhythmias
  • Angina or MI.

Altered sensations:

  • Tingling, chest or throat tightness, pressure.

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