Migraine

History Taking

​​Chief complaint:

• Recurrent, severe headaches, often unilateral

• Associated with nausea, vomiting or photophobia

• Visual disturbances or "auras" prior to headache onset

History of Presenting Complaint:

• Duration, frequency, and intensity of headaches

• Character of pain, typically described as throbbing or pulsating

• Aggravating and relieving factors, such as light, noise, or certain activities

• Presence of aura: visual disturbances like flashing lights or zigzag lines

• Associated symptoms such as sensitivity to light, sound, or smell

• Any triggers identified like stress, specific foods, menstrual cycle

System review:

• Neurological symptoms such as tingling or numbness

• Gastrointestinal disturbances such as nausea, vomiting

• Sleep disturbances

Past Medical History:

• Previous diagnosis of migraine or other headaches

• Other neurological conditions

• Comorbid conditions like depression, anxiety, or epilepsy

• History of stroke or cardiovascular disease

Drug History:

• Current medications, including over-the-counter drugs

• Use of migraine-specific medications like triptans, ergots

• Any medications that seem to trigger or worsen the headaches

• Any medication overuse, especially pain killers, as this can lead to medication overuse headaches

Family History:

• Family members diagnosed with migraine or severe headache disorders

• Family history of neurological disorders

Personal History:

• Sleep patterns, stress levels, and exercise habits

• Menstrual cycle and any association with headache occurrence

• Any specific dietary habits, including caffeine and alcohol intake

Social History:

• Employment status and any impact of symptoms on work performance

• Support network, how the condition is affecting relationships with family and friends

• Lifestyle adjustments made due to the condition

OBG History:

• Menstrual cycle patterns and any association with migraines

• Use of hormonal contraceptives and any impact on migraines

• History of migraines during previous pregnancies, if applicable

• Changes in migraine pattern with menopause, if applicable

Physical Examination

General Examination:

• Assessment of the patient's overall appearance, including any signs of distress or discomfort

• Evaluation of vital signs including blood pressure (which might be elevated during severe migraine episodes)

Examination of hands, arms:

• Tremors, if present, could indicate anxiety or overuse of certain medications

Examination of the face (eyes, nose, mouth):

• Conjunctival pallor may be observed due to nausea or vomiting associated with severe migraines

• Pupil reactivity and extraocular movements could be assessed if the patient reports visual disturbances

• Signs of sinus tenderness if sinusitis is a potential differential diagnosis

Examination of the neck:

• Assessment of neck stiffness, if there's a suspicion of meningitis based on the history

Neurological Examination:

• Full cranial nerve examination, especially the visual fields and acuity in case of reported visual disturbances or auras

• Fundoscopic examination may reveal normal results, but should be performed to rule out papilledema

• Motor, sensory, coordination, and reflex examination should be normal unless there is an aura with sensory or motor features

• Examination of speech and language to rule out any neurological deficits

Investigations

Laboratory Investigations:

• Complete Blood Count: to rule out infection or anemia, which can sometimes present with headache

• Blood glucose: to rule out hypoglycemia or hyperglycemia as a cause of headache

• Thyroid Function Tests: as thyroid disease can be associated with headaches

• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): elevated in conditions like temporal arteritis which can cause headache

• Liver and kidney function tests: if there's suspicion of systemic illness

Imaging Studies:

• MRI Brain: to rule out structural abnormalities, tumours, stroke or demyelinating diseases

• CT Head: if there's an urgent need to rule out acute pathologies such as hemorrhage

Invasive Investigations:

• Lumbar Puncture: if there's a suspicion of central nervous system infection or subarachnoid hemorrhage, especially if the headache is sudden onset, severe and different from previous episodes.

Management

General Management:

• Identifying and avoiding known triggers

• Lifestyle modifications including regular exercise, adequate hydration, balanced diet, and stress management techniques

• Regular sleep patterns

• Cognitive behavioral therapy for stress management and coping strategies

Medical Management:

• Acute attack management with NSAIDs, triptans, or antiemetics

• Prophylaxis in cases of frequent migraines with medications like beta-blockers, calcium channel blockers, antidepressants, antiepileptic drugs

• Botulinum toxin injections for chronic migraines

• Hormonal therapies or management strategies in case of menstrual-related migraines

Surgical Management:

• Reserved for refractory cases and includes procedures like occipital nerve stimulation and migraine surgery (trigger site deactivation surgery)

Other:

• Physiotherapy might be beneficial in patients with neck strain contributing to migraines

• Complementary therapies such as acupuncture, biofeedback, or herbal supplements (under supervision) could be considered

• Patient education about the nature of the condition, prognosis, and treatment options

• Regular follow-ups for assessment of treatment efficacy and side effects.