1. MANAGAMENT OF MIGRAINE

12. MIGRAINE: CLINICAL FEATURES Patient complains of visual disturbances and may have mood variations During headache, patient complains of phonophobia and photophobia Unilateral throbbing headache and later becomes generalised Unilateral throbbing headache may be accompanied by nausea and vomiting Aura or prodrome is present No aura or Prodrome Migraine With Aura Migraine Without Aura

14. NEUROVASCULAR PROCESS

15. Arterial Activation Release of Neurotransmitter Worsening of Pain

17. DIFFERENTIATING COMMON PRIMARY HEADACHES Strictly unilateral Tension headaches : Do not have the associated features like nausea, vomiting, photophobia, phonophobia. The muscle contraction leads to headache. Headache quality is of a tightening (non-pulsating) quality. Usually bilateral. Intensity is mild or moderate Cluster headaches : Severe unilateral pain. Headache associated with lacrimation, nasal congestion, rhinorrhea, facial sweating or eyelid edema. Pain lasts for 15 to 180 minutes. More common in men

18. THE TREATMENT APPROACH TO MIGRAINE

21. MIGRAINE: ABORTIVE THERAPY Non-specific treatment Oral 500 mg-4 g Paracetamol Oral 500-650 mg Aspirin Route Dose Drug Oral 500-750 mg Naproxen Oral/IM 50-100 mg Diclofenac Oral 200- 300 mg Ibuprofen

22. ABORTIVE THERAPY FOR MIGRAINE Specific treatment Orally 10 mg Rizatriptan Orally SC 25-300 mg 6 mg Sumatriptan 5-HT receptor agonists SC 0.75-1 mg Dihydroergotamine Oral 1-2 mg/d; max-6 g/d Ergotamine Ergot alkaloids Route Dose Drug

23. ANTI-NAUSEANT DRUGS FOR MIGRAINE TREATMENT Oral/IV 10-25 mg Chlorpromazine Oral/IM 50-125 mg Promethazine Oral/IV 5-10 mg Metoclopramide Oral 10-80 mg Domperidone Route Dose (mg)/d Drug

29. ROLE OF PROPRANOLOL IN MIGRAINE PROPHYLAXIS

33. PROPRANOLOL-LA CLINICAL EFFICACY IN MIGRAINE

34. PROPRANOLOL REDUCES THE FREQUENCY OF ATTACKS PER MONTH IN BOTH COMMON AS WELL AS CLASSIC MIGRAINE PATIENTS Cephalalgia 1990; 10: 101-105 n = 51 Duration = 12 weeks Propranolol-LA 80 mg appears to have adequate prophylactic effect for migraine and may be better tolerated than propranolol-LA 160 mg, which appears to offer no additional benefits. *p < 0.001 n = 18 n = 27 Side effects 3.9* 3.4* 6.1 Frequency (per month) Propranolol-LA 80 Propranolol-LA 160 Placebo (run in) Variable

35. Propranolol long-acting reduces the attack severity * p = 0.003 Headache 1998; 28: 607-611 n = 48 6.7* 11.1 Severity score End-period Baseline Parameter

36. Propranolol vs. Flunarizine 48 50 0 10 20 30 40 50 60 70 Flunarizine (p<0.01) Propranolol (p<0.0005) No. of attacks reduced by more than 50% % of Patients Headache 1989; 29: 218-223

37. Propranolol showed a significant reduction in the severity of attacks 1.6 1.6 1.4 1.2* 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 Flunarizine Propranolol Severity score Baseline 16 weeks * p<0.05 Headache 1989; 29: 218-223

38. Propranolol significantly reduced the number of analgesics used 4.5 6.3 4.1 3.4 0 1 2 3 4 5 6 7 Flunarizine Propranolol Baseline 16 weeks No of analgesics/month * Headache 1989; 29: 218-223 *p<0.0005