Migraine 2: Clinical

this video is about the clinical aspects of migraine that is migraine as a medical disorder hello my name is Craig Blackwell I'm an ophthalmologist in Santa Cruz California in this video we will discuss clinical aspects of migraine as a medical disorder how you might distinguish it from a stroke or a retinal detachment and an overview of treatment options in the first video we described the migraine experience that is what you see and feel with the migraine in a separate video we will cover the mechanism in more detail remember this is for your information and does not replace consultation with your doctor let us start off by recognizing that migraine is not defined by the headache it is best to think of migraine is a group of various neurologic symptoms that occur in episodes and that all come from a common cause there is usually a headache but not always and it appears to be inherited speaking of the various neurologic symptoms this is the full International Headache Society list of different types of migraines there are too many to cover them all so we will concentrate on the three most common types these are different ways of combining two things headache and hora hora is a particular visual display or sensory defect that comes just before the headache if there is one the three types are one common migraine which is the headache alone with no aura two classic migraine which is hora followed by the headache and three the aura alone visual or otherwise but with no following headache the International Headache Society has different terms but I will stick with these historic names because they are familiar and easy to remember the features that identify a headache as being a migraine are the headache is one-sided usually throbbing usually it is moderate to severe in intensity there is nausea possibly vomiting there is sensitivity to light and sound pain is made worse by physical activity the headache lasts from 4 to 72 hours the aura is a sensory disturbance that occurs with the migraine episodes it can involve vision sensation or movement 30% of people with migraine have the aura here is the beginning of a typical visual display first there is a little missing area like in the picture on the left which grows over a few minutes into a crescent of zigzag flashing lights like the one on the right some describe it as like a kaleidoscope others use the term scintillations at full development it may cover up to half the whole field of vision within the Crescent there is an area of vision that goes missing that is called a scotoma note that it is the same half of vision in both eyes after 15 to 30 minutes sometimes longer the flickering lights gradually fade away and vision returns like the picture on the right other descriptions of visual symptoms include a sensation of watery movement a blurred area or a star-shaped figure rarely there can be a blackout of vision but that must be distinguished from other worrisome causes like stroke some people have an aura that is not visual instead it involves sensations of numbness and tingling that march down the arm or numbness of the hand or around the mouth for some there's a feeling of heaviness of a limb or there may be difficulty speaking to recap the features of the aura are it contains positive features such as the flickering light and negative features such as the missing area the scotoma visual symptoms occur on 1/2 of vision affecting both eyes while sensory symptoms occur only on the one side all the features are reversible that is they usually return to normal symptoms usually last from 5 to 60 minutes here is the frequency of symptoms people report notice about a third have the aura which leads us to the next question how do you distinguish various migraine symptoms from other worrisome things like a stroke or attachment sometimes that is a difficult question to answer even for your doctor we will take a look at the general concepts a migraine headache is distinguished by the presence of specific features we listed but headache symptoms alone are so variable they are not reliable enough to make a definite diagnosis headaches can have so many possible causes and such a range of symptoms and associations that you really need your doctor's help to decide if further evaluation is in order the visual aura can be a source of confusion the visual description is not always a scintillating Crescent but may be more vague and sometimes it must be distinguished from stroke or retinal detachment regarding ocular symptoms they usually occur in one eye only floaters are dark spots or cobwebs that float around as you move your eye they may obscure a little patch of vision but only until they float to a new spot light flashes can come from the retina but they are distinctly different they are usually brief lightning flashes separated in time there would not be the scintillating Crescent continuous four minutes of a time if the retina is detached there is a dark grey area that you can't see into that covers part of vision like pulling a window shade it doesn't return to normal but gradually increases in extent the appearance of any of these things means you need a retina check by your ophthalmologist right away regarding stroke there are two kinds sudden blockage of a blood vessel leading to the brain causes that area not to function that is an ischemic stroke for example sudden inability to move an arm or a whole side or sudden loss of half of vision the other kind is a hemorrhagic stroke where bleeding around the brain causes dysfunction by taking up space and pressing on important structures the TIAA is a transient ischemic attack that is where there is a temporary blockage of a blood vessel with some kind of dysfunction that is of short duration and function returns to normal the following features help distinguish ischemic stroke from migraine aura stroke and migraine both primarily affect the brain so they have some things in common vision and involve is involved than it is the same half a vision in both eyes for sensation only one side is affected which is opposite the brain defect in migraine the aura progresses slowly over time the illustration shows the scintillating Crescent gradually increasing similarly the sensation of pins and needles would slowly march down the arm stroke would be a relatively sudden onset to a full deficit the migraine visual aura has positive flickering lights stroke would usually only have a missing area though there is caution here because there are other things that may produce flickering lights migraine comes in repeated episodes that follow a pattern TI a can be repeated but it doesn't follow the migraine pattern note that repeating TI ASR a red flag warning of impending stroke migraine symptoms are reversible in the illustration on the right the scintillations in scotoma are clearing with vision returning to normal very rarely is there a lasting functional defect it is important to specifically recognize that there is nothing else suspicious going on and take into account presence of other risk factors again you need your doctor to help sort that out we have been talking about distinguishing migraine from stroke here is a twist on that subject it turns out migraine has a significant association with cardiovascular disease I'm going to show you data from two sources first this is a report from the women's health study a large nationwide study of female health professionals over age 45 of nearly 28,000 participants about 5000 reported a migraine history 36 hundred were actively having migraine over the 10 years of the study they were looking for a major cardiovascular event such as stroke heart attack heart surgery or death this graph sums up the result the dashed line is the control no migraine history the blue line is women with migraine with no aura it follows the controls in other words no extra risk the orange line is women with migraine with aura their risk is about double that of controls what the biologic link here is only speculation so far but this is not a new finding and there is ongoing research on the vascular system in migraine this study was a review and analysis of all the studies on this subject I'm adding this because it makes additional points worth knowing about overall women who had migraine had twice the risk of stroke but not men other studies confirmed the extra risk of ischemic stroke and heart attack were only present when there was the aura in people with migraine there were too big additional risk factors for cardiovascular disease smoking caused a nine-fold increase in risk of stroke yet another reason not to smoke and women taking oral contraceptives had a sevenfold increase in stroke so if you have migraine with aura and are on oral contraceptives you should have a talk with your doctor as an ophthalmologist is not my scope of practice to treat non ocular conditions that would fall to your medical doctor or neurologist however I can pass on some general comments for educational purposes migraine treatments are divided into three categories treating the acute attack of migraine these are medicines taken at the beginning of an attack to decrease the severity and duration historically are gotta mean was very popular and may be used in some cases today but it has been superseded by the trip tans like imitrex which have a very high success rate 80% or higher there are now seven of them on the market adding an analgesic like aspirin Naprosyn or ibuprofen made provide additional pain relief prevention if migraine attacks occur frequently enough to interfere with daily life there are medicines you can take on a daily basis to decrease the frequency and intensity of attacks the current first-line recommendations include the antidepressant elavil beta blockers like inderal and anticonvulsants like valproate and there are other options your doctor may choose people with migraine sometimes benefit from other approaches reducing stress to the extent that is possible getting sufficient regular sleep and eating regularly avoiding food triggers the American Academy of Neurology has a website that has more information at the top left of the home page there is a choice one section for patients and caregivers which gets you basic information the other choice is members and professionals which gets you full technical detail if you are interested I have also listed selected references at the end of this video in the third video we will discuss the mechanism of migraine what is going on in your head to produce all those symptoms you

Channel: Craig Blackwell

Views: 137,942

Keywords: Migraine, Clinical

Id: jduJpQCc5ao

Length: 12min 39sec (759 seconds)

Published: Sun Dec 19 2010