Rural Emergency Medicine

This is part of the Med in Small Doses series, which aims to give you a snapshot of a disease or disorder. For information about the series, or common abbreviations click here.

Recurrent headaches a/w visual & GI disturbances.    30-40yo.    F>M.    Stress most common trigger.

  • Vascular Theory: initial vasoconstriction & ischaemia → neuro SSx. Vasodilation/oedema of vessels → headache.
  • Neuronal Theory: neuronal excitation followed by wave of inhibition. Caused by problems in brainstem/trigeminovascular system.
  • 5-HT Theory: 5-HT ↑ with prodromal Sx, ↓ 5-HT during headache.
 Genetic Component currently under investigation (e.g. CACNA1A, ATP1A2, KCNK18 & SCN1A).

CFs: P O U N D, Aura (20% - Visual, hemi-sensory, hemiparesis aura, dysphasia aura, central vision loss), depression, fatigue/sleepiness.

P ulsating, photophobia
O nset: 4-72hrs
U nilateral
N ausea & Vomiting
D isabiling

Dx Criteria (Classic Migraine):
At least two attacks, including at least three of:
  • Reversible brain symptoms (cortical / brainstem)
  • Gradual development over 4 minutes
  • Aura duration <60 minutes
  • Headache follows aura in <1 hour

Mild Migraine – NSAIDS, combo analgesics | AVOID OPIODS | Oral 5-HT1 Agonists
Acute Tx: Analgesics (Paracetamol, NSAIDs), Anti-emetics (DA Antagonists), Triptans (5-HT1 agonists), Ergot Alkaloids (5-HT1 partials).

Prevention: Indicated if headaches are persistent, of long duration or significantly disabling.
  • β-Blockers, Ca Channel Blockers, Pizotifen, Methysergide.
  • ACE inhibitor - lisinopril
  • Serotonin antagonists, Botulinum toxin, Antiepileptic drugs (sodium valproate, gabapentin, & topiramate),TCAs, SSRIs.
  • Avoid triggers, CBT, meditation, diet.

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