MIGRAINE

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ARDHAVABHEDAKA
MIGRAINE
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PRESENTATION BY
NEHA ATHALEKAR
3
It is a type of shiro roga

• Reference is found in almost all samhitas

4
Shiro rujati martyana vatapittakaphastribhihi
Isannipatena raktena kshayena krimibhistathaIIsu
ryavartanantavatardhavabhedakashankhakIekadasha
prakarasy lakshana sampravakshyetII
(su.utt.25\2)
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11 TYPES OF SHIROROGA

• Vataja
• Pittaja
• Kaphaja
• Sannipataj
• Raktaja
• Kshayaja
• Krimija
• Suryavarta
• Anantavat
• Ardhavabhedaka
• shankhaka

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Ardhe tu murdhna so ardhavabhedaka I
(va.utt.23\7)The disease in which
there is pain in one side of the head is called
as ardhavabhedaka
7
Yasyottamangardhamativa janto sambhedtodabhramash
oolajushtamIpakshaddashahadathava S
pyakasmattasyardhabheda..II (su.utt.2515)the
person whose half of utamanga has very severe
pain like bheda toda bhrama shoola and which
reoccurs after 10 or 15days is said to be
suffering from ardhavabhedaka.
8
Rukshatyashanat purvavatavashyayamaithunaiIvegas
andharanayasavyayamaikupitoSnilakevala sakapho
vaSrdha gruhitva shirastatamanyabhrushankhakarna
kshilalatardhativedanamIshastrarininibha
kuryattivra soSrdhavabhedakanayanam vaSthava
shrotramativrudhovinashayet
(ch.si.974)
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HETUruksha padarthaadhyashanapurvavatasevanaa
vashyasevanamaithunvegasandharanaaayasvyayam
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SAMPRAPTI

• Hetusevana
• Vataprakopa kaphaprakopa
• Grahanirmiti at ardha shira
• ardhavabhedaka

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LAKSHANA

• severe pain at
• Neck
• Brow region
• Temporal region
• Ears
• Eyes
• Forehead
• Pain is described as if being cut by sharp
  instruments

12
UPADRAVA

• Chakshurendriya nasha
• Srotrendriya nasha

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MIGRAINE

• A severe reoccurring headache, usually affecting
  only one side of the head, that is charectorized
  by sharp pain and is often accompanied by nausea,
  vomiting and visual disturbances.
• Also called as hemicrania, megrim, sick headache

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AETIOLOGY

• Aetiology of migraine is largely unknown
• Genetic predisposition - usually family history
  is seen
• Hormonal influence-
• female predominance
• Some women tend to have migraine attacks at
  certain points of their menstrual cycle

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PRECIPITATING FACTORS

• Dietary precipitants- cheese, chocolates, red
  wine
• Psychological factors- stress
• Disturbed sleep pattern
• Drugs
• Physical exertion
• Visual stimuli
• Auditory stimuli
• Weather changes
• hunger

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changes in daily cycle
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environment or diet
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mental
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HOW COMMON IS MIGRAINE

• World- 15-20 of women and 10-15 of men suffer
  from migraine
• In India 15-20 of people suffer from migraine
• Adults-female male ratio is 21
• In childhood migraine, boys and girls are
  affected equally until puberty when predominance
  shifts to girls

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PATHOPHYSIOLOGY

• Vascular theory-
• Intracerebral blood vessel constriction aura
• Intracranial/extra cranial blood vessel
  vasodilatation-headache
• Serotonin theory-
• Decreased serotonin levels linked with migraine
• Specific serotonin receptors found in blood
  vessels of brain

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3
4
Chemicals in the brain cause blood vessel
dilation and inflammation of the surrounding
tissue
Changes in nerve cell activity and blood flow
may result in visual disturbance, numbness or
tingling, and dizziness.
5
2
The inflammation irritates the trigeminal nerve,
resulting in severe or throbbing pain
Electrical impulses spread to other regions of
the brain.
1
Migraine originates deep
within the brain
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CLASSIFICATION

• Migraine with aura
• Migraine without aura
• Complicated migraine

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PHASES OF ACUTE MIGRAINE

• prodrome
• aura
• headache
• postdrome

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PRODROME

• Vague premonitory symptoms that begin from 12 to
  36 hrs before the aura and headache
• Symptoms include-
• yawning
• Excitation
• Depression
• Lethargy
• Craving or distaste for various foods
• Duration- 15-20min

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AURA

• Aura is a warning or signal before onset of
  headache
• Symptoms include
• Flashing of lights
• Zig zag lines
• Difficulty in focussing
• Duration15-30 min

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HEADACHE

• Headache is generally unilateral and is
  associated with symptoms like
• Anorexia
• Nausea
• Vomiting
• Photophobia
• Phonophobia
• Tinnitus
• Duration4-72 hrs

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POSTDROME

• Following headache, patient complains of
• Fatigue
• Depression
• Severe exhaustion
• Some patients feel unusually fresh
• Duration few hrs to 2 days

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CLINICAL FEATURES
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MIGRAINE WITHOUT AURA

• No aura or prodrome
• Unilateral throbbing headache may be accompanied
  by nausea and vomiting
• During headache patient complains of photophobia
  or phonophobia

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MIGRAINE WITH AURA

• Aura or prodrome is present
• Unilateral throbbing headache and later becomes
  generalized
• Patient complains of visual disturbances and may
  have mood variations

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DIFFERENTIAL DIAGNOSIS

• Headaches have numerous causes
• It is one of the common locations of pain
• Primary headache-headache without any organic
  cause
• Secondary headache-headache associated with
  organic causes

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PRIMARY HEADACHE

• Tension type headache
• Cluster headache
• Migraine headache

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TENSION TYPE HEADACHE

• Pain begins in back of the head and upper neck
• Described as pressure encircling head with most
  intense pressure over eyebrows
• Pain is mild and unilateral
• Not associated with aura
• Pain occurs infrequently, without any pattern

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CLUSTER HEADACHE

• Pain typically occurs once or twice daily
• Each episode of pain lasts from 30-90minutes
• Attacks tend to occur at about the same time
  everyday
• Pain is located around or behind eye
• Affected eye becomes red inflamed and watery
• Nose of affected side may become congested and
  running

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(No Transcript)
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SECONDARY HEADACHE

• head and neck trauma
• Transient ischemic attack
• Carotid artery inflammation
• Temporal arteritis
• Brain tumors
• Seizures
• Meningitis
• Encephalitis
• Hypertension
• Hypothyroidism
• Problems with eye ear nose throat teeth

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DIAGNOSIS

• Medical history
• Headache diary maintaining records of site,
  frequency, duration of pain and associated
  symptoms)
• Migraine triggers- stress, diet etc.
• Organic disease must be excluded
• Other pointers include-family history of migraine
• age of onset
• presence of aura
• Menstrual association

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COMPLICATIONS

• Nausea
• Vomiting
• Vascular headache
• Visual impairment
• Cerebrovascular accident
• Photophobia
• Vertigo
• Abdominal pain
• Eye pain

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PROGNOSIS

• migraine usually doesn't represent a significant
  threat to health
• In rare cases, people with migraine may be at
  risk of serious complications
• A severe migraine may result in a stroke possibly
  due to prolonged constriction of blood vessels
• For many people migraines eventually go into
  remission and sometimes disappear completely
  particularly as they age.

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INVESTIGATIONS

• Usually done to exclude secondary causes
• EEG
• CT brain
• MRI

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PREVENTION

• understanding you headache triggers can help you
  avoid foods and situations that cause your
  migraine
• Avoid smoking
• Avoid alcohol
• Avoid artificial sweeteners
• Get regular exercise
• Get plenty of sleep each night
• Reduce stress by relaxing and meditating

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TREATMENT
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Tatha S rdhavabhedake vyadhau praptmanyaccha
yadbhavet Ishirishmulakfalairavapedo S
nayerhitaII (su.utt 26\31)

• Line of treatment is similar to that of
  suryavartak
• Avapidana nasya with sirish mula and phala rasa.

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Vanshmulakakarpurairavapida prayojayet Iavapido
hitashchatra vachamagadhikayuta I
(su.utt 26/32)

• Two yoga of avapidana nasya are mentioned
• Vanshmoola and karpor-kalka made by adding water
• Vacha pippali kalka nasya

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Madhukenavapido va madhuna saha sanyutaImana
shilavapido va madhuna chandanen va II
(su.utt26\33)

• Avapidana nasya of yashtimadhu honey
• 
  Chandanyashtihoney

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Teshamante hitam nasya sarpirmadhurasanvitam
Isarivotpalkushthani madhukam chamlapeshitam II
(su.utt.26\34)

• Medicines of sweet taste processed into ghee form
  is also beneficial.

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Chatu snehottama matra shirakaya virechanam
Inadiswedoghrutam jirnam bastikarmanuwasanam ii
(ch.chi.9\78)

• Ghruta, taila vasa majja- sevana in uttam matra
• Shirovirechana
• Kayavirechana
• Nadisweda
• Purana ghruta
• Niruha basti
• Anuwasana basti
• shirobasti

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According to yoga ratnakara

• Raktamokshana
• Milkghee nasya
• Milk intake, ghee intake
• Virechana
• Fumigation
• shirolepa

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TREATMENT GOALS FOR MIGRANT SUFFERER

• Reducing the attack frequency and severity
• Avoiding escalation of headache medication
• Educating and enabling the patient to manage the
  disorder
• Improving the patients quality of life

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MIGRAINE MANAGMENT

• Non pharmacological treatment
• Identification of triggers
• Meditation
• Relax techniques
• Psychotherapy
• Pharmacological treatment
• Abortive treatment
• Preventive treatment

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ABORTIVE TREATMENT

• Non specific treatment-
• Aspirin
• Paracetamol
• Ibuprufen
• diclofenac

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ABORTIVE THERAPY

• Specific treatment-
• Ergot alkaloids-ergotamine
• dihydroergotamine
• Triptans- sumatriptan
• rizatriptan
• Antinauseant drugs- metaclopramide
• 
  chlorpromazine
• Triptans work best in 1st couple of hrs of attack
• Ergotamine works at any time during the attack

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MODE OF ACTION

• ERGOTAMINE
• Structurally similar to amines serotonin dopamine
• Interact with multiple receptors in these
  symptoms
• Causes constriction of blood vessels
• Wide range of effect

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MODE OF ACTION

• TRIPTANS-
• Serotonin is involved in migraine attack
• Triptans mimic the action of serotonin
• Triptans act on receptors at smooth muscle cells
  of brain vessels
• They are an advance over ergots

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PREVENTIVE THERAPY

• Beta blockers e.g.. Propanolol
• Calcium channel blocker eg.verapamil
• TCA3 amitriptylene
• SSRIs fluxetine
• anticonvulsant- - sodium valproate
• Anti histaminic - cyproheptadine

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NEED FOR PROPHYLACTIC TREATMENT

• Abortive drugs should not be used for more than
  2-3 times a week
• Long term prophylaxis improves quality of life by
  reducing frequency and severity of attacks

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INDICATION OF PROPHYLAXIS

• Patients who have very frequent headaches (more
  than 2-3/week)
• Attack durationgt 48hrs
• Headache severity is extreme
• Migraine attacks are accompanied by severe aura
• Contraindication to acute treatment
• Unacceptable adverse effects occur with acute
  migraine treatment
• Patients preference

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KEY TOWARDS SUCCESSFUL MIGRAINE TREATMENT

• Listen to patients
• Migraine is mixed up with lot of things-
• emotional factors-husbands, bosses, general
  dissatisfaction with life
• sleep disturbances
• hormonal changes
• If you do not address this, you will not be
  treating your patients
• Dont just throw drugs at your patients
• Be attentive and empathetic