A Killer Migraine

 

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Q. A 23 year old woman comes to the physician because of a severe headache that began 7 hours ago. The pain is located on the right side of her head and is made worse by head motion or sneezing. She also complains of ringing in her left ear, tenderness over her face and scalp on the right side of her head, and severe pain with brushing her hair. She has had some relief by lying down in a dark, quiet room. She has had no change in vision. Her temperature is 37.1 Celsius (98.8 F), her blood pressure is 118/72 mmHg, and her pulse is 95 bpm. Examination reveals photophobia. The remainder of the exam shows no other abnormalities. Modulation of which of the following neurotransmitters is most likely necessary to treat this patient’s disease in the acute setting?

A.     Dopamine

B.    Gamma –aminobutyric acid

C.    Histamine

D.   Serotonin

E.    Norepinephrine

F.    Acetylcholine

G.    Norepinephrine

H.   Adrenocorticotrophic hormone

I.     Neurotensin

J.     Vasopressin

K.   Somatostatin

L.    Growth hormone releasing hormone

M.  Thyrotropin-releasing hormone

N.   Vasoactive peptide

 

The correct answer is D. Serotonin. The patients headache is characteristic of a migraine headache: unilateral, throbbing, accompanied by nausea, vomiting, photophobia, or aura symptoms such as audio or visual changes. Migraine headaches have a complex pathophysiology but they are believed to be caused (in part) by a dyregulation of the serotonergic control of the cerebral blood vessels.

During migraine attacks there is a relative deficiency of neuro-active serotonin, this results in a cerebral vasodilation. Now, between attacks there is often an excess of serotonin.

Acute treatment of migraines (abortive) is accomplished mainly by the famous “triptan” class of drugs i.e. (Sumatriptan), although NSAIDs, acetaminophen and ergotamines are frequently used. These “triptans” work mainly as agonists of serotonin receptors and are believed to result in cerebral vasoconstriction of those dilated arteries causing the migraine symptoms, in addition to other central effects.

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