1: Migraines Flashcards
What is the dose for topiramate (Topamax)?
25 mg BID.
200 mg doses max.
Which tricyclic is used to prevent migraines?
Amitriptyline
Often used at bedtime.
10-25 mg qPM
Can titrate up to 150 mg daily (max 400 mg daily).
Diagnostic criteria for migraines.
Repeated attacks lasting 4–72 hours Normal neuro exam No other reasonable cause for headache At least two of the following: -Unilateral pain (~60% of the time) -Throbbing/pulsating pain -Aggravation by movement or activity -Moderate to severe intensity Plus at least one: -Nausea and vomiting -Photophobia or phonophobia
What is the #1 recommended preventative med?
Propanolol
How long do auras typically last?
30-60 minutes
What is the dose for valproic acid?
250 mg 2-3x daily.
Titrate up to effectiveness.
What are the first-line preventative meds with low efficacy (3)?
Cyproheptadine
Gabapentin
Lamotrigine
What are the 2 general types of treatment for migraines?
Abortive
Preventative
T/F Early migraine treatment that includes a single, large dose is most effective.
True
Are migraines more common in men or women?
Women. 20-25% of women and 8-10% of men.
Name 2 combination drugs for migraines.
Sumatriptan + naproxen (Treximet)
Acetaminophen + butalbital (sedative) + caffeine (Fioricet)
What are the second-line preventative meds with high efficacy (3)?
Methysergide
Flunarizine
MAOIs
T/F With migraines, the focus should be on a cure.
False. Focus should be on adequate control, not a cure.
T/F CCBs may relieve migraine auras but are not as effective as BBs.
True
What are the first-line preventative meds with high efficacy (4)?
BB
Tricyclics
Valproate (anticonvulsant)
Topiramate (anticonvulsant)
What are the first-line preventative meds with low efficacy (3)?
Verapamil
NSAIDs
SSRIs
What are possible tolerance issues with propanolol?
Bradycardia
Low blood pressure
What is a major concern when using valproic acid (VPA) or topiramate?
Black box warning of suicide risk for those with major depression disorders.
T/F Preventative treatment provides relief in approximately 4 weeks.
False. May take up to 8-12 weeks to have noticeable effect.
Severe migraine can lead to _____ and may necessitate IV. Nausea or vomiting may require an IV as well.
Severe migraine can lead to gastric stasis and may necessitate IV. Nausea or vomiting may require an IV as well.
What percentage of migraine sufferers have an aura?
20%
T/F Amitriptyline may cause insomnia.
True
T/F Tension-type headache is more common, but migraine is more often presented in primary care for treatment.
True
How do triptans work to abort migraines?
Promote vasoconstriction.
Block pain pathways to brain.
What is the treatment for severe migraines that are incapacitating?
Go to ED for IV treatment.
T/F Aura symptoms can be both negative and positive in the beginning.
False. Typically begin with positive symptoms (scintillation or parasthesia) and negative symptoms comes later (numbness, aphasia, scotoma).
Name abortive treatments (4).
NSAIDs
Acetaminophen
Aspirin
Triptans
What is the most commonly used CCB and what is the dose?
Verapamil
Start with 80 mg 3-4x daily.
720 mg daily max.
What are indications for preventative treatment (4)?
Overuse of abortive treatment.
Different types of migraines.
Frequent migraines.
Long-lasting pain, causing significant disability.
What are 7 examples of foods that trigger migraines?
Chocolate Cheeses Fried foods Nitrites Red wine Oranges Hot dogs
_____ treatment should be aggressive. _____ treatment should start low and go slow.
Abortive treatment should be aggressive. Preventative treatment should start low and go slow.
What additional treatments would be considered for moderate migraines that inhibit daily activities but are not incapacitating?
Triptan combinations
Consider regular, preventative treatment
Antiemetics for n/v
Name the triptans listed in asynch (3).
Sumatriptan (Imitrex)
Naratriptan (Amerge)
Zolmitriptan (Zomig)
Name abortive treatments for mild symptoms with minimal alteration in daily routine.
OTCs (Tylenol, ASA, NSAIDs)
Excedrin (with caffeine)
Triptans
What happens if a patient develops tolerance to CCBs?
Switch to another CCB.
T/F Preventative treatment should not be discontinued without a taper.
True
If response to preventative migraine treatment is too mild, what do you do?
Increase dose or add 2nd agent
What is the starting dose for preventative treatment with propanolol?
Start with 10-20 mg 2-3x daily.
Can increase to 240 mg daily.
Available as extended release, too.
Which NSAIDs work best with migraines?
There is no data comparing efficacy of different NSAIDs.
T/F Auras are mostly visual.
True
Do migraines begin at an earlier age in men or women?
Men
T/F There is no data to support the use of SSRIs in preventing migraines.
True
Name 14 common migraine triggers.
Change in weather Stress Alcohol Hunger Fatigue/lack of sleep Loud noises Flickering lights Noxious stimuli Foods Exertion Nitroglycerin Minor head trauma Menses Surgical menopause
How can you figure out migraine triggers?
Headache diary
