Ch 46: Migraines Flashcards
migraine definition
chronic headaches that can cause sig pain for hours or days, may cause NV and sens to light/sound
auras
warnings s/s like flashes of light, blind spots or tingling in the arms/legs, most migraines do not have this
women with migraine with aura
higher risk of stroke and should not use estrogen containing contraceptives
Dx
5 migraine attacks lasting 4-72 h and recur sporadically, 1 of the following (N +/- V, photophobia, phonophobia), 2+ of following (unilateral location, pulsating, mod-severe pain and aggravated by - or causing avoidance of routine physical activity)
non drug tx
headache diary to ID triggers, stress mgmt, massage, spinal manipulation, cold compress, acupuncture
natural products
caffeine + apap or asa combo. butterbur, coenz q10, feverfew, mg, peppermint topically, riboflavin alone or in combo.
Triptans
MOA: agonist for 5HT1 receptor to vasoconstrict the cranial blood vessels, inhibit neuropeptide release, and dec pain tranmission. 1st line for acute tx.
OTC acute tx
apap, advil migraine (ibu), excedrin migrain (asa/apap/caffeine), aleve (naproxen)
Rx acute tx
triptans (5HT agonists), ergotamine- and butalbital- containing meds, opioids alone or in combo, diclofenac (cambia) in package form indicated for migraine tx. opioids and butalbital not rec 1st line d/t abuse potential –> use only in select cases
sumatriptan brands and forms
Imitrex, Onzetra Xsail, Zembrace, SymTouch, +naproxen is Treximet. tab, SC (autoinjector and needle-free) via lateral thigh or upper arm, nasal spray (no prime - x1 dose) or powder.
rizatriptan brand and form
maxalt as tab and ODT
triptan contraindications, warnings, ADRs,
CIs: cerebrovascular disease (stroke/TIA), uncontrolled HTN, IHD, use <24 h of another triptan or ergotamine type med.
Warning: risk of inc BP.
ADRs: triptan sensations (pressure in chest or heaviness or pressure in neck region) usually dissipates after admin
if nausea
ODT, nasal sprays, or injection forms of triptans useful.
for children
almotriptan tabs (axert) or zolmitriptan nasal spray (zomig) for 12+ YO rizatriptan (maxalt) for 6-17 YO.
triptan half life
shorter t1/2 faster onset, LA t1/2 have slower onset (frovatriptan/frova has longest at 26 h, naratriptan/amerge also long) useful for recurrent migraines or MAM
MAM definition and tx
menstrual assoc migraines. may ppx with extended cycle PO contraceptives or start NSAIDs/ triptan with long t1/2 prior to menses and continue for 5-7 d.
ergotamine MOA, indication, warnings, contraindications, BBW
nonselective agonist of 5HT causing cerebral vasoconstriction. indicated in pts with contraindications to triptans or who do not find benefit with triptan. 2nd line. warnings: CV events and cerebrovascular events DDIS. CIs: uncontrolled HTN, preg, IHD. BBW: potent 3a4 inhibitors d/t life-threatening peripheral ischemia.
dihydroergotamine
DHE 45, Migranal. IV/IM/SC and intranasal. nasal spray: prime by pumping 4x. avoid <24 h of 5HT agonists and <2 wks of MAOIs.
ergotamine + caffeine brand and forms
calergot, migergot. tab and suppository
butalbital containing products
barbiturate. apap + butalbital + caffeine (fioricet), asa + butalbital + caffeine (fiorinal). fioricet and fiorin have form with codeine. not rec for acute migraines d/t abuse/dependence and lower efficacy. if used long term, needs taper.
ppx tx info
pick 1: if pt requests it, if use acute tx >2 d/wk or >3/mo, if dec qol, or if acute txs are ineffective or contraindicated. ppx will reduce migraines ~50%. find the agent that works well. adequate trial is 2-6 mo.
ppx tx options
BBs like propranolol (most lipophillic)/timolol/metoprolol. AEDs like topiramate (approved) and valproic acid. TCAs like low-dose amitriptyline (most evid). venlafaxine. natural products.
Botox indication
botulinum toxin type A used for chronic migraines only aka >15 HA/mo
medication overuse
limit acute tx to 2-3x/wk otherwise will have rebound HA
