CNS - migraine

Question 1

Is migraine a primary or secondary headache disorder

Answer 1

Primary - no known underlying cause

Question 2

Which gender is migraine more common in

Answer 2

Females

Question 3

What is migraine characterised by

Answer 3

Recurrent attacks of typically moderate to severe headaches that usually last between 4-72hours

Question 4

Describe the headache in migraine

Answer 4

Usually unilateral (one side), pulsating, aggravated by routine physical activity, may be severe enough to impact or prevent daily activities
Often accompanied by n+v, photophobia, phonophobia

Question 5

How is migraine subdivided

Answer 5

Migraine with aura
Migraine without aura

Question 6

What is migraine with aura

Answer 6

Symptoms such as the following occur, which usually develop gradually and resolve within 1 hour, and they usually precede the onset of headache:
- visual symptoms (zigzag or flickering lights, lines, loss of vision)
- sensory symptoms (numbness, pains and needles)
- dysphasia

Question 7

What is episodic migraine

Answer 7

Headache which occurs in less than 15 days a month
Low freq = 1-9 days a month
High freq = 10-14 days a month

Question 8

What is chronic migraine

Answer 8

Headache which occurs on at least 15 days a month
Has the characteristics of migraine headache on at least 8 days a month for more than 3 months

Question 9

How can a period trigger migraine

Answer 9

In some women, drop of oestrogen just before menstruation is a trigger
Symptoms generally occur from 2 days before bleeding, up until 3 days after bleeding

Question 10

Medication overuse headache

Answer 10

Complication of migraine - frequent use of acute treatments increases the frequency and intensity of headache and can become the cause of the headache

Question 11

Aims of treatment of acute migraine

Answer 11

To stop attack or significantly reduce severity of headache and other accompanying symptoms

Question 12

Aims of preventative migraine treatment

Answer 12

Reduce freq, severity and duration of migraine attacks
Reduce development of medication overuse headaches

Question 13

Lifestyle advice

Answer 13

Eat regular meals
Maintain adequate hydration, sleep and exercise
Avoid known triggers
Keep a headache daily to identify potential triggers, for minimum 8 weeks

Question 14

What are some potential triggers of migraine

Answer 14

Stress
Relaxation after stress
Some food and drink (e.g. aged cheese, caffeine, alcohol esp red wine,)
Bright lights

Question 15

1st line for acute migraine treatment

Answer 15

Monotherapy with aspirin, ibuprofen or 5HT1 receptor agonist (triptans)
Take as soon as pt knows they are developing migraine
Migraine with aura: take at the start of headache, not at the start of aura

Question 16

1st line simple analgesia for migraine, including doses

Answer 16

Ibuprofen 400mg (if ineffective, consider increasing to 600mg) OR
Aspirin 900mg OR
Paracetamol 1000mg

Offer triptan alone or in combo with paracetamol or an NSAID:
oral sumatriptan 1st choice (50-100mg) and offer others if this fails
If vomiting restricts oral treatment, consider non oral formulation e.g. intranasal or SC

Consider offering anti emetic (e.g. metoclop 10mg or prochlorper 10mg) in addition to other acute meds even in absence of N+V

Question 17

What is the recommended 5HT1-receptor agonist (triptan) of choice and why

Answer 17

Sumatriptan
Based on clinical efficacy and safety profiles

Question 18

Alternative triptans that may be used if sumatriptan is unsuitable

Answer 18

Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Zolmitriptan

Question 19

What to do if a patient doesn’t respond to one triptan

Answer 19

Try a different triptan as response can be variable between patients

Question 20

Which types of triptans to use in patients with early vomiting or severe migraine attacks

Answer 20

Consider SC sumatriptan or nasal zolmitriptan

Question 21

Is ibuprofen the only NSAID that can be used for treatment of acute migraine

Answer 21

Naproxen (unlicensed indication)
Tolfenamic acid
Diclofenac potassium
Consider diclofenac sodium suppositories in pt with severe n+v
Mefenamic acid (unlicensed indication) can be used for menstrual migraine in women already using it for other indications such as dysmenorrhoea, menorrhagia

Question 22

Use of mefenamic acid in migraine

Answer 22

Mefenamic acid (unlicensed indication) can be used for menstrual migraine in women already using it for other indications such as dysmenorrhoea, menorrhagia

Question 23

Can paracetamol be used for pt with migraine

Answer 23

Consider if unable to take other acute treatment options (aspirin, ibuprofen, triptans)

Question 24

What to do if pt doesn’t respond to 1st line mono therapy

Answer 24

Combination therapy with sumatriptan + naproxen

Question 25

Use of antiemetics in migraine

Answer 25

Metoclopramide and prochlorperazine: can be given as single dose at onset of migraine symptoms for treatment of headache Both unlicensed indications Can be given orally or by injection depending on severity of symptoms and the setting Do not regularly use metoclopramide - risk of extrapyramidal SE Domperidone is an alternative (unlicensed in <35kg)

Question 26

How often should patients use acute migraine medication

Answer 26

Ideally restrict treatment to 2 days a week

Question 27

Dose titration for migraine prophylaxis

Answer 27

Start at low dose, gradually increase to max effective & tolerated dose

Question 28

1st line preventative treatment in pt with episodic or chronic migraine

Answer 28

Propranolol (80-240mg daily in divided dose)

Question 29

Alternative beta blockers if 1st line is unsuitable in migraine prophylaxis

Answer 29

If propranolol unsuitable, consider metoprolol, atenolol (unlicensed indication), nadolol, timolol

Question 30

Can bisoprolol be used for migraine prophylaxis

Answer 30

Unlicensed indication May be considered, esp if pt already taking it for cardiac reasons under the advice of their cardiologist

Question 31

What treatment can patients take for migraine prophylaxis if beta blockers are not suitable (AED

Answer 31

Topiramate 50-100mg daily in divided doses contraindicated in pregnancy highly effective contraception required prior to initiation

Question 32

Can TCAs be used for migraine prophylaxis

Answer 32

- Amitriptyline effective for migraine prophylaxis , 25mg-75mg at night - Consider for episodic or chronic migraine - Less sedative TCA can be considered if amitriptyline not tolerated

Question 33

Important advice regarding use of topiramate in females

Answer 33

○ Females of childbearing potential need to be informed of associated risks of use during pregnancy ○ Highly effective contraception ○ Seek further advice if pregnant or planning to be ○ PPP needed

Question 34

Can candesartan be used in migraine prophylaxis

Answer 34

Candesartan (unlicensed use) can be considered in episodic or chronic migraine, but limited evidence to support its use

Question 35

Important considerations for female patients taking candesartan for migraine prophylaxis

Answer 35

○ Avoid in pregnancy ○ Females of child bearing potential should be advised to seek advice about alternative treatments if planning pregnancy or pregnancy

Question 36

Can sodium valproate be used for migraine prophylaxis?

Answer 36

Can be considered in pt 55 or over with episodic or chronic migraine Immediate release sodium valproate Do not use in women of childbearing potential unless conditions of PPP met and alternative treatments ineffective or not tolerated Do not use in pregnancy

Question 37

What is flunarizine

Answer 37

Calcium antagonist Unlicensed in UK Can be considered in pt with episodic or chronic migraine Avoid in pregnancy Specialist use only

Question 38

What is pizotifen

Answer 38

Used to treat troublesome headache including migraine prophylaxis Take dose at night Evidence to recommend its use is limited

Question 39

How long should prophylactic treatment be trialled before deeming if it is effective? And what is defined as good response?

Answer 39

Try preventative treatment for at least 3 months at max tolerated dose before deciding if it is effective or not Good response to treatment = 50% reduction in severity and freq of migraine attacks

Question 40

Review of prophylactic treatment

Answer 40

Should be considered after 4-12 months Treatment can be gradually withdrawn in many patients

Question 41

When to refer

Answer 41

Refer to neurology or specialist headache clinic if trials with 3 or more drugs have been unsuccessful

Question 42

Use of botulinum toxin type A

Answer 42

Specialist use only Recommended for prophylaxis of chronic migraine where medication-overuse has been addressed and where 3 or more oral prophylactic treatments have failed

Question 43

Use of calcitonin gene related peptide inhibitors

Answer 43

Under specialist care Can be used for prophylaxis These are mabs

Question 44

Menstrual migraine prophylaxis - which drugs can be given?

Answer 44

- Frovatriptan (unlicensed indication) can be given instead of, or in addtion to, standard prophylactic treatment in women with pre-menstrual migraine - Given from 2 days before, until 3 days after, menstruation starts - Zolmitriptan or naratriptan (both unlicensed indication) are alternatives

Question 45

Menstrual migraine prophylaxis - conditions & counselling

Answer 45

- Pt menstrual cycle must be regular for treatment ot be effective!! - Women with menstrual-related migraine who are using 5HT1-ra for both peri-menstrual prophylaxis and at other times in the month should be advised of the increased risk of developing medication overuse headache

Question 46

Medication over use headache

Answer 46

- Should be addressed in pt overusing acute treatments (e.g. 5HT1-ra, combination analgesics, ergots, opioids) for migraine - Withdrawing the overused medication can reduce the freq and intensity of headaches, but is often associated with transient worsening - Not all pt overusing acute treatment will develop it - In some pt continued headaches may be sign of poorly treated migraine

Question 47

A patient is prescribed sumatriptan 50mg tabs. They ask you how to take it for treatment of acute migraine. What is the dose

Answer 47

Initially 50mg fro one dose to be taken at onset of headache, not aura Can take another 50mg tab after at least 2 hours if needed, but only if migraine recurs - DO NOT take second dose for the same attack of migraine