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afsha - pain > CNS - migraine > Flashcards

CNS - migraine Flashcards

1
Q

Is migraine a primary or secondary headache disorder

A

Primary - no known underlying cause

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2
Q

Which gender is migraine more common in

A

Females

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3
Q

What is migraine characterised by

A

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

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4
Q

Describe the headache in migraine

A

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

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5
Q

How is migraine subdivided

A

Migraine with aura
Migraine without aura

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6
Q

What is migraine with aura

A

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

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7
Q

What is episodic migraine

A

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

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8
Q

What is chronic migraine

A

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

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9
Q

How can a period trigger migraine

A

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

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10
Q

Medication overuse headache

A

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

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11
Q

Aims of treatment of acute migraine

A

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

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12
Q

Aims of preventative migraine treatment

A

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

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13
Q

Lifestyle advice

A

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

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14
Q

What are some potential triggers of migraine

A

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

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15
Q

1st line for acute migraine treatment

A

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

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16
Q

1st line simple analgesia for migraine, including doses

A

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

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17
Q

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

A

Sumatriptan
Based on clinical efficacy and safety profiles

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18
Q

Alternative triptans that may be used if sumatriptan is unsuitable

A

Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Zolmitriptan

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19
Q

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

A

Try a different triptan as response can be variable between patients

20
Q

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

A

Consider SC sumatriptan or nasal zolmitriptan

21
Q

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

A

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

22
Q

Use of mefenamic acid in migraine

A

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

23
Q

Can paracetamol be used for pt with migraine

A

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

24
Q

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

A

Combination therapy with sumatriptan + naproxen

25
Q

Use of antiemetics in migraine

A

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)

26
Q

How often should patients use acute migraine medication

A

Ideally restrict treatment to 2 days a week

27
Q

Dose titration for migraine prophylaxis

A

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

28
Q

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

A

Propranolol (80-240mg daily in divided dose)

29
Q

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

A

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

30
Q

Can bisoprolol be used for migraine prophylaxis

A

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

31
Q

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

(AED

A

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

32
Q

Can TCAs be used for migraine prophylaxis

A
  • 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
33
Q

Important advice regarding use of topiramate in females

A

○ 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

34
Q

Can candesartan be used in migraine prophylaxis

A

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

35
Q

Important considerations for female patients taking candesartan for migraine prophylaxis

A

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

36
Q

Can sodium valproate be used for migraine prophylaxis?

A

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

37
Q

What is flunarizine

A

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

38
Q

What is pizotifen

A

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

39
Q

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

A

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

40
Q

Review of prophylactic treatment

A

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

41
Q

When to refer

A

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

42
Q

Use of botulinum toxin type A

A

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

43
Q

Use of calcitonin gene related peptide inhibitors

A

Under specialist care
Can be used for prophylaxis
These are mabs

44
Q

Menstrual migraine prophylaxis - which drugs can be given?

A
  • 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
45
Q

Menstrual migraine prophylaxis - conditions & counselling

A
  • 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
46
Q

Medication over use headache

A
  • 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
47
Q

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

A

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

afsha - pain (9 decks)

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