CNS - migraine Flashcards
Is migraine a primary or secondary headache disorder
Primary - no known underlying cause
Which gender is migraine more common in
Females
What is migraine characterised by
Recurrent attacks of typically moderate to severe headaches that usually last between 4-72hours
Describe the headache in migraine
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
How is migraine subdivided
Migraine with aura
Migraine without aura
What is migraine with aura
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
What is episodic migraine
Headache which occurs in less than 15 days a month
Low freq = 1-9 days a month
High freq = 10-14 days a month
What is chronic migraine
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
How can a period trigger migraine
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
Medication overuse headache
Complication of migraine - frequent use of acute treatments increases the frequency and intensity of headache and can become the cause of the headache
Aims of treatment of acute migraine
To stop attack or significantly reduce severity of headache and other accompanying symptoms
Aims of preventative migraine treatment
Reduce freq, severity and duration of migraine attacks
Reduce development of medication overuse headaches
Lifestyle advice
Eat regular meals
Maintain adequate hydration, sleep and exercise
Avoid known triggers
Keep a headache daily to identify potential triggers, for minimum 8 weeks
What are some potential triggers of migraine
Stress
Relaxation after stress
Some food and drink (e.g. aged cheese, caffeine, alcohol esp red wine,)
Bright lights
1st line for acute migraine treatment
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
1st line simple analgesia for migraine, including doses
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
What is the recommended 5HT1-receptor agonist (triptan) of choice and why
Sumatriptan
Based on clinical efficacy and safety profiles
Alternative triptans that may be used if sumatriptan is unsuitable
Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Zolmitriptan
What to do if a patient doesn’t respond to one triptan
Try a different triptan as response can be variable between patients
Which types of triptans to use in patients with early vomiting or severe migraine attacks
Consider SC sumatriptan or nasal zolmitriptan
Is ibuprofen the only NSAID that can be used for treatment of acute migraine
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
Use of mefenamic acid in migraine
Mefenamic acid (unlicensed indication) can be used for menstrual migraine in women already using it for other indications such as dysmenorrhoea, menorrhagia
Can paracetamol be used for pt with migraine
Consider if unable to take other acute treatment options (aspirin, ibuprofen, triptans)
What to do if pt doesn’t respond to 1st line mono therapy
Combination therapy with sumatriptan + naproxen
Use of antiemetics in migraine
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)
How often should patients use acute migraine medication
Ideally restrict treatment to 2 days a week
Dose titration for migraine prophylaxis
Start at low dose, gradually increase to max effective & tolerated dose
1st line preventative treatment in pt with episodic or chronic migraine
Propranolol (80-240mg daily in divided dose)
Alternative beta blockers if 1st line is unsuitable in migraine prophylaxis
If propranolol unsuitable, consider metoprolol, atenolol (unlicensed indication), nadolol, timolol
Can bisoprolol be used for migraine prophylaxis
Unlicensed indication
May be considered, esp if pt already taking it for cardiac reasons under the advice of their cardiologist
What treatment can patients take for migraine prophylaxis if beta blockers are not suitable
(AED
Topiramate 50-100mg daily in divided doses
contraindicated in pregnancy
highly effective contraception required prior to initiation
Can TCAs be used for migraine prophylaxis
- 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
Important advice regarding use of topiramate in females
○ 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
Can candesartan be used in migraine prophylaxis
Candesartan (unlicensed use) can be considered in episodic or chronic migraine, but limited evidence to support its use
Important considerations for female patients taking candesartan for migraine prophylaxis
○ Avoid in pregnancy
○ Females of child bearing potential should be advised to seek advice about alternative treatments if planning pregnancy or pregnancy
Can sodium valproate be used for migraine prophylaxis?
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
What is flunarizine
Calcium antagonist
Unlicensed in UK
Can be considered in pt with episodic or chronic migraine
Avoid in pregnancy
Specialist use only
What is pizotifen
Used to treat troublesome headache including migraine prophylaxis
Take dose at night
Evidence to recommend its use is limited
How long should prophylactic treatment be trialled before deeming if it is effective? And what is defined as good response?
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
Review of prophylactic treatment
Should be considered after 4-12 months
Treatment can be gradually withdrawn in many patients
When to refer
Refer to neurology or specialist headache clinic if trials with 3 or more drugs have been unsuccessful
Use of botulinum toxin type 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
Use of calcitonin gene related peptide inhibitors
Under specialist care
Can be used for prophylaxis
These are mabs
Menstrual migraine prophylaxis - which drugs can be given?
- 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
Menstrual migraine prophylaxis - conditions & counselling
- 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
Medication over use headache
- 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
A patient is prescribed sumatriptan 50mg tabs. They ask you how to take it for treatment of acute migraine. What is the dose
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
