CNS migraines Flashcards
migraine: common type of primary headache disorder, more common in females.
how is it characterised?
recurrent attacks of typically moderate to severe headaches that usually last between 4–72 hours
MIGRAINES SYMPTOMS?
describe the headache
Unilateral/pulsating
accompanied by N&V, photophobia & phonophobia
migraine can come with aura which usually precede onset of headache
what are the 3 types of symptoms with aura?
Visual (zigzag/flickering lights, spots, lines)
Sensory (pins & needles, numbness)
Dysphasia
Symptoms usually develop gradually and resolve within 1 hour
MIGRAINE LIFESTYLE ADVICE?
Maintain hydration/sleep/exercise
Avoid chocolate+wine
Relax after stress
Headache diary- identify triggers
X is defined as headache which occurs on less than 15 days per month, and can be further subdivided into low frequency (1–9 days per month) and high frequency (10–14 days per month)
episodic migraine
Y is defined as headache which occurs on at least 15 days per month and has the characteristics of a migraine headache on at least 8 days per month for greater than 3 months
chronic migraine
In some females, the drop in X levels just before menstruation is a trigger for migraine, with symptoms generally occurring from two days before the start of bleeding up until three days after.
oestrogen
MIGRAINE
ACUTE TREATMENT 1ST LINE?
Aspirin/Ibuprofen/5HT-1 receptor agonist (Sumatriptan favoured)
take as soon as patient knows they’ve got a migraine
triptans are ocntraindicated in pts with CVD why?
they work by constricting BV in brain, this increases BP and can worsen CVD
Treatment should ideally be restricted to 2 days per week and patients should be advised of what
the risk of developing medication-overuse headache.
ACUTE MIGRAINE tx
With AURA?
REPEAT?
Take triptan at the START of headache and NOT at the start of aura
Repeat Triptans after 2 hours (Naratriptan 4 hours) ONLY if there has been a response to 1st dose (but inadequate)
ACUTE MIGRAINE
tx if unable to take first-line options?
soluble paracetamol - faster onset of action
which triptans can be given to patients who present with early vomiting or who have severe migraine attacks
Subcutaneous sumatriptan or nasal zolmitriptan
ACUTE MIGRAINE
ANTIEMETICS?
MP
Metoclopramide/Prochlorperazine (unlicensed) can be given as single dose at onset of migraine symptoms
Don’t use Metocopramide regularly- EPse (5 days)
Domperidone- unlicensed in <35kg (7 days)
In patients who fail to respond to monotherapy, combination therapy with what 2 drugs can be given
sumatriptan and naproxen
Other NSAIDs that may be used for the treatment of acute migraine include, naproxen [unlicensed indication], tolfenamic acid, and diclofenac potassium.
In patients with severe nausea and vomiting, diclofenac sodium suppositories [unlicensed] may be an option.
what drug can be used for menstrual migraine in females already using it for other indications such as dysmenorrhea, or menorrhagia.
Mefenamic acid [unlicensed]
MIGRAINE PROPHYLAXIS
1st LINE?
2nd LINE?
1st LINE? PROPRANOLOL
2nd LINE? METOPROLOL/NADOLOL/timolol
(bisoprolol unlicensed may also be considered, especially in patients already taking it for cardiac reasons under the advice of their cardiologist.)
PM-Night
MIGRAINE PROPHYLAXIS
AMITRIPTYLINE is effective BUT if not tolerated.. what to use?
Use less sedating TCA
If a beta-blocker is unsuitable in patients with episodic or chronic migraine, wjhat to give instead
topiramate BUT teratogenic. PPP
what drug can be considered as an option in patients aged 55 years and over with episodic or chronic migraine. but need PPP in place
sodium valproate
under specialist use
Preventative treatment should be tried for at least 3 months at the maximum tolerated dose, before deciding whether or not it is effective. A good response to treatment is defined as what?
50% reduction in the severity and frequency of migraine attacks.
A review of ongoing prophylaxis should be considered after X months; treatment can be gradually withdrawn in many patients.
6-12
Patients should be referred to a neurology or specialist headache clinic if trials with X or more drugs have been unsuccessful.
3
