Exam 1: Migraine Flashcards
list the 4 primary headache disorders
- migraine
- tension
- cluster
- hemicrania
list the 7 secondary headache disorders
- traumatic brain injury
- pseudotumor cerebri
- brain tumor
- reversible cerebral vasoconstriction syndrome
- subarachnoid
- medication overuse
- substance withdrawal
Migraine, no aura dx
at least 5 attacks with:
- last 4-72 hours
- 2/4 characteristics:
1. unilateral
2. pulsating
3. moderate-severe pain
4. aggravation by routine activity
AT LEAST 1 of
- photophobia
- phonophobia
Migraine with aura dx
at least 2 attacks with:
- one or more reversible aura sx:
>visual, sensory, speech, motor, brainstem, retinal
- at least 3/6 characteristics
1. one aura sx spreads gradually over ≥5 min
2. two or more sx in succession
3. each sx lasts 5-60min
4. at least 1 sx is unilateral
5. at least 1 sx is positive
6. aura w/ headache within 60 min
Migraine Aura sx
visual sx
gradual onset, spread
sequential progression
repetitive attacks, identical nature
flurry of attacks midlife
lasts <60 min
50% chance headache
Transient ischemic attack sx
Visual LOSS
ABRUPT, stepwise evolution
Simultaneous occurence of symptoms
lasts < 15 minutes (shorter)
no headache usually
Principles of migraine pharmacotherapy
BIG dose better
The SOONER given the better
Don’t overuse - more headache
Mild migraine
NSAID, APAP, Caffeinated options
Mod-severe
or refractory to OTC
triptans>DHE
Gepants, ditans if triptans contraindicated
Refractory mod-severe
Triptans + NSAID
Gepants
Lasmiditan
Analgesic w/ codeine/tramadol if infrequent
Opioids if infrequent (butorphanol)
Nasal/injectable formulations
for severe N/V, swallowing difficulties
Sx reach max intensity rapidly
inadequate response to traditional oral therapies
+ antiemetics (prochlorperazine, metoclopramide)
NSAID oral solutions use
rapid absorption
try if tablet takes too long to kick in
Mix with water
- diclofenac
- celecoxib
When to use Butalbital + caffeine + APAP
tension type, or migraine
Risks of Butalbital + caffeine + APAP
APAP = BBW hepatotoxicity
Medication overuse headache
AE butalbital + caffeine + APAP
cns depression
stomach upset
controlled migraine medications
Fiorcet/Fiorinal+codeine CIII
Lasmitidan (reyvow) CV
Triptans use limit for MOH
<10 days/month
give early in course of attack
caution in older adults d/t CV risk
start low go slow
Triptans ADR
flushing
chest pains
palpitations
dizziness
fatigue
xerostomia
serotonin syndrome
Triptans contraindication
hx hemiplegic migraine or w/brainstem aura
Known/suspected heart disease
Arryhtmias/cardiac pathway conduction disorder
Cerebrovascular syndromes
PVD (ischemic bowel disease)
Uncontrolled HTN
use within 24 h ergotamine or other triptan
MAOIs C/I with which triptans?
RIZ
SUM
ZOL
(maoi ex: hydrazine)
Triptan CV risk study: Hall
only looked at patients w/ less CV risk - inconclusive
Triptan CV risk study: Velentgas
excluded pt with history of CV or cerebrovascular in year prior
Triptan CV risk study: Albieri
no info on non-migrainers
triptan increased risk for stroke
(migraines worsen CV, not the drug)
Longest half life triptan
- frovatriptan
- naratriptan
- eletriptan
- almotriptan
pro/con of long half-life triptan
Pro: prevents reoccurrence
con: slower onset
Renal adjust triptans
Almotriptan ≤30ml.min
Naratriptan ≤15 ml/min
hepatic adjust triptans
Almotriptan
Naratriptan
Almotriptan unique
lower chest pain/tightness
SULFA group
reduce for CYP inhibitor, renal, hepatic
better tolerated
shortest half life
Eletriptan unique
Contraindicated CYP 3A4 inhibitor
most lipophillic
avoid severe hepatic impairment
Naratriptan unique
better than suma, slower onset
Contraindicated severe hepatic
dose reduce hepatic/renal
SQ Triptans
only sumatriptan
ODT triptan
RIZ
ZOL
Intranasal triptans
SUM
ZOL
Rizatriptan unique
dose reduce if propanolol
Sumatriptan unique
SQ 10 min
Nasal 15-30 min
lowest PO bioavailability
Zolmitriptan unique
Dose reduce/d/c if hepatic
Lasmitidan unique
give once. repeat dose not helpful
AVOID if severe hepatic….
WAIT 8 H between dosing and driving
Lasmitidan ADR
CNS depression
Serotonin syndrome
decreased HR, increased BP, palpitation, dizziness, N/V
Lasmitdan onset
30-60 min
Gepants
small molecule CGRP antagonist
Nurtec (rimegepant) use
Acute: 75 QD
Prevent: 75mg every other day
Nurtec AVOID
severe hepatic impairment
renal ≤15 (not studied)
Nurtec benefit
acute and prevention
ODT onset ≤2 hrs for acute
Nurtec ADR
abdominal pain
dyspepsia
nausea
Ubrogepant (ubrelv) use
ACUTE only: 50-100mg x1
may repeat dose after ≥2 hrs
MDD 200mg
Affected by high fat meal
Ubrelvy contraindication
strong CYP3A4 inhibitors
renal <15
Ubrelvy ADR
nausea
drowsiness
xerostomia
Quilipta (Atogepant) use
prevention only of episodic
10/30/60mg x 1
Atogepant hepatic/renal
severe hepatic avoid
renal <30 reduce
Atogepant ADR
constipation
nausea
drowsiness/fatigue
weight loss
CGPR Mabs pro/con
Pro: long half life, not many DDI
con: caution CV
Drug interaction CGRP mab
Efgartigimod (vygart)
monitor closely
CGRP mab for cluster prevention
Galcanezumab (emaglity)
CGRP with constipation ADR
Aimovig (erenumab)
CGRP with nasopharyngitis, nausea
Eptinezumab (Vyepti)
targets ligand
Epitinezumab (Vyepti)
Fremanezumab (Ajovy)
Galcanezumab (Emaglity)
targets receptor
Erenumab (Aimovig)
CGRP ab IV
Eptinezumab (Vyepti)
Every 3 months
CGRP SQ
Erenumab (Q month)
Fremanezumab (Q month/3month)
Galcanezumab (Q month)
Greater occipital nerve block drugs
lidocaine
bupivacaine
Methylprednisolone (avoid in pregnancy)
Nonpharm migraine
Stress reduce, Diet, avoid trigger
alt migraine tx
magnesium
B2
feverfew
Butterbur
neuromod device
PO magnesium use
prophylaxis, esp aura
menstrual migraine
400mg BID
citrate>oxide
start low go slow
PO magnesium ADR
diarrhea
n/v
B2 riboflavin use
well tolerated
prophylaxis
good for menstration
400mg QD for 3 months reduce duration/pain
Feverfew use
prophyalxis
AVOID PREGNANCY - contractions
50-150mg QD for 4 months
Feverfew ADR
GI
Butterbur (petasites) use
prophylaxis
avoid products not labeled “PA free”
d/t toxic alkaloid formation
Butterbur ADR
GI (belch,n/v/d)
drowsiness
fatigue
pruritis, rash
hepatotoxicity (RARE)
Ergot BBW
contraindicated with potent CYP3A4 inhibitors
- protease
- macrolide antibiotics
- azole antifungals
Causes vasospasm and ischemia
ERGOT class serious ADR
cardiac valvular fibrosis
ergotism (vasoconstriction/gangrene)
Serotonin syndrome
Contraindication Ergot
pregnancy/breastfeeding
24 hr or triptans, other serotonin agents, ergot-like agents
Ergotamine use
acute mod-severe migraine
not for older adults
Sublingual tablet
Ergotamine ADR
N/V
ecg change, HTN, ischemia, vasospasm
numbness, paresthesia, gangrene, etc
Ergotamine d/c
even after limited use – withdrawal rebound headache
Dihydroergotamine use
SQ/IM/IV: acute cluster headache, migraine
nasal spray: acute migraine
DHE off label use
medication overuse headache
status migrainosus
DHE contraindication
CV history
post vasular surgery
use of other periphera/central vasoconstrictors
nasal spray: hemiplegic migraine/brainstem
DO NOT USE in Hemiplegic migraine/brainstem headache
Triptans
DHE
Severe migraine treatment in the ED
IV/IM dexamethasone (decrease recurrence)
SQ sumatriptan (fast onset)
IV prochlorperazine + diphenhydramine (VERY GOOD)
IV DHE + antiemetic
IV valproate
IV/IM ketorolac
IV magnesium
Purpose of diphenhydramine
prevent dystonia
Topiramate use
Prevention for ≥12 y.o
Topiramate ADR
cognitive dysfunction, CNS
nephrolithiasis
metabolic acidosis
angle closure glaucoma
oligohidrosis/hyperthermia
suicidal ideation
weight loss
paresthesias
AVOID in pregnancy
Topiramate off label
cluster headache prevention
Topiramate counseling
DRINK WATER - stay hydrated
Topiramate MOA
block na channel
enhance GABA
antagonize AMPA glutamate R
weak CA inhibition (acidosis..)
Valproic acid use
migraine prevention
Valproic acid BBW
hepatotoxicity
mitochondrial disease
fetal risk
pancreatitis
Valproic acid ADR
CNS
hematologic
hepatotoxicity
pancreatitis
suicidal ideation
encephalopathy
TEN/SJS/DRESS
Valproic acid contraindications
pregnant/childbearing (lack contraception)
severe hepatic impairment
mitochondrial disorder (increase acute LF)
Beta blocker use
prevention
timolol, propanolol
TCA use
prevention (-triptyline)
start low go slow
takes 2-3 month for effect
TCA BBW
suicide risk
TCA ADR
anticholinergic
CNS depression
cardiac conduction abnormalities
SS
orthostatic hypotension
Venlafaxine use (SNRI)
prevention
neuropathic pain
Venlafaxine ADR
CNS depression
weight loss, anorexia
HTN
hepatotoxicity
hyponatremia
acute angle closure glaucoma
serotonin syndrome
drugs that cause acute angle closure glaucoma
topiramate
venlafaxine
Menstural migraine treatment
occurs day 1-2
fovatriptan
naratriptan
zolmitriptan
magnesium (if plan to conceive)
estrogen contraception
AVOID estrogen contraception for menstural headache if
AURA = stroke risk
estrogen = risk for ischemic stroke
Frovatriptan dose
2.5mg po qd or BID 2 days prior to menses
continue 6 days total
Naratriptan dose
1mg po BID 2-3 days prior to menses
continue 5-6 days total
Zolmitriptan
take 2.5mg po BID or TID 2 days prior to menses
continue until 5 days after menses (7 days total)
Patients with CV disease, what to use for acute migraine?
Gepants
Lasmitidan (reyvow)
CGRP mab (caution if recent event)
Pregnant patient acute migraine
APAP
Avoid NSAID if 3rd trimester
pregnancy progression helps
Cluster headache prevention
- verapamil
- glucocorticoids
- CGRP mab Galcanezumab
- lithium
- Topiramate
- greater occipital nerve block
Cluster headache acute tx
oxygen
SQ/nasal sumatriptan
nasal zolmitriptan
Hemicrania continua treatment
- Indomethacin
- botoxA
- occipital stimulation
- vagus stimulation
- peripheral block
Subarachnoid headache
thunderclap - max pain in seconds
life threatening emergency (hemorrhage)
photophobia, neck stiffness, n/v
brief loss of consciousness
overuse ≥10 days/month
Triptans
opioids
ergots
overuse ≥5 days/month
butalbital
≥15 days/month
non opioid pain meds
nsaid/apap/asa/etc
headache red flags
SNOOP
S in SNOOP
HA red flags
Systemic s/s
- fever
- myalgias
- weight loss
systemic disease
- malignancy/acquired immune deficiency
N in SNOOP
HA red flags
neurologic s/s
First O in SNOOP
headache red flags
Onset sudden “thunderclap”
Second O in SNOOP
headache red flgs
Onset after age 40
P in SNOOP
headache red flags
pattern change
progressive headache with loss of headache-free periods
change in type of headache
