Exam 3: Migraine Flashcards by Natalie Khamis

Migraine without Aura

most common

at least five attacks

headaches lasting 4-72 hours

unilateral location, pulsating quality, moderate/severe pain, aggravation by routine activity

N/V, photophobia, phonophobia

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Migraine with Aura

classic

at least 2 attacks

at least one fully reversible aura

no aura lasting more than 60 minutes

headache follows aura within 60 minutes

visual, sensory, speech/language, motor, brainstem, retinal

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Migraine Headache Phases: Prodrome

hours or days before onset of headache

may experience euphoria, depression, irritability, food craving, constipation, neck stiffness, yawning

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Migraine Headache Phases: Aura (15-30% of patients)

commonly visual, may be sensory, verbal, or motor

before or during migraine, lasts less than 60 minutes

photopsia, scotoma, zigzag lines, numbness/tingling in arms, legs, face

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Migraine Headache Phases: Migraine Headaches

dull ache that intensifies

unilateral and throbbing

phonophobia, photophobia

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Migraine Headache Phases: postdromal

may last several days after headache has ended

tiredness, head pain, GI distress, weakness, cognitive difficulties

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Migraine Triggers: Medication Overuse

associated with analgesics, ergots, triptans: rebound headaches from medications overuse more than 2x per headache or two times per week chronically

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Migraine Triggers: Medications

oral contraceptives
hydralazine
nitroglycerine
nifedipine
cocaine

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Migraine Triggers: Diet

chocolate
oranges
tomatoes
onions
aged cheese
processed meats
cultured dairy
alcohol (red wine and champagne)
caffeine

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Migraine Triggers: additives/preservatives

aspartame
monosodium glutamate

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Migraine Triggers: environment

altitude/weather changes
perfume
tobacco smoke
loud noises
flickering lights

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Migraine Triggers: Other

too little/too much sleep
skipping meals
stess
hormone changes

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General Treatment Overview

avoid analgesic overuse

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Abortive Treatment

education to avoid medication overuse

mild to moderate: NSAIDs, acetaminophen

moderate-severe: triptans/ergots

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Preventative Treatment

four or more attacks/month with disability at least 3 days/month

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Abortive Treatment First Line

triptans, NSAIDS

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Abortive Treatment Second Line

NSAIDs

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Prevention Treatment First Lines

monotherapy

valproate, topiramate, metoprolol, propranolol, frovatriptan

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Prevention Treatment Second line

monotherapy

amitriptyline

NonPharm

Biofeedback and relaxation therapy

CBT

Diet

Sleep

Transcutaneous electrical nerve stimulation device

exercise, massage, acupuncture, thermal, biofeedback, heat/cold applications

headache diary

Contraindications of Triptans for Abortive Treatment

recent use (within 24 hours) of an ergot or other triptan

MAO-A inhibitor use in the last 2 weeks (frovatriptan, rizatriptan)

ischemic heart disease, angina, stroke, TIA, hemiplegic/basilar migraine, arrhythmias, peripheral vascular disease, uncontrolled hypertension, ischemic bowel disease, sevvere hepatic impairment

Warnings/precautions for abortive treatment

MI, pain, pressure, tightness in chest/throat/neck/jaw, CVA, HTN, GI ischemic reactions or peripheral vasospasm, medication overuse headache, serotonin syndrome,

sulfa allergy (almotriptan)

corneal opacities (almotriptan)

seizures (use with caution)

Side Effects of Triptans

oral tingling

dizziness

drowsiness

fatigue

chest tightness/pressure

flushing

Drug interactions Triptans

SSRIs/SNRIs theoretically the use of a triptan with SSRI/SNRI can increas the risk of serotonin syndrome. This drug interaction is extremely rare and may not be due to the triptans

avoid strong 3A4 inhibitors with eletriptan

Erogt Alkaloids in Abortive Treatment Warnings/Precaution

boxed warning for serious/life-threatening peripheral ischemia warnings for cardiac valvular fibrosis, vasospasms, or vasoconstriction, cerebrovascular events, ergotism (overdose of ergot-containing medications: cramps, spasms, dry gangrene from vasoconstriction)

Ergot Alkaloids Side Effect

retroperitoneal, pleuropulmonary and valvular fibrosis ergotism vasoconstriction complications (ischemia, cyanosis, cold in extremeites, numbness, weakness, N/V)

Ergot Alkaloids Drug Interactions

3A4 Inhibitors ergot toxocity `

Which CGRP Antagonists are FDA approved for abortive treatment

rimegepant ubrogepant zavegepant

Contraindications with CGRP Antagonists

contraindicated with strong 3A4

Drug interactiosn CGRP Antagonists

moderate/strong 3A4 inducers and inhibitors, pgp inhibitors

Lasmiditan warnings/precuations

medication overuse headaches sedation dizziness serotonin syndrome driving impairment (avoid at least 8 hours after dose)

Side Effects Lasmiditan

dizziness, fatigue, parasthesia, sedation

Drug interactions Lasmiditan

use with caution with other CNS depressants and serotonergic medications; avoid use with pgp or BRCP substrates, other medications tha can decrease heart rate

monitor lasmiditan

LFTs blood pressure heart rate

Other abortive therapies

butorphanol nasal spray as resuce medication

Beta Blockers

FDA approved propranolol 80-240 mg/day metoprolol 100-200 mg/day contraindicated in asthma and raynaud's syndrome

Tricyclic antidepressants

not FDA approved amitryptiline 25-150 mg/day (mixed migraine/tension type)

Preventative: CGRP Antagonists

atogepant: nausea, constipation, fatigue rimegepant: nausea, rash, dyspnea

Preventative Therapy: Antiseizure Drugs

valproate topiramate approved val: 500-1500 mg/day topiramate 50-100 mg/day not recommended in people of child-bearing age unless using contraception

Preventative Therapy Miscellaneous and Natural Products

Butterbur/petasites 150 mg/day

Almotriptan FDA approval

for children 12 years of age and older

Rizatriptan FDA approval

6 years of age and older as abortive therapy

Zolmitriptan Nasal Spray

approved for children 12 years of age and older

Sumatriptan Nasal spray

not FA approaved in children

Sumatripatn/naproxen combination

12 years and older

topiramate approval

12 years of age and old