Exam 3: Migraine Flashcards
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
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
Migraine Headache Phases: Prodrome
hours or days before onset of headache
may experience euphoria, depression, irritability, food craving, constipation, neck stiffness, yawning
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
Migraine Headache Phases: Migraine Headaches
dull ache that intensifies
unilateral and throbbing
phonophobia, photophobia
Migraine Headache Phases: postdromal
may last several days after headache has ended
tiredness, head pain, GI distress, weakness, cognitive difficulties
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
Migraine Triggers: Medications
oral contraceptives
hydralazine
nitroglycerine
nifedipine
cocaine
Migraine Triggers: Diet
chocolate
oranges
tomatoes
onions
aged cheese
processed meats
cultured dairy
alcohol (red wine and champagne)
caffeine
Migraine Triggers: additives/preservatives
aspartame
monosodium glutamate
Migraine Triggers: environment
altitude/weather changes
perfume
tobacco smoke
loud noises
flickering lights
Migraine Triggers: Other
too little/too much sleep
skipping meals
stess
hormone changes
General Treatment Overview
avoid analgesic overuse
Abortive Treatment
education to avoid medication overuse
mild to moderate: NSAIDs, acetaminophen
moderate-severe: triptans/ergots
Preventative Treatment
four or more attacks/month with disability at least 3 days/month
Abortive Treatment First Line
triptans, NSAIDS
Abortive Treatment Second Line
NSAIDs
Prevention Treatment First Lines
monotherapy
valproate, topiramate, metoprolol, propranolol, frovatriptan
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
