headache & migraine Flashcards

Question

chronic migraine

Answer 1

>3 mnths =/>15 MHDs (mnthly headache day) and =/> 8MMDs (mnthly migraine day)

Answer 2

a day with migraine-type or TTH

Answer 3

=/>2 migraine characteristics * Unilateral * pulsating * moderate/ severe * aggravation by, or causing avoidance of, routine physical activity If no aura =/> 1 of the following migraine sx * Photophobia/ phonophobia * NV

Answer 4

=/> 1 of following reversible aura sx: (visual/ sensory/ speech, lanaguge / motor/ retinal/ brainstem) =/>3 of the characteristics *1 aura sx spread gradually over >5mins * 2 or more aura sx occur in succession * each indiv aura sx lasts 5-60mins * =/>1 sx unilateral * =/>1 sx is positive * HA follow/ accompanied by aura (within 60mins)

Answer 5

prodrome +/- aura ictal postdrome

Answer 6

Activation of hypothalamus, neuropeptides (involved in homeostasis) Regulate homeostasis : burdensome non-pain sx (prodrome, other phases): NV,LOA, fatigue (migraine) Incr blood flow in early premonitory phase > nitroglycerin induced migraine

Answer 7

leptin, neuropeptide Y and Orexin A/B

Answer 8

* Nociceptive processing * Control sleep-wake cycle * Feeding * Thirst * Arousal * Autonomic and endocrine regulation

Answer 9

Few hrs - days * Fatigue * Cognitive difficulties * Mood changes * Food cravings * Neck pain * Yawning

Answer 10

Cortical spreading depression in cortex 1) CSD = Large wave of slow spreading depolarisation within grey matter a. Inhibits cortical activity b. 2-6mm/min 2) Change in synaptic activity, EC ion conc, blood flow, metabolism a. Inhibit cortical activity, reduced blood flow 3) CSD activate trigeminovascular system Drive aura sx

Answer 11

5-60mins * Visual aura * Sensory disturbances * Speech disturbances * Motor sx

Answer 12

Neuropeptides (eg CGRP calcitonin-gene related peptide) cause sensitisation, inflammation in central and peripheral trigeminovascular system lead to pain and non-pain sx in ictal phase

Answer 13

- Head pain and other, non-pain sx - its receptor expressed in multiple anatomic regions relevant to migraine □ Trigeminovascular □ Cranial parasympathetic systems evidence: - When infused, can induce migraine-like attacks - CGRP lvls incr sig during migraine attack - CGRP therapeutics effective

Answer 14

- Sensitise 1* nociceptors and central trigeminovascular neurons - MRI shows struc abnormalities in brainstem □ Altered sensory processing and brainstem structure contribute to □ Severity of allodynia, hypersensitivity to migraine pain

Answer 15

- Retinal and trigeminal nociceptive inputs --> converge in thalamus □ projects to nociceptive areas of cortex S1/S2 □ exacerbate migraine by LIGHT - Hypersensitise visual cortex (V1/V2) can also contribute to the photosensitive effect

Answer 16

4-72hrs * Headache * N, V * Photophobia * Phonophobia

Answer 17

* Region of brain remain activated after headache cessation, olfactory regions, midbrain, hypothalamus

Answer 18

* Fatigue, food cravings, cognitive sx Continue in attack but overshadowed by HA sx (pain, NV, aura) Few hrs - days * Fatigue * Difficult conc * Neck stiffness

Answer 19

periods b. migraine attacks hrs - days after attack * regions remain abnormally active (olfactory, midbrain, hypothalamus) + light, - pain ○ Activate visual cortex bilaterally in migraine pts +light,+ pain ○ Concomitant pain stimulation potentiated visual cortex activation in pt with migraine

Answer 20

- peripheral components - central components 1) sensitisation/ hyperexcitability

Answer 21

Relays TGM nociceptor input from meningeal vessels and dura mater --> CNS

Answer 22

(inside the BBB) ○ TGM ganglion receives peripheral nociceptive pain signal ---> TGM complex (brain stem) --> thalamus --> cortex - Experience of pain ○ Activation of other central regions (project TO/ FROM the TGM system) contributes to non-pain sx

Answer 23

Repeated activation of the trigeminovascular system over time results in a state of nervous system hypersensitivity and sustained pain Feedback from a sensitized brain may: 1) Potentiate pain signaling 2) Contribute to common migraine symptoms - Photophobia, phonophobia, and cutaneous/mechanical allodynia

Answer 24

Calcitonin gene-related peptide 37 aa neuropeptide (calcitonin family of peptides) roles: nociception, sensory modulation, vasodilation

Answer 25

migraine patho: - TGM ganglion - cerebral and meningeal vasculature - brainstem - brain (thalamus eg) other cell types - vascular smooth muscle cells -neurons - glial cells - mast cells

Answer 26

CLR (calcitonin receptor-like receptor) + RAMP1 (receptor activity modifying protein) = heterodimer translocates from ER --> cell mem

Answer 27

1) ligand binding leads to transient receptor activation 2) induce cellular resp (2nd messenger signalling) 3) receptors inactivated and internalised -- ENDOCYTOSIS - recycled/ degraded

Answer 28

1) activate CGRP-R in TGM 2) CGRP released from storage vesicle by Ca2+ dependent exocytosis 3) peripheral release of CGRP from TGM nerve ending, triggers multiple responses induced by CGRP-R binding ==> sensitise nociceptor TGM neurons 4) peripheral TGM neurons relay migraine pain signals (brainstem --> brain) exp pain 5) central CGRP effect: pain transmission through sensitisation and activation of central processes - feedback

Answer 29

vasodilation peripheral nociceptor activation neurogenic inflammation CSD central TGM sensory activation central sensitisation hypothalamic dysfunction and descending control of brainstem, structures

Answer 30

AMY1-R (has RAMP1 subunit in common) expressed in vasculature, pancreas and TGM ganglion physiologic roles: regulate pp glucose, glycemic control, satiation

Answer 31

Mild-mod: NSAID, non-opioid analgesic, combination Mod-severe/ mild-mod, respond poorly: migraine-specific agents = triptans > ergotamine others: opioids (abusable) Ditans (5HT1F receptor) Gepants (Block CGRP receptor)

Answer 32

metoclopramide Anti-emetics: Relief of migraine-related NV when combined with analgesic medication

Answer 33

efficacy, safety, comorbidities, concomitant medications Rapid pain relief & associated sx Restore ability to function

Answer 34

Benefits: * Sx relief Limitations: * Potential ADR - PUD, dependency, tolerance, risk of med overuse headache * Pt specific CI to use of particular med * DDI

Answer 35

AHS: based on HDM and degree of disability caused by attacks EHF: any pt with migraine, not well-controlled w/ acute + willingness

Answer 36

offered: =/>6 HDM, no diasbility =/>4 HDM, some disability =/> 3 HDM, severe disability considered: 4-5 HDM, no disability 3 HDM + some 2 HDM + moderate * attacks sig interfere with pt daily routines despite acute tx * freq attacks (=/>4MHD) * CI/ failure/ overuse of acute tx * ADR to acute tx * pt preference

Answer 37

IMPAIRS QOL + 1) attacks cause =/> 2days DISABILITY per mnth & optimised acute tx does not prevent attack or 2) risk of overuse of acute tx + pt willing to take daily meds normal is 4-72hrs

Answer 38

Potential benefits: - Avoid escalation in use of acute medications - May reduce overall cost associated with migraine tx - MOH Limitations - Often associated with pt adherence (ROA) - SE: dep, cognitive dysfunction, somnolence, constipation, weight gain - cost of drugs (CGRP ~$2000/ mnth)

Answer 39

antiseizure meds bb (propanolol, metoprolol) ARB CGRP - gepants (CGRP-R) - MABS (anti-CGRP antibody// anti-CGRP receptor Ab) Neuromodulation device Neurotoxins

Answer 40

age =/> 18yo and 1 1) 4-7 MMD + inability to tolerate SE/ inadequate 8wk trial of 2 tx clasess + mod disability MIDAS =/>11, HIT >50 or 2) 8-14 MMD + inability to tolerate SE/ inadequate 8wk trial of 2 tx clasess or 3) chronic migraine + inability to tolerate SE/ inadequate 8wk trial of 2 tx clasess // inability to tolerate/ inadequate resp to min. 2 injs (6mnths) onabotulinumtoxinA

Answer 41

Grade 1 (0 to 5): little or no disability. Grade 2 (6 to 10): mild disability. Grade 3 (11 to 20): moderate disability ** Grade 4 (>21): severe disability. * how many days in last 3mnths, miss work/ shool * how many days in last 3mnths productivity reduced by 50% * how many days in last 3mnths, not do HH work * how many days in last 3mnths productivity in HH work reduced by 50% * how many days in last 3mnths did you miss regular activities (family, social, leisure)

Answer 42

little or no impact (49 or less) some impact (50–55) ** substantial impact (56–59) severe impact (60–78). -how often is pain severe -how often limit daily activities - how often wish to lie down - past 4 wks, how often too tired to work/ daily activities - past 4 wks, how often felt fed up over HD - past 4 wks, how often is conc limited

Answer 43

1. headache diary 2. MIDAS (disability assessment) 3. ADR of medications (affect compliance)

Answer 44

- reduction in MHD =/> 50% - improvement in any of the migraine-specific pt reported outcome measures * MIDAS (=/>5 pt: base 11-20) (reduce >30%: base >20) * HIT-6 (=/>5 pt) * MPFID (=/>5 pt)