Headaches (migraines)- MJ Flashcards
90% of primary headaches are which 3 types?
- Migraine
- Tension-type
- Cluster headaches
90% of primary headaches are migraine, tension-type, or cluster headaches–> which one is most frequent? Which one is most common type of headache leading to a PCP visit?
Most frequent= Tension-type
Most common leading to PCP visit= Migraine
Are the following considered primary or secondary headaches?
- Migraine
- Tension-type
- Trigeminal autonomic cephalalgias (includes cluster headaches)
- Other (new daily persistent headache)
Primary headaches
The following is the definition of which type of headache?
• episodic attacks of severe headaches often associated with nausea, photophobia, and/or phonophobia
Migraine headache
What are the 4 phases of migraine headache?
- Prodrome – hours to days prior to headache
- Aura
- Headache
- Postdrome – following headache resolution (may last up to 48 hrs)
*Not everyone gets every phase*
The following are symptoms of which phase of migraine headache?
- Fatigue
- Difficulty concentrating
- Neck stiffness
- Photosensitivity
- Phonophobia
- Nausea
- Blurred vision
- Yawning
- Pallor
Prodrome symptoms
The following are symptoms of which phase of migraine headache?
- Feeling tired
- Difficulty concentrating
- Neck stiffness
Postdrome symptoms
- Are migraines more common in men or women?
- Whites or blacks?
- Higher or lower SES?
- Women
- Whites
- Lower SES
What is the most common age group for migraine headache?
30-39
(still common 18-29, 40-49)
T/F, family history of migraine increases your risk for migraine headaches?
True
1st degree relative w/ migraines gives you a 4-9x higher risk
What 2 comorbid conditions increase risk for migraine headache?
Obesity
Depression/anxiety
The following are potential triggers for which type of headache?
- Alcohol
- Smoke
- Sleep disturbances
- Heat
- Food
- Exercise
- Sexual activity
Migraine triggers
The following is the pathophysiology behind which type of HA?
- Neuron dysfunction in the trigeminal system
- Trigger → brainstem neuronal hyper-excitability
- ↑ nerve cell activity and ↑ blood flow
- Alteration in neuropeptide levels (serotonin and norepinephrine)
- ↑ blood vessel dilation and inflammation of adjacent dura matter
- •Activation of trigeminal nerve pain receptors
- Migraine headache
What does the concept of a “threshold” have to do with migraine progression?
It means that a person can handle a certain amount of triggers before they hit their threshold and get a migraine
Is it more common to have a migraine with or without an aura?
Without
If a patient presents with c/o headache with associated N/V, photophobia and phonophobia, what type of headache is this most likely?
Migraine headache
What is an aura?
transient focal neurologic symptoms preceding or accompanying the headache
The following is the pathophysiology of what?
- cortical spreading depression, a wave of neuronal and glial depolarization that moves slowly across the cerebral cortex corresponding to the clinical symptoms (ie, occipital cortex and visual aura).
Aura
The following describes criteria for which type of headache?
A. Fulfils criteria for migraine with aura
B. ≥2 of the following fully reversible brainstem symptoms:
- Dysarthria
- Vertigo
- Tinnitus
- Hypacusis
- Diplopia
- Ataxia
- Decreased level of consciousness
C.No motor or retinal symptoms
Migraine with aura-
Brainstem aura (AKA “basilar migraine”)
Which type of migraine should have ≥2 of the following reversible symptoms?
- Dysarthria
- Vertigo
- Tinnitus
- Hypacusis
- Diplopia
- Ataxia
- Decreased level of consciousness
Migraine with aura-
Brainstem aura (AKA “basilar migraine”)
Other than fulfilling criteria for migraine with aura, a retinal migraine should also have an aura of fully reversible monocular positive/negative visual phenomena that is confirmed during an attack by what 2 tests?
Either or both of the following:
- Clinical visual field examination
- Patient’s drawing of a monocular field defect
The following describes criteria for what type of migraine?
A. Fulfils criteria for migraine with aura
B. Aura consists of both of the following:
- Fully reversible motor weakness (NOT paralysis)
- Fully reversible visual, sensory, and/or speech/language symptoms
Hemiplegic migraine
(this is just weakness, NOT paralysis)
- Menstrual migraines are related to decline in which hormone?
- This has a temporal relationship with which days of a womans menstrual cycle?
- Estrogen
- Days -2 to +3 of cycle
Is aura common or uncommon with menstrual migraines?
uncommon
What is the treatment for menstrual migraines?
•Abortive = same as other migraine
•Preventive
- NSAIDS (naproxen from day -7 to +6)
- Scheduled dosing of triptans (Frova from day -2 to +4)
- Magnesium (throughout menses)
- Extended-cycle hormonal treatment
A chronic migraine is a HA occurring:
- ≥ _____days/month for > _____ months;
- on at least ____ days/month, has the features of migraine headache (or believed by patient to be a migraine at onset, and relieved by a triptan or ergot)
- Has had > 5 attacks fulfilling criteria for migraine +/- aura
- ≥ 15 days/month for > 3 months
- 8 days/month
What is abortive therapy for migraines (in general)?
•Rest, quiet, dark
•Pharmacologic treatment (give early in course of HA, PO not always best)–> “EATAN”
- NSAIDS
- Acetaminophen
- Triptans
- anti-emetics
- Ergotamines
What is 1st line mild-moderate abortive therapy for migraines?
NSAIDS
(OTC- ibuprofen, naproxen)
(Prescription- Indomethacin, diclofenac, ketorolac)
What is 2nd line mild-moderate abortive therapy for migraines? When should these be used?
Acetaminophen
- less effective than NSAIDS
- Use in pts that can’t take NSAIDS
What is 3rd line mild-moderate abortive therapy for migraines? What is this medication a common cause of?
ASA/Acetaminophen/Caffeine (Excedrin)
- For intermittent use
- Common cause of medication overuse HA
What is the 1st line moderate-severe abortive therapy for migraines?
Triptans
The following is the MOA of which migraine abortive therapy medication?
- Activates serotonin receptors on trigeminal neurons causing vasoconstriction
Triptans
(1st line abortive therapy for moderate-severe migraines)
You should take caution in prescribing Triptans as abortive therapy for moderate-severe migraines in which patients?
Patients with controlled HTN
When should you avoid prescribing Triptans as abortive therapy for moderate-severe migraines?
- Pregnancy
- Hemiplegic or basilar migraine
- Hx stroke or TIA, or uncontrolled HTN
Triptans are contraindicated in what 3 conditions?
- Coronary or peripheral vascular disease
- Prinzmetal angina
What are the side effects of triptans?
- Nausea
- Vomiting
Triptan can be combined with which medication for improved efficacy in the treatment of moderate-severe migraines?
Naproxen
What is 2nd line moderate-severe abortive therapy for migraines?
Ergots
(Ergotamine tartrate/caffeine, Dihydroergotamine)
What is the MOA of Ergots?
Non-selective serotonin agonists
Ergots are less effective and have more adverse effects than which medications?
Ergots
T/F: Ergots are contraindicated in pregnancy?
True
Avoid giving Ergots (migraine abortive therapy) in what condition and in combination with what group of meds?
- CVD
- In combo w/ potent CYP 3A4 inhibitors (-azoles)
- Which abortive treatment is the last resort for migraines?
- When should you prescribe this?
- Opiods
- Use only if pt cant take/does not respond to other tx
Are opiods more or less beneficial than migraine specific drugs?
less beneficial (last resort as abortive therapy)
- Should be used only as rescue medications
What can regular use of opiods as alternative abortive therapy for migraines lead to?
- Can lead to tolerance, opioid-induced hyperalgesia, and medication overuse headaches
- Potential for abuse and dependence
Which adjuct therapy- abortive therapy would you use in a patient w/ migraines who also has nausea and vomiting?
Antiemetics/dopamine receptor blockers
(ex: Metoclopramide, Prochloperazine, Promethazine)
What is the risk of Butalbital containing combination oral analgesics as adjunct therapy for abortive treatment of migraines?
High risk for overuse and dependence
(this is a Barbituate)
Why is hydration an important adjunct therpay as abortive treatment for migraines?
- Dehydration can trigger migraines
- N/V can lead to dehydration
What are 4 non-pharmacologic preventative therapy options for migraines?
- Acupuncture
- Avoidance of triggers
- Behavioral modification (regular meals, exercise, sleep hygiene, relaxation techniques, CBT)
- Headache diary
What are 3 indications for pharmacologic preventative treatment of migraines?
- > 2-3 x / month (b/c will put at threshhold for medication overuse from abortive meds)
- Significant disability with attacks
- Last > 48 hours
- Acute treatments contraindicated, ineffective, or overused
Which prophylactic migraine medication has the following side effects:
- Somnolence
- Concentration difficulties
- Visual disturbances (nystagmus, diplopia)
- renal calculi
- weight loss
- Topiramate
Which prophylactic migraine medication has the following side effects (popcorn):
- GI sxs (N/V/D)
- weight gain
- alopecia
- hepatotoxicity
- pancreatitis
- drowsiness
- thrombocytopenia
- tremor
(she only talked about the bolded ones in class)
Valproic Acid
Which 2 cardiovascular meds are most commonly used as prophylactic medications to prevent migraines?
Propanolol
Verapamil
Which prophylactic migraine medication has the following side effects :
- Fatigue
- dizziness
- hypotension
- brandycardia
- depression
- insomnia
- N/V
- constipation
Propanolol
(so don’t give to a cardio patient)
Which prophylactic migraine medication has the following side effects (popcorn):
- HA
- Hypotension
- Edema
- Flushing
- May aggravate AV block/heart failure
- constipation
Verapamil
(so don’t give to a cardio patient)
Which prophylactic migraine medication has the following side effects:
- Sedation (so helps w/ insomnia)
- urinary retention
- dry mouth
- constipation
- weight gain
- blurred vision
- edema
- hypotension
Amitriptyline
(this is good for a patient who also has insomnia)
Which prophylactic migraine medication has the following side effects:
- Somnolence
- sexual dysfunction
- nausea
- dry mouth
- dizziness
- diaphoresis
- anxiety
- weight loss
Venlafaxine
(this is good for a patient that also has depression)
The following MOA is for which prophylactic treatment of migraines?
- Blocks release of Substance P and CGRP
- Inhibits peripheral signals to CNS and blocks central sensitization
Botulinum toxin
What are 3 investigational treatment options for migraines that would most likely be managed by neuro?
•Neurostimulation techniques
- Transcranial direct current stimulation
- Vagal (and other cranial nerve) stimulators
- Implantable occipital nerve stimulation
What is the main complication of pharmacologic treatment of migraines?
•Medication overuse headache (aka analgesic rebound headache)
- All abortive meds may cause (least likely with NSAIDS)
- Limit acute meds to < 10 days per month
- Introduce use of prophylactic treatment
How many days per month should you limit taking medications as treatment for migraines in order to avoid medication overuse headache?
<10 days
The following are considered what type of symptoms?
- Visual (ex:blind spot, scintillating scotoma)
- Sensory
- Speech/language
- Motor
- brainstem
- retinal
Aura
