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MJ- F2 E4- Neuro > Headaches (migraines)- MJ > Flashcards

Headaches (migraines)- MJ Flashcards

1
Q

90% of primary headaches are which 3 types?

A
  1. Migraine
  2. Tension-type
  3. Cluster headaches
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2
Q

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?

A

Most frequent= Tension-type

Most common leading to PCP visit= Migraine

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3
Q

Are the following considered primary or secondary headaches?

  • Migraine
  • Tension-type
  • Trigeminal autonomic cephalalgias (includes cluster headaches)
  • Other (new daily persistent headache)
A

Primary headaches

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4
Q

The following is the definition of which type of headache?

• episodic attacks of severe headaches often associated with nausea, photophobia, and/or phonophobia

A

Migraine headache

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5
Q

What are the 4 phases of migraine headache?

A
  • Prodrome – hours to days prior to headache
  • Aura
  • Headache
  • Postdrome – following headache resolution (may last up to 48 hrs)

*Not everyone gets every phase*

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6
Q

The following are symptoms of which phase of migraine headache?

  • Fatigue
  • Difficulty concentrating
  • Neck stiffness
  • Photosensitivity
  • Phonophobia
  • Nausea
  • Blurred vision
  • Yawning
  • Pallor
A

Prodrome symptoms

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7
Q

The following are symptoms of which phase of migraine headache?

  • Feeling tired
  • Difficulty concentrating
  • Neck stiffness
A

Postdrome symptoms

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8
Q
  • Are migraines more common in men or women?
  • Whites or blacks?
  • Higher or lower SES?
A
  • Women
  • Whites
  • Lower SES
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9
Q

What is the most common age group for migraine headache?

A

30-39

(still common 18-29, 40-49)

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10
Q

T/F, family history of migraine increases your risk for migraine headaches?

A

True

1st degree relative w/ migraines gives you a 4-9x higher risk

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11
Q

What 2 comorbid conditions increase risk for migraine headache?

A

Obesity

Depression/anxiety

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12
Q

The following are potential triggers for which type of headache?

  • Alcohol
  • Smoke
  • Sleep disturbances
  • Heat
  • Food
  • Exercise
  • Sexual activity
A

Migraine triggers

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13
Q

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
A
  • Migraine headache
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14
Q

What does the concept of a “threshold” have to do with migraine progression?

A

It means that a person can handle a certain amount of triggers before they hit their threshold and get a migraine

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15
Q

Is it more common to have a migraine with or without an aura?

A

Without

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16
Q

If a patient presents with c/o headache with associated N/V, photophobia and phonophobia, what type of headache is this most likely?

A

Migraine headache

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17
Q

What is an aura?

A

transient focal neurologic symptoms preceding or accompanying the headache

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18
Q

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).
A

Aura

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19
Q

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:

  1. Dysarthria
  2. Vertigo
  3. Tinnitus
  4. Hypacusis
  5. Diplopia
  6. Ataxia
  7. Decreased level of consciousness

C.No motor or retinal symptoms

A

Migraine with aura-

Brainstem aura (AKA “basilar migraine”)

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20
Q

Which type of migraine should have ≥2 of the following reversible symptoms?

  1. Dysarthria
  2. Vertigo
  3. Tinnitus
  4. Hypacusis
  5. Diplopia
  6. Ataxia
  7. Decreased level of consciousness
A

Migraine with aura-

Brainstem aura (AKA “basilar migraine”)

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21
Q

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?

A

Either or both of the following:

  1. Clinical visual field examination
  2. Patient’s drawing of a monocular field defect
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22
Q

The following describes criteria for what type of migraine?

A. Fulfils criteria for migraine with aura

B. Aura consists of both of the following:

  1. Fully reversible motor weakness (NOT paralysis)
  2. Fully reversible visual, sensory, and/or speech/language symptoms
A

Hemiplegic migraine

(this is just weakness, NOT paralysis)

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23
Q
  • Menstrual migraines are related to decline in which hormone?
  • This has a temporal relationship with which days of a womans menstrual cycle?
A
  • Estrogen
  • Days -2 to +3 of cycle
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24
Q

Is aura common or uncommon with menstrual migraines?

A

uncommon

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25
Q

What is the treatment for menstrual migraines?

A

•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
26
Q

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
A
  • ≥ 15 days/month for > 3 months
  • 8 days/month
27
Q

What is abortive therapy for migraines (in general)?

A

•Rest, quiet, dark

•Pharmacologic treatment (give early in course of HA, PO not always best)–> “EATAN”

  • NSAIDS
  • Acetaminophen
  • Triptans
  • anti-emetics
  • Ergotamines
28
Q

What is 1st line mild-moderate abortive therapy for migraines?

A

NSAIDS

(OTC- ibuprofen, naproxen)

(Prescription- Indomethacin, diclofenac, ketorolac)

29
Q

What is 2nd line mild-moderate abortive therapy for migraines? When should these be used?

A

Acetaminophen​

  • less effective than NSAIDS
  • Use in pts that can’t take NSAIDS
30
Q

What is 3rd line mild-moderate abortive therapy for migraines? What is this medication a common cause of?

A

ASA/Acetaminophen/Caffeine (Excedrin)

  • For intermittent use
  • Common cause of medication overuse HA
31
Q

What is the 1st line moderate-severe abortive therapy for migraines?

A

Triptans

32
Q

The following is the MOA of which migraine abortive therapy medication?

  • Activates serotonin receptors on trigeminal neurons causing vasoconstriction
A

Triptans

(1st line abortive therapy for moderate-severe migraines)

33
Q

You should take caution in prescribing Triptans as abortive therapy for moderate-severe migraines in which patients?

A

Patients with controlled HTN

34
Q

When should you avoid prescribing Triptans as abortive therapy for moderate-severe migraines?

A
  • Pregnancy
  • Hemiplegic or basilar migraine
  • Hx stroke or TIA, or uncontrolled HTN
35
Q

Triptans are contraindicated in what 3 conditions?

A
  • Coronary or peripheral vascular disease
  • Prinzmetal angina
36
Q

What are the side effects of triptans?

A
  • Nausea
  • Vomiting
37
Q

Triptan can be combined with which medication for improved efficacy in the treatment of moderate-severe migraines?

A

Naproxen

38
Q

What is 2nd line moderate-severe abortive therapy for migraines?

A

Ergots

(Ergotamine tartrate/caffeine, Dihydroergotamine)

39
Q

What is the MOA of Ergots?

A

Non-selective serotonin agonists

40
Q

Ergots are less effective and have more adverse effects than which medications?

A

Ergots

41
Q

T/F: Ergots are contraindicated in pregnancy?

A

True

42
Q

Avoid giving Ergots (migraine abortive therapy) in what condition and in combination with what group of meds?

A
  • CVD
  • In combo w/ potent CYP 3A4 inhibitors (-azoles)
43
Q
  • Which abortive treatment is the last resort for migraines?
  • When should you prescribe this?
A
  • Opiods
  • Use only if pt cant take/does not respond to other tx
44
Q

Are opiods more or less beneficial than migraine specific drugs?

A

less beneficial (last resort as abortive therapy)

  • Should be used only as rescue medications
45
Q

What can regular use of opiods as alternative abortive therapy for migraines lead to?

A
  • Can lead to tolerance, opioid-induced hyperalgesia, and medication overuse headaches
  • Potential for abuse and dependence
46
Q

Which adjuct therapy- abortive therapy would you use in a patient w/ migraines who also has nausea and vomiting?

A

Antiemetics/dopamine receptor blockers

(ex: Metoclopramide, Prochloperazine, Promethazine)

47
Q

What is the risk of Butalbital containing combination oral analgesics as adjunct therapy for abortive treatment of migraines?

A

High risk for overuse and dependence

(this is a Barbituate)

48
Q

Why is hydration an important adjunct therpay as abortive treatment for migraines?

A
  • Dehydration can trigger migraines
  • N/V can lead to dehydration
49
Q

What are 4 non-pharmacologic preventative therapy options for migraines?

A
  • Acupuncture
  • Avoidance of triggers
  • Behavioral modification (regular meals, exercise, sleep hygiene, relaxation techniques, CBT)
  • Headache diary
50
Q

What are 3 indications for pharmacologic preventative treatment of migraines?

A
  • > 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
51
Q

Which prophylactic migraine medication has the following side effects:

  • Somnolence
  • Concentration difficulties
  • Visual disturbances (nystagmus, diplopia)
  • renal calculi
  • weight loss
A
  • Topiramate
52
Q

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)

A

Valproic Acid

53
Q

Which 2 cardiovascular meds are most commonly used as prophylactic medications to prevent migraines?

A

Propanolol

Verapamil

54
Q

Which prophylactic migraine medication has the following side effects :

  • Fatigue
  • dizziness
  • hypotension
  • brandycardia
  • depression
  • insomnia
  • N/V
  • constipation
A

Propanolol

(so don’t give to a cardio patient)

55
Q

Which prophylactic migraine medication has the following side effects (popcorn):

  • HA
  • Hypotension
  • Edema
  • Flushing
  • May aggravate AV block/heart failure
  • constipation
A

Verapamil

(so don’t give to a cardio patient)

56
Q

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
A

Amitriptyline

(this is good for a patient who also has insomnia)

57
Q

Which prophylactic migraine medication has the following side effects:

  • Somnolence
  • sexual dysfunction
  • nausea
  • dry mouth
  • dizziness
  • diaphoresis
  • anxiety
  • weight loss
A

Venlafaxine

(this is good for a patient that also has depression)

58
Q

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
A

Botulinum toxin

59
Q

What are 3 investigational treatment options for migraines that would most likely be managed by neuro?

A

•Neurostimulation techniques

  1. Transcranial direct current stimulation
  2. Vagal (and other cranial nerve) stimulators
  3. Implantable occipital nerve stimulation
60
Q

What is the main complication of pharmacologic treatment of migraines?

A

•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
61
Q

How many days per month should you limit taking medications as treatment for migraines in order to avoid medication overuse headache?

A

<10 days

62
Q

The following are considered what type of symptoms?

  • Visual (ex:blind spot, scintillating scotoma)
  • Sensory
  • Speech/language
  • Motor
  • brainstem
  • retinal
A

Aura

MJ- F2 E4- Neuro (19 decks)

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