Migraine Flashcards
Migraine is a common type of (?) headache disorder
primary
Are migraines more common in men or women?
Women
What type of symptoms can precede a migraine with aura?
- Visual symptoms (zigzag or flickering lights, spots, lines, or loss of vision)
- Sensory symptoms (pins and needles, or numbness)
- Dysphasia
Symptoms usually develop gradually and resolve within 1 hour
What is the definition of an episodic migraine?
Headache that occurs LESS than 15 days per month
Low-frequency (1-9 days per month)
High frequency (10-14 days per month)
What is the definition of a chronic migraine?
Headache that occurs on AT LEAST 15 days per month
AND
has the characteristics of a migraine headache on at least 8 days per month for greater than 3 months
What is the trigger of migraines in women that occur between two days before the start of menstruation up to 3 days after after the start of menstruation?
Drop in oestrogen
What is the name of the complication of migraine that is caused by frequent use of acute treatment for migraines?
Medication-overuse headache
Frequent use of acute treatment for migraine increases the frequency and intensity of headache
What lifestyle advice should be given to patients who suffer from migraines?
- Eat regular meals
- Maintain adequate hydration
- Sleep
- Exercise
- Avoid known triggers
- Keep a headache diary to identify potential triggers
For how many weeks should a patient suffering from migraines keep a headache diary in the hope of identifying potential triggers?
Minimum 8 weeks
Ideally, how many times a week should acute migraine treatment be restricted to?
2 days per week
Patients should be advised of the risk of developing medication-overuse headache
What are the three drug options that are considered first-line for an acute migraine and should be taken as soon as the patient knows that they are developing a migraine (i.e. start of headache phase)?
Aspirin
Ibuprofen
5-HT1-receptor agonist (‘triptan’)
Monotherapy
In patients who experience aura with their migraine, what drug would be given at the start of the headache (NOT the start of aura)?
5-HT1-receptor agonist (‘triptan’)
When should a patient with migraine with aura, take a triptan?
At the start of the headache (NOT the start of the aura)
Unless the aura and headache start at the same time
How long after the first dose of a triptan (5HT1-receptor agonist) can a patient with migraine take a second dose in the response is inadequate?
2 hours
Same or different drug
What is the 5HT1-receptor agonist of choice based on its clinical efficacy and safety profile?
Sumatriptan
Alternatives:
- Almotriptan
- Eletriptan
- Frovotriptan
- Naratriptan
- Rizatriptan
- Zolmitriptan
What two drug options are there for migraine patients who present with early vomiting or who have severe migraine attacks?
- Sumatriptan
- Subcutaneous: 3-6 mg for 1 dose, followed by 3-6 mg after at least 1 hour if required - Zolmitriptan
- Intranasal: 5 mg into one nostril only, followed by 5 mg after at least 2 hours if required
Apart from ibuprofen, which other NSAIDs may be used in the treatment of acute migraine?
Naproxen [unlicensed]
Tolfenamic acid
Diclofenac potassium
Which NSAID can be used for acute migraine is the woman is already using it for other indications such as dysmenorrhoea or menorrhagia?
Mefenamic acid [unlicensed]
If a patient with a migraine fails to respond to monotherapy, combination therapy with (drug?) and (drug?) can be given
Sumatriptan
Naproxen
Which two antiemetics can be given as a single dose at the onset of migraine symptoms for the treatment of the headache?
Metoclopramide hydrochloride [unlicensed]
Prochlorperazine [unlicensed]
Orally or by injection, depending on the severity of the patients’ symptoms and the setting
Which 3 antiemetics can be given to relieve nausea or vomiting in patients with a migraine?
- Metoclopramide hydrochloride (do not use regularly - extrapyramidal side effects)
- Prochlorperazine
- Domperidone [unlicensed in those weighing less than 35 kg]
Why should you not use metoclopramide hydrochloride regularly to relieve nausea and vomiting in patients with migraines?
Risk of extrapyramidal side effects
What is the first-line preventative treatment in patients with episodic or chronic migraine?
Propranolol hydrochloride
Treatment should be started at a low dose and gradually increased to the maximum effective and tolerated dose
If propranolol is unsuitable for preventative treatment in patients with migraine, what are the other options?
Second line:
- Other beta-blockers (metoprolol tartrate, atenolol [unlicensed], nadolol, and timolol maleate. Bisoprolol [unlicensed] if already taking it for cardiac reasons)
Third line:
- Topiramate (if beta-blocker is unsuitable)
Others:
- Amitriptyline hydrochloride
- Candesartan cilexetil [unlicensed] (limited evidence)
- Sodium valproate [unlicensed] (NOT in women of childbearing potential)
- Flunarizine [unlicensed]
- Botulinum toxin type A
- Calcitonin gene-related peptide inhibitors
What drug can be used for preventative treatment of migraines if beta-blockers are not suitable?
Topiramate
What is needed for patients of childbearing potential if they need topiramate for preventative treatment of migraines?
Highly effective contraception
How long should a patient try preventative treatment for a migraine before deciding whether or not it is effective?
At least 3 months at the maximum tolerated dose
A good response is defined as a 50% reduction in the severity and frequency of migraine attacks
What is the definition of a good response to preventative treatment for migraines?
A 50% reduction in the severity and frequency of migraine attacks
How often should ongoing prophylaxis (if continuing after the first 3-month trial) for migraines be reviewed?
6-12 months
Treatment can be gradually withdrawn in many patients
What drug can be considered for prophylaxis of chronic migraine where medication-overuse has been addressed and where 3 or more oral prophylactic treatments have failed?
Botulinum toxin type A
(?) gene-related peptide inhibitors (such as erenumab, galcanezumab and fremanezumab) are recomended in eligible patients for prophylaxis of migraine
Calcitonin
Eligibility in adults:
- 4 or more migraine days a month
- At least 3 preventative drug treatments have failed
What is the eligibility criteria for the use of calcitonin gene-related peptide inhibitors for the prophylaxis of migraines? (2)
- 4 or more migraine days a month
- At least 3 preventative drug treatments have failed
Calcitonin gene-related peptide inhibitors = erenumab, galcanezumab, fremanezumab
What is the eligibility criteria for the use of botulinum toxin type A for the prophylaxis of migraines?
- Chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine)
- Not responsed to at least 3 prior therapies
- Condition is approppriated managed for medication overuse
What preventative drug can be given instead of, or inaddition to, standard prophylactic treatment in women with perimenstrual migraine?
Frovatriptan [unlicensed]
Given from 2 days before until 3 days after menstruation starts
Alternatives:
- Zolmitriptan [unlicensed]
- Naratriptan [unlicensed]
Menstrual cycle must be regular
What do women with menstrual-related migraine who are using 5HT1-receptor agonists for both preventative prophylaxis and at other times in the month be advised about?
Increased risk of developing medication-overuse headache
Medication overuse should be addressed in patients overusing acute treatments such as (?), (?), (?), or (?) for migraine
5HT1-receptor agonists (triptans)
Combination analgesics
Ergots
Opioids
In a patient with medication-overuse headaches, withdrawing the overused medication can reduce the frequency and intensity of headaches but is often associated with (?)
transient worsening
What are the indications for the use of sumatriptan? (2)
- Treatment of acute migraine
- Oral, subcutaneous injection, intranasal administration - Treatment of acute cluster headache
- Subcutaneous injection, intranasal administration
What are the contraindications to the use of sumatriptan? (9)
- Coronary vasospasm
- Ischaemic heart disease
- Mild uncontrolled hypertension
- Moderate and severe hypertension
- Peripheral vascular disease
- Previous cerebrovascular accident
- Previous MI
- Previous TIA
- Prinzmetal’s angina
What are the common side effects for sumatriptan? (13)
- Asthenia
- Dizziness
- Drowsiness
- Dyspnoea
- Feeling abnormal
- Flushing
- Myalgia
- Nausea
- Pain
- Sensation abnormal
- Skin reactions
- Temperature sensation altered
- Vomiting
Patients should discontinue the use of sumatriptan if which symptoms occur? (2)
- Heat
2. Heaviness, pressure or tightness (including, throat and chest)
Patients with a sensitivity to (drug?) may have cross-sensitivity to sumatriptan
sulfonamides
Sumatriptan can be found in breastmilk, for how long after treatment should a patient withhold breastfeeding?
12 hours
What is the indication for the use of almotriptan?
Treatment of acute migraine
What class of drug is amitriptyline?
Tricyclic antidepressant (TCA)
What are the indications for the use of amitriptyline?
- Abdominal pain or discomfort (in patients who have not responded to laxatives, loperamide, or antispasmodics)
- Major depressive disorder [not recommended - increased risk of fatality in overdose]
- Neuropathic pain
- Migraine prophylaxis
- Chronic tension-type headache prophylaxis
- Emotional lability in multiple sclerosis
What are the contra-indications for the use of amitriptyline?
- Arrhythmias
- During manic phase of bipolar disorder
- Heart block
- Immediate recovery period after MI
Which patients are particularly susceptible to the psychiatric and cardiac side effects of tricyclic antidepressants?
Elderly patients
What are the 3 common side effects of amitriptyline?
- Anticholinergic syndrome
- Drowsiness
- QT interval prolongation
How can you reduce the risk of side effects in patients taking amitriptyline?
Titrating slowly to the minimum effective dose (every 2-3 days)
Consider using a lower starting dose in elderly patients
What are the signs and symptoms of amitriptyline overdose? (12)
- Dry mouth
- Coma
- Hypotension
- Hypothermia
- Hyperreflexia
- Extensor plantar responses
- Convulsions
- Respiratory failure
- Cardiac conduction defects
- Arrhythmias
- Dilated pupils
- Urinary retention
Within how many days after stopping amitriptyline do withdrawal effects occur?
Within 5 days
The risk of withdrawal symptoms is increased if amitriptyline is stopped suddenly after regular administration for (?) weeks or more
8 weeks
When stopping amitriptyline treatment, the dose should be gradually reduced over about (?) weeks, or longer if withdrawal symptoms emerge
4 weeks
6 months in patients who have been on long-term maintenance treatment
What dose of aspirin is indicated for the treatment of acute migraine?
900 mg for 1 dose (oral)
To be taken as soon as migraine symptoms develop
What are the indications for the use of atenolol?
- Hypertension
- Angina
- Arrhythmias
- Migraine prophylaxis
- Early intervention within 12 hours of MI
When is bisoprolol considered for migraine prophylaxis?
In patients already taking it for cardiac reasons
[unlicensed indication]
What are the indications for the use of candesartan cilexetil?
- Hypertension
- Heart failure with impaired left ventricular systolic function
- Migraine prophylaxis
Which ARB can be considered for migraine prophylaxis in patients with episodic or chronic migraine?
Candesartan cilexetil
- Oral: 16 mg once daily
But there is limited evidence to support its use
What are the indications for the use of diclofenac potassium? (5)
- Pain and inflammation in rheumatic disease and other musculoskeletal disorders
- Acute gout
- Post-operative pain
- Migraine
- Fever in ear, nose, or throat infection
What are the common side effects of diclofenac potassium? (10)
- Appetite decreased
- Diarrhoea
- Dizziness
- GI discomfort
- Gi disorders
- Headache
- Nausea
- Skin reactions
- Vertigo
- Vomiting
What is the indication for the use of eletriptan?
Treatment of acute migraine
- Oral: 40 mg, followed by 40 mg after 2 hours if required
What are the contraindications for the use of eletriptan? (11)
- Arrhythmias
- Coronary vasospasm
- heart failure
- Ischaemic heart disease
- Peripheral vascular disease
- Previous cerebrovascular accident
- Previous MI
- Previous TIA
- Prinzmetal’s angina
- Severe hypertension
- Uncontrolled hypertension
What are the common side effects of eletriptan? (22)
- Arrhythmias
- Asthenia
- Chest discomfort
- Chills
- Dizziness
- Drowsiness
- Dry mouth
- Feeling hot
- Flushing
- GI discomfort
- Headache
- Hyperhidrosis
- Increased risk of infection
- Muscle complaints
- Muscle tone increased
- Muscle weakness
- Nausea
- Pain
- Palpitations
- Sensation abnormal
- Throat tightness
- Vertigo
Erenumab is a human monoclonal antibody that binds to the (?) (CGRP) receptor, inhibiting the function of CGRP, and thereby preventing migraine attacks.
Calcitonin gene-related peptide
Erenumab, fremanezumab, galcanezumab are a human monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) receptor, inhibiting the function of CGRP, and thereby preventing (?) attacks.
Migraine
What are the common side effects of erenumab?
- Constipation
- Muscle spasms
- Skin reactions
Why should a mother taking erenumab for migraines avoid breastfeeding during the the first few days after birth?
Possible risk from transfer of antibodies to infant
Erenumab is a human monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) receptor, inhibiting the function of CGRP, and thereby preventing migraine attacks.
After this time, use during breastfeeding only if clinically needed
Also should avoid during pregnancy (limited information available)
What are the indications for the use of frovatriptan? (2)
- Treatment of acute migraine
2. Menstrual migraine prophylaxis
What are the contraindictions for the use of frovatriptan? (9)
- Coronary vasospasm
- Ischaemic heart disease
- Peripheral vascular disease
- Previous cerebrovascular accident
- Previous MI
- Previous TIA
- Prinzmetal’s angina
- Severe hypertension
- Uncontrolled hypertension
What are the common side effects of frovatriptan? (12)
- Asthenia
- Chest discomfort
- Dizziness
- Dry mouth
- Flushing
- GI discomfort
- Headache
- Hyperhidrosis
- Nausea
- Sensation abnormal
- Throat complaints
- Vision disorders
How long after taking frovatriptan should a patient withhold from breastfeeding?
24 hours
What are the indications for the use of metoclopramide hydrochloride? (7)
- Symptomatic treatment of nausea and vomiting including that associated with acute migraine
- Delayed (but not acute) chemotherapy-induced nausea and vomiting
- Radiotherapy-induced nausea and vomiting
- Prevention of postoperative nausea and vomiting
- Hiccup in palliative care
- Nausea and vomiting in palliative care
- Acute migraine
What are the contraindications for the use of metoclopramide hydrochloride? (6)
- 3-4 days of GI surgery
- Epilepsy
- GI haemorrhage
- GI obstruction
- GI perforation
- Phaechromocytoma
In elderly patients, a metroclopromide hydrochloride prescription may be potentially inappropriate in which patients (STOPP criteria)?
Patients with parkinsonism (risk of exacerbating parkinsonian symptoms)
What are the common side effects of metoclopramide hydrochloride?
- Asthenia
- Depression
- Diarrhoea
- Drowsiness
- Menstrual cycle irregularities
- Movement disorders
- Parkinsonism
Which patient demographic are at an increased risk of acute dystonic reactions to metroclopramide?
The young (especially girls and young women) and the very old
Involves facial and skeletal muscle spasms and oculogyric crises
They usually occur shortly after starting treatment with metoclopramide and subside within 24 hours of stopping it
Injection of an antiparkinsonian drug such as procyclidine will abort dystonic attacks
A patient starts have facial and skeletal muscle spasms and oculogyric crises shortly after starting treatment with metoclopramde. What should you do to abort this dystonic attack?
Injection of an antiparkinsonian drug (e.g. procyclidine)
Dose adjustments in renal impairment for metoclopramide:
- Reduce daily dose by (1?)% in end-stage renal disease
- Reduce dose by (2?)% in moderate to severe impairment
- 75%
2. 50%
What are the two roles metoclopramide can play in the treatment of migraines?
- Antiemetic
2. Treatment of pain in acute migraine (taken at the onset of the migraine symptoms)
What are the indications for the use of metoprolol tartrate? (7)
- Hypertension
- Angina
- Arrhythmias
- Migraine prophylaxis
- Hyperthyroidism (adjunct)
- In surgery
- Early intervention within 12 hours of infarction
What are the indications for the use of nadolol?
- Hypertension
- Angina
- Arrhythmias
- Migraine prophylaxis
- Thyrotoxicosis (adjunct)
What are the indications for the use of naratriptan?
- Treatment of acute migraine
2. Menstrual migraine prophylaxis
What are the indications for the use of pizotifen? (5)
- Prevention of vascular headache
- Prevention of classical migraine
- Prevention of common migraine
- Prevention of cluster headache
- Prophylaxis of migraine
What are the two purposes of using prochlorperazine in the treatment of migraines?
- Nausea and vomiting in previously diagnosed migraine
- Buccal administration: 3-6 mg twice daily - Acute migraine (for pain)
- Oral: 10 mg for 1 dose as soon as migraine symptoms develop
What is the indication for the use of rizatriptan?
Treatment of acute migraine
- Oral: 10 mg, dose to be taken as soon as possible after onset, followed by 10 mg after 2 hours if required
The dose of rizatriptan should be reduced from 10 mg to 5 mg if the patient is taking concurrent (drug?)
propranolol
What are the contraindications to the use of rizatriptan? (9)
- Coronary vasospasm
- Ischaemic heart disease
- Peripheral vascular disease
- Previous cerebrovascular accident
- Previous MI
- Previous TIA
- Prinzmetal’s angina
- Severe hypertension
- Uncontrolled hypertension
What are the common side effects for rizatriptan?
- Alertness decreased
- Asthenia
- Diarrhoea
- Dizziness
- Drowsiness
- Dry mouth
- Dyspepsia
- Feeling abnormal
- Headache
- Insomnia
- Musculoskeletal stiffness
- Nausea
- Pain
- Palpitations
- Sensation abnormal
- Throat complaints
- Vasodilation
- Vomiting
How long after taking rizatriptan should a patient withhold from breastfeeding?
24 hours
What are the indications for sodium valproate?
- All forms of epilepsy
2. Migraine prophylaxis
What are the contraindications for the use of sodium valproate? (4)
- Acute prophyrias
- Known or suspected mitochondrial disease
- Personal or family history of severe hepatic dysfunction
- Urea cycle disorder
What are the indications for the use of timolol maleate? (6)
- Hypertension
- Angina
- Prophylaxis after MI
- Migraine prophylaxis
- Chronic open-angle glaucoma
- Ocular hypertension
What is the indication for the use of tolfenamic acid?
Treatment of acute migraine
- Oral: 200 mg, dose to be taken at onset, then 200 mg after 1-2 hours if required
NSAID
What are the indications for the use of topiramate?
- Monotherapy or Adjunctive treatment of generalised tonic-clonic seizures or focal seizures with or without secondary generalisation
- Adjunctive treatment for seizures associated with Lennox-Gastaut syndrome
- Migraine prophylaxis
Which eye side effect is associated with topiramate and typically occurs within 1 month of starting treatment?
Acute myopia with secondary angle-closure glaucoma
What are the indications for the use of zolmitriptan?
- Treatment of acute migraine
- Treatment of acute cluster headache
- Menstrual migraine prophylaxis
The max. dose of zolmitriptan is reduced to 5 mg in 24 hours if the patient is concurrently taking moderate and potent inhibitors of (?), cimetidine and moclobemide
CYP1A2
The max. dose of zolmitriptan is reduced to 5 mg in 24 hours if the patient is concurrently taking moderate and potent inhibitors of CYP1A2, (drug?) and (drug?)
Cimetidine
Moclobemide
What are the contraindications to the use of zolmitriptan?
- Arrhythmias associated with accessory cardiac conduction pathways
- Coronary vasospasm
- Ischaemic heart disease
- Moderate to severehypertension
- Peripheral vascular disease
- Previous cerebrovascular accident
- Previous MI
- Prinzmetal’s angina
- TIA
- Uncontrolled hypertension
- Wolff-Parkinson-White syndrome
Which triptan (5HT1-receptor agonist) is contraindicated in patients with Wolff-Parkinson-White syndrome?
Zolmitriptan
