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