Migraine Flashcards
What are the types of headaches?
tension (most common), cluster, migraine (recurrent, severe)
What is the cause of tension headaches?
muscle contraction and peripheral sensitization of nociceptors caused by a multitude of things, such as: stress, physical causes, dehydration, ect.
What is the clinical presentation of tension headaches?
mild-moderate severity, non-pulsating, band-like pressure/tightness, bilateral
What is the 1st line acute treatment of tension headaches?
OTC acetaminophen or NSAIDs
note: no evidence for muscle relaxants
What is the 2nd line acute treatment of tension headaches?
if first line failed, prescription NSAIDs or combo products, such as: butalbital OR codeine + aspirin or acetaminophen
note: no evidence for muscle relaxants
What is the cause of cluster headaches?
decreased sympathetic and increased parasympathetic activity, vasoactive neuropeptide release and neurogenic inflammation, caused by heat, light, high altitude, cigarettes, alcohol, coffee, exercise, foods high in nitrites
What is the clinical presentation of cluster headaches?
-unilateral, severe, intermittent, sharp/stabbing
-parasympathetic symptoms= lacrimation (tearing), rhinorrhea (nasal discharge/mucus), sweating
-typically at night but may occur throughout day
-excited or restless
What is 1st line acute treatment of cluster headaches?
100% oxygen mask
What is 2nd line acute treatment of cluster headaches?
if oxygen fails, -triptans or ergotamine derivative
What agents may be given to prevent cluster headaches?
-verapamil, lithium, corticosteroids, galcanezumab (Emgality)
Describe the dosing of galcanesumab (Emgality) for cluster headaches
300 mg subq at the onset of cluster period and then once monthly until end of cluster period
What is the pathophysiology of migraines?
serotonin (5-HT) is an important mediator of -> vascular vasodilation is a result of vasoactive neuropeptides (CGRP, neurokinin A, substance P) leading to inflammation and pain
What is the International Headache Society (IHS) diagnostic criteria for migraines?
-at least 5 attacks
-headaches last 4-72h
-must have 2 of the following characteristics: unilateral, pulsating, moderate-severe intensity, aggravation by or avoidance of routine physical activity
-during the headache, must have one of the following symptoms: nausea, vomiting, photophobia AND phonophobia
What does POUND stand for for migraine diagnosis?
-P: pulsating or throbbing pain
-O: one-day average duration
-U: unilateral location
-N: nausea or vomiting
-D: disabling
What are the goals of therapy for migraine treatment?
-reduce migraine frequency, severity, and disability
-improve quality of life
-minimize use of backup and rescue medications
-treat attacks rapidly and consistently
-optimize self-care, utilize cost effective treatments, and decrease emergency visits
-minimize adverse effects
What are the non-pharmacological treatment options for migraines?
-identify and avoid triggers
-lifestyle changes: regular sleep, exercise, limited caffeine, smoking cessation
-behavioral interventions: relaxation, cognitive behavioral therapy
-icepacks, rest in a dark area
What are common triggers for migraines?
alcohol, caffeine, chocolate, fatty foods, loud noises, strong smells, smoke, flickering lights, menstraution
When is migraine medication most effective?
when administered within 1 hour of symptom onset
How many days a month is it recommended to take symptomatic medication?
< 10days
What are the acute treatment options for migraines?
-analgesics
-serotonin agonists (triptans)
-lasmiditan
-ergotamine derivatives
-CGRP receptor antagonists (gepants)
-antiemetics
-opioids
-dexamethasone
What is the 1st line treatment for mild-moderate pain associated with migraines?
analgesics
What is the 1st line treatment for moderate-severe pain associated with migraines?
serotonin agonists (triptans)
MOA: serotonin agonists (triptans)
increased vasoconstriction, inhibition of vasoactive peptide release, inhibition of transmission from trigeminovascular system
Adverse Effects: serotonin agonists (triptans)
paresthesia, fatigue, dizziness, flushing, warm sensations, chest tightness, somnolence
Contraindications: serotonin agonists (triptans)
ischemic heart disease, previous MI, hemiplegic/basilar migraine, uncontrolled HTN
Precautions: serotonin agonists (triptans)
high risk for coronary heart disease (older men with risk factors and postmenopausal women) or SSRI use due to risk of serotonin syndrome
Drug Interactions: serotonin agonists (triptans)
ergotamine derivatives, MAOIs
MOA: Lasmiditan
serotonin (5HT1F) agonist, decreases trigeminal system without causing vasoconstriction
Adverse Effects: Lasmiditan
dizziness (do not drive for 8h after taking medication)
Indication: Ergotamine derivatives
moderate-severe migraine episodes, not generally first line due to tolerability
MOA: Ergotamine derivatives
nonselective serotonin (5HT1) agonist, vasoconstriction of intracranial blood vessels and inhibition of neurogenic inflammation in the trigeminovascular system, caffeine enhances absorption and potentiates analgesia
Adverse Effects: Ergotamine derivatives
nausea and vomiting, abdominal pain, weakness, fatigue, paresthesia, muscle pain, chest tightness, peripheral ischemia (rare)
Contraindications: Ergotamine derivatives
pregnancy/breastfeeding, renal/hepatic failure, cardiac disease, uncontrolled HTN, strong CYP3A4 inhibitors
Drug Interactions: Ergotamine derivatives
triptans, MAOIs
What is the role of CGRP in migraines?
calcitonin gene-related peptide, a neuropeptide released from activated trigeminal sensory nerves, dilates intracranial and extracranial blood vessels and centrally modulates vascular nociception
Indication: CGRP antagonists (gepants)
used for acute treatment or prevention of migraines
Indication: antiemetics
treats N/V symptoms associated with migraines or used prior to giving medication during attack to improve absorption
Indication: Opioids
last line for migraine treatment, inadequate evidence
What are the indications to implement preventative therapy?
-recurrent migraines with significant disability despite acute therapy
- > 2 headaches/week
-issues with/failed acute therapy
-patient preference
-predictable patterns
Indication: Anti-CGRP monoclonal antibodies
used for prevention (all except rimegepant which can be used for acute treatment), typically utilized when inadequate response or tolerance with at least 2 other agents
Indication: OnabotulinumtoxinA
approved for the prevention of chronic migraines ( 15+ headaches/months lasting 4+ hours) in pt >18 yo
