Migraine Flashcards
Migraine
Rx list
- Propranolol
- Valproate
- Topiramate
- Onabotulinum toxin
- Ergotamine + Dihydroergotamine
- Sumatriptan
- Metaclopromide
- Caffeine
- NSAIDs
Migraine
Mech
*vascular headache = vasodilation
2 versions :
- classic = aura
- common = w/o aura
Classic migraine
- 20%
- visual/sensory aura
- aphasia, vertigo, pallor, chills, tremor, unilateral weakness
Migraine
Who?
- women
- genetic
- start in adolescence
Migraine
s/s
*Onset w/ waking
*4 hour - 3 days
*from trigger
*n/v
*photophobia
*scalp tenderness
*lightheadedness
*vertigo
MORE THAN PAIN
Migraine triggers
- mental
- endogenous
- exogenous - food, ETOH, allergens, MSG, etc.
- other - lights, smells, temp, altitude
Dx
Repeated headache attacks, lasting 4 hours - 3 days
2 of these:
- unilateral pain
- throbbing pain
- aggravation w/ movement
- moderate/severe intensity
+1 of these:
N/V
Photophobia/phonophobia
CGRP calcitonin g related peptide
From trigeminal ganglian neuron
*Sterile inflammation / sensitization of blood vessels AND affect brain
Serotonin
role in migraine
- 5HT + metabolites change (increase) during migraine
- triggers pain afferents
- 5HT constricts cerebral vessels
- Migraine - other serotonin behaviors = sleep, appetite,depression
- DON’T REALLY KNOW
- best Rxs address serotonin
Serotonin
Periphery - hemostasis
*hemostasis. = platelet aggregation, vasoconstriction (spasm = too much)
Serotonin
Periphery
GI
- Motility
- Malignant carcinoid tumors secrete
- emesis, nausea
Prophylactic Tx
- frequent occurence (>3-5/month)
- mild-moderate therapy
- classic>
- over 1/2 success rate
- > 6 weeks tx to work
- may need tolerance break after 6 months
- UP CSD threshold (supress)
Prophylactic Tx
Rx 1st line
1st line =
*B-blocker
Propranolol
Timolol
*Anticonvulsants
Valproate
Topiramate
+others REVIEW SLIDE
Beta blockers
Migraine prophylaxis
*mech unknown
*many S.E
Fatigue, GI disturbance
Depression, insomnia,nightmare
*NO IN ASTHMA, DEPRESSION, HF
*NO w/ CCB
*withdrawal = CV distress
Anticonvulsants
Topiramate
- block sodium + calcium channel
- block glutamate receptors
- UP gaba
- stop TNC
- SE - paresthesia, fatigue, cognitive impairment, weight loss
Onabotulinum Toxin (BoTox)
- Chronic 15< per month
- Every 12 weeks
- Cleaves snares in release of CGRP
1) lowers peripheral sensitization
2) lowers central sensitization
Onabotulinum toxin
SE
- Neck pain
- Muscular weakness (Ach)
- eyelid/eyebrow ptosis (improper technique)
Acute Tx
Mild ot moderate
- Naproxen
- Caffeine
- vasoconstriction
- aids in absorption of analgesics
- adjuvant
- Metoclopramide REGLAN
- 5ht3 + D2 receptors
- anti-emetic, up gastric emptying
- adjuvant
Severe Migraine Tx
Rx
Ergots
Triptans
Ergots
Mech
- oldest
- Dx and Treatment
- Vasoconstrictor CNS
- non- selective 5ht ags
Ergots
Routes
- Dihydroergotamine (DHE) - parenteral/nasal
- eratic w/ oral response
- PR - nausea
*combos = caffeine, sedatives
Ergot
Therapy
- Must take Early - not rescue drugs
- S.E. w/ ergotamine may be limiting
- dependence
Ergots
S.E.
Dihydroergotamine = parenteral admin faster
Less S.E.
Drug interactions = triptans, b blocker, nicotines
Triptans
Sumatriptan IMITREX
Triptans
1st line
- selective 5HT1 ags (b/d/f)
- multiple routes
- rapid
- good response
Triptans
S.E.
- Minimal effects - receptor selectivity
- Re-emergent migraine
- Coronary disease (watch) - vasoconstriction
Triptans
Rx interaction
MAOIs (break down??)
Triptans
“Stratified care”
- mix = oral/nasal/injectable as needed
- injectible (5 mins)- rescue
- nasal (15mins) - fast
- NSAID (naproxen)= adjuvant
New migraine therapies
*-Ditans = 5-H1F receptor ag, only TG path,no vessels, good with CV dz
- CGRP antags (gepants)
- CGRP antibodies
Triptans
- onset
* duration
Sumatriptan
Mech
- serotonin derivative
* Selective ags = 5HT 1b/1d
Other mild/moderate migraine Tx
- opiods
- phenothiazines (don’t use - S.E.)
- Combos - vasoconstrict + analgesic + sedative. (Acetaminophen+Aspirin+caffeine)
CSD = cortical spreading depression
- Spread from back to front
- Decrease (depole) in Blood flow, Then Increase (hyperpole) in blood flow
- aura
- dilation = pain
TG system activatoin
Input from meningial vessels
Trigem afferents –> Trigem ganglion –> trigem nucleus caudalis –> thalamus –> cortex
Input from Locus ceruleus + Periaqueductal gray + raphe nucleus (serotonin) =. (bstem)
=CSD activates this
CSD =
TG system =
CSD = aura
TG system = pain
Serotonin targets for Migraine
5HT1 = B/D/F
Migraine Prophylaxis
Anti-convulsants
Valproate
- up GABA-mediated transmission (down inflammation)
* S.E. = N/V, weight, NO PREGGER
Migraine prophylaxis
Anti-convulsants
Topiramate
- Block Na+/Ca2+ channel
- Down Glutamate, UP Gaba, STOP TNC
*S.E. = topiramate = paresthesias
Migraine prophylaxis
Anti depressants
TCAs
- amitriptyline
- nortriptyline
Migraine prophylaxis
CCB
Verapamil
*block 5-HT
*S.E. - hypoTN
Migraine prophylaxis
NSAIDs
Naproxen
*frequent use - withdrawal, s/s worse
Triptans vs. ergots
Later in migraine
Triptans effective!
Which give rebound headache
Triptans
Don’t take too close together
Migraine = main tx ideas
Directly constrict blood vessels
Rx
Caffeine
Triptans
Migraine = main tx ideas
Inhibit vasodilation
Shut off inflammatory mediators = CGRP
Inhibit leakage with vasodilation
Migraine = main tx ideas
Work centrally
TNC
