Migraine Flashcards
What is a primary HA?
MC-No identifiable underlying cause.
What is a secondary HA?
Organic cause. 2. Dental infx 3. Brain Tumor 4. Subarachnoid hemorr
What is diff btwn cluster
severe- U/L lacrimating temporal TX- verapamil, prednisone
What is diff btwn Tension
MC- B/L TX-OTC
What is diff btwn migrain?
debilitating- U/L, W 15-30yo-Trigger-trigeminal nerve-vasodilation-inflammation-nociceptive-peripheral sensitization. Prodrome- mood, food. Aura- tingling lips, motor speech. HA- UL throbbing 4-72hrs, pain INC activity HA- reverts to vomiting spontaneous, Postdrome-fatigue, AN (pseudo seizure)
What are trigger for Migraine?
Stress, mood, light, hunger, MSG, tyramine, Nitrites, chocolate, menses,
What is best method for Acute Migraine tX?
Large single dose. 2. parenteral best
What is benefit of caffeine in Excedrin OTC used for acute migraine?
helps absorb faster- NOT REC for single agent. OK for peds and Pregs
What is ideal for tension HA?
Fiorinal-caffeine+aspirin/APAP
How are NSAIDs use in HA?
Mild to mod 2. Avoid 3rd trimester 3. Metoclopramide for absorption 4. Avoid excess d.t rebound HA
What can be used as monotherapy for HA antiemetic?
Injection-prochlorperazine, metoclopramide, chlorpromazine 2. Used with diphenhydramine to prevent ADEs akathisia/dystonic rxn
What are ADEs and use of metoclopramide?
- USE- delay gastric emptying so better absorption. 2. ADE- sedation, confusion dyskinesia
What is not first line for migraine HA?
Opioids- INC rebound HA- meperidine, codeine, Stadol
What is REC for intractable severe migraine?
Ergot-Dihydroergotamine DHE-LONG LAST HA ADE-n/v rebound HA, NEVER MONO, Used in ED, poor absorption
Which ERgot interacts with serotonin and cause vasoconstriction and vasodilation?
Ergotamine Tartrate- LAST RESORT-FOR MIGRAINE AND CLUSTER RECURRENCE OR PROLONGED ATTACKS
What are ADE of ergotamine
GI, *peripheral vasoconstriction: cold, DEC pulses, tingling. AVOID in PVD and CAD, PregX, Ischemic bowel dz, CVA, . BB may INC effects. TX OD- Nitroglycerin
What are DI of ergotamine tartrate?
Triptains! and CYPs INC Ergo TARTRAte in serum, INC toxicity
This MOA is 5HT1b, 1d agonist receptors located in CNS, PNS that stimulate vasoconstriction in cranial vessels, and inhib trigeminal nerve 1d, dec neuropeptides responsible for vasodilation and reduce transmission?
Triptans- suma, riza, nara, zolmi, frova, ele. The IRanian triptans
WHich triptan should be avoided in elderly, short t 1/2, quickers relief SC?
Sumatriptan- GMa suma like natural
What are ADE of SUMA?
1st GEN GMa- gets chest to throat pressure, SOB, Signs of GAD. Anxious Grandma. Resolves in 30 min. Patch scars
What is concern with Suma in women?
PREG C- excreted in breastmilk.
What BB inhibits Rizatriptan and thus Riza must be DEC by 50% if pt on BB?
Propranolol- “Aunt Riza and her CHF”. Riza- has a fast onset w/ good response. “But Riza so helpful”
Which triptan is best tolerated, LOWEST recurrence?
Aunt Nara- “nice and slow Aunt Nara”
Which triptan has CYP many DI, short duration bc INC lipo, Well tolerated, LOW recurrence?
Almotriptan- “Crazy Aunt Almo never getting along with family bc her short tempe with wt talks”
Which triptan is ideal for AURAs LONGEST t/1/2, slow relief, low HA recurrence?
FRovatriptan- “Aunt Frova forever long mystical stories but she never repeats?
Which triptan is avoid 72 hr with other drugs due to CYP inhib?
Eletriptan- “Aunt Ele is live 72hr away”
Which Triptans have consistent success?
Riza, Ele, Almo- Trials said oral are effective. Choice individualized. Switch if one not working
Which drugs have least ADE?
Nara and Frova
Which drug has most delivery options?
Sumatriptan- GMa got all the recipes
Which Triptan CANNOT be repeated 2hrs?
Nara-Slow AUNTy. All other can repeat 2 or >2hrs. EXCEPT Sumatriptan SC- 1hr
What have nasal spray option?
Zolmi and Suma
What RX can be used in 2-3 trimester for migraine?
APAP+metoclopramide. AVOID-nsaid, ergos, triptans preg c
When can prophylaxis be used?
HA > 3day/mo, or >2 day/week or severe long lasting >12hr
How should prophylaxis be dosed?
Lowest effective dose, slowly, Trial 2-3mo, Avoid other RX meds. Re-evaluate 1 yr via slow taper
What BB is most studies, but overall any BB has 60-80 complete or partial relief, DOC bc safe, effective, tolerable?
Propranolol- may take 3-6 mo of max. Titrate to max dose 325 mg
What are ADEs of BB?
AVOID asthma,DM, cardiac arrhythmias. Fatigue, exercise intolerance, MDD, ortho hypotension
What CCB is used in migraines?
Verapamil- 50% relief ADE- dizzy, edema, flushing, constipation, tolerance
What is the most effective prophylaxis antidepressant?
Amitriptyline-TCA ADE- sedation, wt gain, anticholinergic (dry as dessert). USE- best if PMH of MDD, GAD, insomnia, tension HA. AT NIGHT
Which AED meds are used in migraines, but are PREG X?
Valproate and Topiramate-
Which ADE is double whammy with prevent migraines and WT LOSS?
Topiramate- Kids age 12+ ADE- birth defect
What new prophylaxis is LAST resort?
Calcitonin gene related peptide- for trigeminovascular pain- Drug Mabs-ADE- cardiovascular, pulmonary, psych. AVOID- children, preg, elderly. 3 deaths
Should transcranial magnetic stimulation be used on epilepsy migraine pts?
NO- 2nd for pt w/ intolerances
What is prophylaxis for cluster HA?
Verapamil, Steroids, Topiramate, Lithium
What is ideal Tx for cluster HA?
Oxygen. Triptans-Suma, Zolmi, Nasal Lidocaine
What can be used has prophylaxis of Tension HA?
TCA-amitriptyline.
