Migraine and Headache Flashcards
Prevalence of migraine
-higher in US than rest of world
-30% people experience Aura
-affects women more than men
-Peaks in ages 25-55
-40% of people benefit from treatment
Pathophysiology of migraine
-wide range of factors and mechanisms involved
-depends on genetics, anatomical, and environmental factors
Diagnosis of migraine
-ICHD-3 criteria
-at least 5 attack fulfilling the criteria
Cortical Spreading Depression (CSD)
responsible for aura and activation of trigeminovascular system
Dysmodulation
-theory that migraines w/o aura are associated with abnormal neuronal excitability and response to sensory stimuli
Describe process of CSD
-5HT and CGRP and other vasoactive neuropeptides released
-causes vasodilation, inflammation, and pain perception
Phases of a migraine attack
-predrome
-aura
-headache: mild, moderate, severe
-Postdrome
Criteria for Migraine without Aura
-4-72 hours
-pain (need 2 of 4): Intensity mod to severe, Unilateral, Pulsing/throbbing, aggravated with activity
-in addition to (1 of 2): N/V, Sensitivity to light/sound
-75% of people experiance neck pain
Tension type headache criteria
-30 mins to 7 days
-pain(2 of 4): Bilateral, pressing/tightening, mild to moderate, not aggravated by activity
-In addition to: no nausea, photo or phonophobia
Mnemonic for diagnosing Migraine Without Aura
-AUSTIN
-Activity aggravates
-Unilateral
-Sensitivity to light/sound
-Throbbing
-Intensity moderate to severe
-Nausea/vomiting
Episodic Migraine
< 15 HD/month
chronic migraine
> 15 HD/month
Headache History
-age of onset
-time from onset to peak intensity
-pain scale
-aggravating
-associated symptoms
Red flags for secondary headache
-Investigate SNOOP symptoms
-Systemic symptoms: fever, rash, stiffness
-Neurologic symptoms: confusion, weakness, vision changes
-onset: sudden, thunderclap
-Onset >40 years
-Pattern change: change in features
What is a migraine?
-loss of central inhibition and ability to accommodate various stressors
Migraine Triggers
-Fasting
-Medication
-Circadian Rhythms
-Environmental
-Hormones
-Stress
MIDAS
-Migraine Disability Assessment
Non-pharmacologic tratments
-biofeedback
-progressive relaxation
-cool compress
-rest in cool dark place
-hydration
-acupuncture/massage
-headache diary
Level A complementary treatments
-butterbur extract 75 mg BID
Level B complementary treatments
-feverfew
-Magnesium oxide (500mg/day)
-B2 (400mg/day)
Level C complementary treatments
-Coenzyme Q-10 300 mg/day
Specific migraine medications
-for moderate to severe HA
-triptans
-ergotamine derivatives
-Gepants
-Lasmiditan
Opiate medications for migraine
-Butorphanol
-tramadol
-Acetaminophen with (codeine/hydrocodone/tramadol)
-NO BUTALBITAL containing products
Dihydroergotamine(DHE)
-high affinity for 5-HT1b/d
-interact with many others
-Many side effects: N/V, diarrhea, vasoconstriction
-Most effective at first sign of migraine
-risk of stroke and/or gangrene when taken with CYP3A4 inhibitors
DHE dosage form
-nasal spray
-injection
5-HT1 agonist
treatment of migraine
5-HT2 antagonist
prevention
5-HT3 antagonist
N/V
What triptans can be repeated in 2 hours?
-Almotriptan
-Eletriptan
-Frovatriptan
-Rizatriptan
-Sumatriptan(PO, nasal spray, powder)
-Zolmitriptan(PO, Nasal spray)
How often can you repeat a dose of Lasmidtan PO?
never, one dose in 24 hours
-don’t drive for 8 hours
How often can you repeat a dose of Naratriptan?
-4 hours
-long half life
Contraindications and precautions for triptans
-heart disease
-coronary vasospasm
-co concurrent us of ergot derivative
-pregnancy: minimize exposure
-MAOI
-SSRI
triptan drug interactions
-MAOI: avoid within 2 weeks
-Ergots: avoid for 24 hours
-SSRIs and SNRIs: Serotonin syndrome
-oral contraceptive: increase triptan conc.
Cimetodine/Zolmitriptan drug interaction
-use zolmitriptan 2.5 mg
Propranalol and Rizatriptan
-increase triptan plasma conc by 70%
Eletriptan drug interactions
-CYP3A4
-avoid nefazodone, clarithromycin
0azoles. grapefruit juice
Common triptan side effects
-tingling
-warmth
-flushing
-chest and neck pressure
-dizziness
-somnolence
-abnormal taste with nasal formulations
-injection site burning at injection site
-REPORT CHEST PAIN
Ubrogepant
-repeat in 2 hours
-nausea, somnolence, dry mouth
Rimegepant
-orally disentegrating tab
-single dose
Zavegepant
-nasal spray
-distorted tased, nausea, nasal discomfort
Medication overuse headache
-more than 15 headaches/month for more than 3 months
-its important to ensure that patients do not over use their medications
Who gets preventative migraine treatment?
-more than 4 migraines/month
-disruption in life
-a lot of pain
Divalproex
-weight gain, hair loss, tremor, tetratogenicity
-migraine prevention
Topiramate
-Migraine prevention
-weight loss, psycomotor slowing, difficulty concentrating
-teratogenicity
Beta Blockers
-migraine prevention
-lowers BP and HR
-exercise intolerance
-depression
-contraindicated in asthma/COPD
Tricyclic antidepressants
-migraine prevention
-sedation, weight gain, anticholinergic syndrome
Botox
-chronic migraine headache
small doses in head and neck every 3 months
-sore neck, droopy eyelids
-effect noticed in a month
CGRP antagonists
-migraine prevention
-reduce frequency of migraines by 50%
-constipation, site irritation
-EXPENSIVE
-can be combined with oral agents
Rimegapant
-ODT 75 mg every other day
-migraine preventionA
Atogepant
-migraine prevention and acute treatment
-10, 30, 60 mg daily
Migraine with aura and birth control
-risk factor for ischemic stroke
-don’t use COC
Menstrual migraine
-acute treatment: ergos or triptans
-phrophalactic treatment: NSAIDs(2 days before), Frovatriptan or naritriptan 6 days before
-COC extended dosing
-estradiol gel 6 days before and after
-magnesium day 15 to end of cycle
