migraine attacks

Question 1

what is migraine?

Answer 1

a severe throbbing headache, starting unilaterally

• usually age 25-55
• a genetic disorder

Question 2

associated symptoms of migraine

Answer 2

• photophobia
• nausea
• vomitting
• prostration(weakness)

Question 3

what happen to GI changes during migraine?

Answer 3

• decrease motility
• stasis
• nausea
• vomitting

Question 4

stages of migraine

Answer 4

1. prodrome up to 48 hours
2. aura (visual disturbance) 5-60 minutes
3. HEADACHE
4. resolution
5. recovery

Question 5

list 3 migraine pathophysiology

Answer 5

1. vascular theory
2. brain hypothesis
3. inflammation hypothesis

Question 6

what is vascular theory? (WOLFF)

Answer 6

1. starts with intracerebral vasoconstriction from posterior and spreads forwards, causing aura. (hypoperfusion)
2. then extracerebral vasodilation at unilateral middle cerebral artery, causing headache.(hyperperfusion)

Question 7

what is brain hypothesis? (LEAO)

Answer 7

when concentration of extracelullar K+ or glutamate increase, cause decreasing of blood flow.
will cause wave of cortical spreading depression.
(aura not headache yet)

Question 8

what is inflammation hypothesis?

Answer 8

1. activation of trigeminal nerve in meninges and extracranial vessels
   2, release of inflammatory mediators
2. cause inflammatory soup
3. trigger hyperexcitability occipital cortex

Question 9

high amounts of neurotransmitter serotonin places?

Answer 9

• midbrain
• peripheral nerves
• platelets aggregation
• blood vessels
• enterochromaffin cells (90%) GI
• myenteric plexus

Question 10

how to confirm it is migraine attack?

Answer 10

• high urinary of serotonin metabolite, 5HIAA

- decrease blood concentration of serotonin

Question 11

what are serotonin receptor for?

Answer 11

1. 5-HT 1B/1D agonists = acute treatment
   - cause migraine vasoconstriction
   - eg drugs: triptans
2. 5-HT 2A antagonist= prevention
   - for migraine prevention
   - eg drugs: dihydroergots, pizotifen, methysergide

Question 12

pathway of treatment of migraine

Answer 12

1. activation of 5HT 1B receptor = direct vasoconstriction in extracerebral vessels
2. 5HT 1D receptor = inhibits trigeminal peptide release and inflammation, blocks vasodilation, inhibits nausea and vomiting.
3. decreased pain transmission
4. inhibition of central pain transmission

Question 13

other roles of drugs

Answer 13

1. degradation inhibitors (MAO)
2. storage inhibitors (amphetamine, methylphenidate, modafinil)
3. reuptake inhibitors (antidepressants)

Question 14

carcinoid syndrome?

Answer 14

• rare disorder with malignant tumours of enterochromaffin cells
• tumour produce a lot of serotonin into blood
• cause flushing, diarrhoea, bronchoconstriction, hypotension
• medication control symptoms: 5HT2 cyproheptadine

Question 15

examples of triptans

Answer 15

• sumatriptan
• zolmitriptan
• naratriptan
• rizatriptan
• almotriptan

Question 16

route for drugs

Answer 16

1. oral- 30 minutes
2. intranasal spray- 15 minutes
3. subcutaneous/ injection- 10 minutes

Question 17

calcitonin gene-related peptide (CGRP)?

Answer 17

• release during migraine
• participates in inflammatory hypothesis
• activates meningeal nociceptors
• causes vasodilation
• causes mast cells degranulation
• TELCAGEPANT- antimigraine drug blocks CGRP receptor

Question 18

prevention of migraine

Answer 18

• decrease blood flow
• inhibit degranulation of mast cells
• inhibit neurogenic inflammation
• inhibit transmission of pain
• nitric oxide antagonism

Question 19

dihydroergotamine (DHE)

Answer 19

• semisynthetic ergot alkaloid
• 5HT partial agonist
• found in fungus Claviceps purpurea
• orally inhaled, effective as IV
• side effects: vomit, dysphoria( unwell), vasoconstriction, dizziness, myalgias, cramps, paresthesias (pins and needle)

Question 20

treatment of migraine

Answer 20

1. avoid triggers
2. prodrome: domperidone, metoclopramide
3. aura: vasodilators, anti-epileptic, carbonic anhydrase inhibitors
4. attack (non-specific): basic analgesic, NSAIDs, caffeine
5. attack (specific): ergots, triptans
6. miscellaneous: anti-emetics, neuroleptics

Question 21

prevention of migraine

Answer 21

1. anti-epileptic drugs:
   - valproate,
   - topiramate(for preggy mom)
2. beta-blockers:
   - metoprolol
   - propranolol
   - timolol
3. butterbur: petasites
4. 5HT: frovatriptan

Question 22

drugs for tension headache(pain like band squeezing the head)

Answer 22

1. acute attack:
   - paracetamol
   - NSAIDs (ibuprofen, naproxen)
   - avoid opioids (codeine)
2. chronic-prevention
   - amitriptyline
   - mirtazapine
   - acupuncture

Question 23

paroxysmal hemicrania?

Answer 23

• severe unilateral headache
• affecting area around the eye
• short headache attack
• NSAIDs as treatment
• unlike migraine, it has no neuro problem

Question 24

cluster headache?

Answer 24

• heat of parasympathetic triggers by sleep
• sharp stabbing headache( worst headache)
• unilateral orbit pain
• 15-3 hours pain
• watery eye, drooping eyelid, runny nose

Question 25

risk factors of cluster headache

Answer 25

• high alcohol/ tobacco usage
• heavy facial features (leonine facies)
• peau d’orange skin
• hazel-coloured eyes
• duodenal ulceration
• type A personality
• stress job

Question 26

medication for cluster headache

Answer 26

• sumatriptan
• verapamil
• steroids