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Stage 3 Case 1 > Migraine care > Flashcards

Migraine care Flashcards

1
Q

Migraine

A

A migraine is usually a moderate or severe headache felt as a throbbing pain on 1 side of the head. Many people also have symptoms such as feeling sick, being sick and increased sensitivity to light or sound.

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2
Q

3 types of migraine

A

Migraine with aura
Migraine without aura
Migraine aura without headache, also known as silent migraine

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3
Q

Migraine aura without headache, also known as silent migraine

A

where an aura or other migraine symptoms are experienced, but a headache does not develop

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4
Q

migraine without aura

A

the most common type, where the migraine happens without the specific warning signs

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5
Q

migraine with aura

A

where there are specific warning signs just before the migraine begins, such as seeing flashing lights

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6
Q

Triggers (7)

A

Lack of sleep
Fatigue
Stress (emotions generally)
Hormonal influences: menstrual cycle, puberty, oral contraceptives, pregnancy and menopause
Vision, sound and smells
Certain foods: cheese, red wine, chocolate, citrus fruits and coffee
Use of vasodilators

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7
Q

What co-morbidities might exacerbate a migraine?

A

Co-morbidities (such as sleep apnoea, insomnia, depression and anxiety) which may exacerbate migraine should be optimally treated

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8
Q

How long is Headache diary used for?

A

For a minimum of 8 weeks

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9
Q

What is recorded in a headache diary? (5)

A
  • The frequency, duration, and severity of headaches.
  • Any associated symptoms.
  • All prescribed and over-the-counter medications taken to relieve headaches and their effect.
  • Possible triggers.
  • Relationship of headaches to menstruation.
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10
Q

What do you do with medication that exacerbate headaches?

A

Discontinue

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11
Q

Suspect that oral contraceptive exacerbating headache?

A

Advise modification, changing or discontinue for a trail period.

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12
Q

Suspect that hormone replacement therapy (HRT) exacerbating headache?

A

Reduce dosage if possible or discontinue if required.

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13
Q

MOH

A

Medication overuse headache

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14
Q

What is MOH?

A

It is a cycle where the acute pain relief wears off leading to the pain coming back, so more medication is taken. This stops the medication form working and start causing headaches.

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15
Q

How often is the acute pain relief taken for it to cause MOH?

A
  • > 10 times in a month for triptans or combination analgesics.
  • > 15 days in a month for simple analgesics
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16
Q

How to avoid MOH?

A

Restrict the use of acute pain relief to a maximum of 2 days per week.

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17
Q

2 options for migraine treatment

A
  1. Simple analgesia

2. Triptan alone or in combination with paracetamol or NSAID.

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18
Q

What 4 things do you consider when decide on treatment for migraine?

A
  1. Seveirty
  2. Accosicted symptoms
  3. Contrainidcation
  4. Cormorbidities
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19
Q

Simple analgesia treatment form migraine (3)

A
  • Ibuprofen (400mg) —if ineffective, consider increasing to 600 mg
  • Aspirin (900 mg)
  • Paracetamol (1000mg).
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20
Q

Triptan treatment for migraine

A 
Oral sumatriptan (50-100mg) is first choice
 Other triptans should be offered if sumatriptan fails.
21
Q

What to do if vomiting restricts oral treatment?

A

Consider non-oral such as intra-nasal or subcutaneous

22
Q

When should a triptan be taken?

A

Taken on the onset and not during an aura as they will not prevent it and not all auras lead to a headache.

23
Q

Possible side effects of triptans

A

Nausea, dizziness, dry mouth, warm sensations and tingling and transient increases in BP.

24
Q

What can frequent use of triptan cause?

A

Chronic or exacerbation of headaches.

25
Q

Follow up

A

Review after the first pack of triptans (typically three to six doses), enquire about the effectiveness of treatment

  • Continue indefinitely if effective (with appropriate medication reviews).
  • Reconsult only if they experience problems in the future
  • If inadequate, or poorly tolerated, reconfirm diagnosis, reassess lifestyle advice, check that usage of treatment is correct, and rule out medication-overuse headache.
  • Consider prescribing a triptan that is more suitable for the person
  • If the person has tried two or more triptans unsuccessfully, or treatment is successful but attacks are frequent, consider preventive treatment
26
Q

The aim of preventative treatment

A

Reduce the frequency, severity, and duration of migraine attacks, and avoid medication-overuse headache.

27
Q

Consider preventative treatment if:

A
  1. Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment.
  2. Acute treatments are either contraindicated or ineffective.
  3. The person is at risk of medication overuse headache (MOH) due to frequent use of acute drugs.
28
Q

What is it essential to rule out before providing preventative treatment?

A

It is essential to rule out medication overuse headache (MOH) before preventive treatment is initiated. If MOH is suspected then the appropriate management is drug withdrawal

29
Q

Choice of therapy considerations

A

Choice of preventative medication depends on contraindications, comorbidities, and risk of adverse events.

30
Q

Before prescribing, discuss

A

The benefits (reduction in attacks) and risks (adverse effects) they should decide whether to try preventive treatment.

31
Q

Advise the person the aim of treatment

A

To reduce the frequency and severity of migraine symptoms and not complete remission or cure of migraine.
Acute treatment and avoidance of known triggers and lifestyle modification will still be required.

32
Q

Pregnancy and treatment for migraine

A

Some preventative therapies are contraindicated in pregnancy —potential harmful effects and the need for highly effective contraception must be discussed before starting treatment.

33
Q

How is drug treatment started?

A

Drug treatment should be initiated at low dose and titrated according to efficacy and tolerability

34
Q

Consider admission or urgent referral if:

A
  1. A serious cause of headache is suspected.

2. The person is in severe, uncontrolled status migrainosus (migraine lasting for more than 72 hours).

35
Q

Seek advice/refer to neurology (with urgency depending on the clinical situation) if:

A
  1. A complicationof migraine has developed.
  2. A typical symptoms (such as motor weakness or poor balance) are present.
  3. The diagnosis is uncertain.
  4. Optimal treatment in primary care does not adequately control the symptoms (medication overuse headache should be considered).
36
Q

Propranolol dose

A

80–160 mg daily, in divided doses)

37
Q

Topiramate dose

A

(50–100 mg daily, in divided doses [contraindicated in pregnancy — highly effective contraception is required prior to initiation])

38
Q

Amitriptyline dose

A

(25–75 mg at night).

39
Q

3 pharmacological therapies for migraine

A

Propranolol
Topiramate
Amitriptyline

40
Q

What do you not offer for migraine prophylaxis?

A

Gabapentin

41
Q

Non-pharmacological therapies

A

Behavioural interventions
Acupuncture
Riboflavin 400 mg once a day

42
Q

Behavioural interventions

A

such as relaxation techniques [for example mindfulness or meditation] or cognitive behavioural therapy).

43
Q

Acupuncture

A

up to 10 sessions over 5–8 weeks) if both topiramate and propranolol are unsuitable or ineffective.

44
Q

Riboflavin 400 mg once a day

A

may be effective in reducing migraine frequency and intensity for some people (avoid if planning a pregnancy or pregnant).

45
Q

How long may improvement take?

A

4-6 weeks

46
Q

When would you consider referral to neurology?

A

If prophylactic treatment in primary care fails, is not appropriate or any red flags or atypical clinical features develop. Treatment is considered to have failed if there is a lack of response to the highest tolerated dose after 3 months of treatment.

47
Q

After 6–12 months of successful therapy:

A

Review the need for continuing migraine prophylaxis. Consider gradual drug withdrawal.

48
Q

Consider admission or urgent referral if:

A
  • A serious cause of headache is suspected.

- The person is in severe, uncontrolled status migrainosus (migraine lasting for more than 72 hours).

49
Q

Seek advice/refer to neurology (with urgency depending on the clinical situation) if:

A
  • A complication of migraine has developed.
  • Atypical symptoms (such as motor weakness or poor balance) are present.
  • The diagnosis is uncertain.
  • Optimal treatment in primary care does not adequately control the symptoms (medication overuse headache should be considered).

Stage 3 Case 1 (12 decks)

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