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Clinical 2.0 winter > Migraine/headache > Flashcards

Migraine/headache Flashcards

1
Q

migrain is more a ___ disorder than a vascular

A

neurological

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2
Q

what is cortical spreading depression phenomenom

A

self propagating wave of enuronal and glial depol that spreads across the cerebral cortex
suppression of brain activity across the cortex

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3
Q

what does cortical spreading depression cause

A

migraine aura
activate trigeminal nerve afferents
disrupt BBB permeability

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4
Q

how does sensitization contribute to migrains

A

nerves becomes more responsive to stimuli

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5
Q

peripheral vs ccentral sensitization

A

peripheral occurs in primary afferent neurons causing greater migrain symptoms
central in 2nd order neurons resulting in greater conversion of episodic to chornic migrain?

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6
Q

what role does serotonin have in migrains

A

just know activation of serotonin receptors is important for acute migraines

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7
Q

migrain subtypes

A 
acute episodic 
chronic 
vestibular
menstrual
retinal 
hemiplegic (paralysis of one side of body)
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8
Q

signs of migrain headache

A 
stable pattern 
positive fmaily history 
normal neurologic exam
food triggers
menstrual association 
improve with sleep 
long standing history
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9
Q

prodrome features

A

1-2 days before onset of headache
neurologic - allodynia, photophobis, ponophobia, difficult concentrating
psychological - anxiety, depression, euphoria, dwosy, restless
autonominc - polyuria, diarrhea, constipation
stiff neck, thirst

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10
Q

migrain aura time frame and symptoms

A 
can precede or be present during headache
<60min duration 
completely reversible 
mix of positive and negative focal neurologic symptoms 
positive - flickering lights, spots
negative - numb, lack of vision 
tingling 
muscle weakness 
dizziness
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11
Q

describe a typical migrain headache

A 
unilateral 
throbbing, pulsating 
attack progressively and worsens
NV 
photophobia/phonophobia 
osmophobia(sensitive to smell) and cutaneous allodynia 
mod - sev pain intensity
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12
Q

red flags

A

onset age >50 (lesion, meningitis)
severe abrupt onset (hemorrage)
worsenign (lesion)
stiff neck, abnormal speech (meningitis, stroke)
fever, rahs (meningitis)
cancer, lyme disease, HIV (metastatis, opportunistic infection)

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13
Q

symptoms warranting meuroimaging

A 
first or worst headache
recent significant change
new unexplained eurological symptoms
headache always on the same side
unresponsive headaches
new onset after 50 
new onset in patients with cancer or HIV..
fever, stiff neck, papilledema, cognitive impairment, change in personality
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14
Q

what is migrainous infarction

A

rare complication of migrain
mostly occurs in the posterior circulation in younger women with a history of migraine with aura
ischemic stroke??

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15
Q

risk of ischemic stroke significantly increased in which type of people with migraines

A 
women 
<45yoa
smokers who have aura
oral contraceptives who have aura 
previous hostory of stroke 
>12 headaches per year
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16
Q

examples of migrain triggers

A 
stress
hormones
weather
sleep disturbance
odor
heat
food
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17
Q

non pharms

A 
avoid triggers
rest in dark quiet room 
headache diary 
relaxation techniques
cbt 
cold/heat packs 
hydration 
routine 
regular meals
caffiene balance
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18
Q

goals of acute therapy

A

relieve pain and associated symptoms
functional headache free state in 2hr with no recurrence in 24 hours
no AE
relieve disability
avoid medicatio overuse headache
avoid development of central sensitization

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19
Q

reasons to treat the headache early

A

reduce overal burden of migrain

reduce likelihood of central sensitization

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20
Q

challenges to treating headaches early

A

some avoid meds unless headache is severe

fear of overuse

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21
Q

drugs for acute and when to take them

A 
triptan 
ergot derivative
nsaids
acetaminopehn
domperidone, metoclopramide 
best taken at onset of head pain
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22
Q

role of triptans

A

mod-sev migraines first line

reduce NV, photo and phonophobia

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23
Q

if dont respond is there a benefit in switching

A

yes

space 24h

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24
Q

triptans CI in

A

CAD
severe liver disease
some caution in renal

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25
triptan MOA
vasoconstrictor | inhibits neurogenic inflammation peripherally prevents central sensitization
26
most common triptan coverage
EDS2
27
when would you use subcutaneous sumatriptan
use if headache builds rapidly or is accompanied by early NV
28
which formulations are good in NV
ODT intranasal SC
29
oral triptan onset and duration
start working in 30-60min | last 2-4 hr
30
which triptans have a slower onset (better tolerated) and longer duration
naratriptan frovatriptan use if have long migraines
31
triptans with sulfonamide moiety
suma | nara
32
triptans with sulfonyl group
ele | frova
33
summary of tri[tan drug interactions
dont take within 24 hr of ergot alkaloid due to additive vasoconstriction avoid within 2 weeks of MAOIs caution with SSRI -serotonin syndrome cyp3A4 inhibitors
34
triptan common SE
``` paresthesia fatigue dizzy fatigue warm somnolence ```
35
triptan sensations are
mild transient burning, tingling, tightness, pressure, heaviness, pain
36
serious rare triptan SE
MI, cornoary vasospasm with ischemia serotonin syndrome see doctor if lasts more than 20 min
37
triptan contraindications
``` cerebrovascular disease IHD uncontrolled HTN PVD hemiplegic or basilar migraine ```
38
ergot actions
non selectiv serotonin agonist alpha and beta agonist dopamine D! and D2 agonist
39
dihydroergotamine dosage forms
SC IM IV
40
common ergot SE
``` NV - pretreat with antiemetic ab pain weak, fatigue paresthesias muscle pain diarrhea chest tightness NAUSEA!! ```
41
serious ergot SE
severe peripheral ischemia - cold numb, pain, claudication gangerenous extremities MI bowel and brain ischemia
42
ergot CI
cardiac/cerebrovascular disease uncontrolled HTN pregnant hemiplegic or basilar migrani
43
role of acetaminopehn
acute treatment fo mild to mod contraidications to nsaids best if taken early better than placebo
44
acetaminophen MOA
may block prostaglandin synthesis in CNS and pain impulse generation in the periphery
45
NSAIDs role
acute migrain treatment of mild-mod severity
46
nsaids MOA
prevent inflammation in the trigeminovascular system via prostaglandin synthesis inhibition
47
why avoid fiorinal
contains butalbital which causes rebound headaches
48
why avoid routine use of opioids for migraine
lack of evidence of superiority increase risk of chronic headache reduce response to other drugs SE abuse
49
what is medication overuse headache
acute meds used lots over several months
50
prevent MOH by limiting use of
tylenol, asa, nsaids <15days/month triptan, opioids(8), combo, ergot <10days/month should be acute med free for >20days/month**
51
management of MOH
taper down and stop drug (would just stop unless an opioid) watch for refractory rebound headache and withdrawal prophylactic treatment may help reduce rebound and withdrawal renewed response to therapy usually occur within 2months of med withdrawal
52
treatmetn algorithm for mild-mod | mod-sev start at 2
1. asa, ibuprofen, diclofenac, naproxen, acetaminophen 2. triptan (try at least 3 diff triptans) 3. triptan +nsaid 4. DHE + antinauseant 5. acet + codiene/tramadol
53
of nausea occurs or to improve efficacy use
metoclopramide or domperidone 10mg
54
treatment in pregnancy
``` non pharm acet metrocolopramide sumtriptan sometimes breast feeding the same except can use nsaids ```
55
when to consider prophylaxis
frequent, long lasting, severe CI or failure to acute therapu >2attacks per week (risk of MOH)
56
goals of migraine prophylaxis
reduce frequency by 50% | prevent transition from acute to chronic
57
prophylaxtic treatments
beta blockers antidepressant antiepileptic butterbur
58
beta blocker MOA
raises migrain threshold by modulating adrenergic system and serotonin transmission in cortical pathways of brain
59
first line beta blockers
propranolol 80-160mg metoprolol timolol
60
beta blocker SE and CI
fatigue, bradycardia, hypotension, cold, vivid dreams, bronchospasm asthma, heart block, heart failure, peripheral vascular disease
61
antidepressant MOA
downregulate central serotonin receptors increase synaptic NE enhances endogenous opioid receptor action
62
consider antidepressants in
comorbidities | depression, insomnia, neuropathic pain, tension headache
63
first line antidepressant
amitriptyline | venlafaxine
64
TCA SE
``` anticholinergic sedation weight gain orthostatic hypotension cardiac toxicity ```
65
TCA CI
``` heart block CVD urinary retention glaucoma prostate disease mani ```
66
avoid venlafaxine in
hypertension kidney failure serotonin syndrome risk
67
serotonin syndrome symptoms
``` agitation rapid HR confusion dilated pupils muscle rigid diarrhea shivering ```
68
effective anticonvulsant drugs
valproate topiramate gabapentin maybe
69
anticonvulsant MOA
enhance GAB modulate glutamate inhibit Na/Ca ion channel activity
70
role for anticonvulsants
second line prophylaxis | pateitns with bipolar, seizures, anxiety
71
valproic acid safety
``` NV alopecia tremor weight gain avoid in liver disease, bleeding disorder, pregnancy, obesity ```
72
topiramate safety
weight loss, paresthesia , fatigue, memory impairment | avoid in kidney problem, pregnancy, cognitive impairment, glaucoma
73
NHP with low-mod quality evidence for efficacy
``` butterbur - long term safety unknown coenzyme q10 magnesium riboflavin not a lto of SE ```
74
prophylactic treatment algorithm
beta blocker or antidepressant if one doesnt work try the other combo BB with anticonvulsant or TCA
75
pregnant prophylaxis
``` non drug magnesium propranolol nortriptyline lactation same but can use valproate ```
76
initiation of prophylactic treatment
start low and titrate to max dose
77
prodrome stage occurs when
24-48 hours before onset of headache
78
prodrome symptoms
``` neurological - difficulty concentraion anxiety, depression, fatigue food cravings, anorexia NVD just feel off ```
79
women with migraine with aura should be encouraged to
stop smoking control their BP use alternative method of contraception
80
migraine triggers
``` stress hormones weather sleep odor lights alcohol smoke heat food or no food sexual activity exercise ```
81
why take and antiemetic in acute therapy
(antiemetic bc gastric motility and drug absorption delayed during attack resulting in NV effect will be slower if delayed motility
82
counseling for SC triptan
to outside of thigh/upper arm do not load autoinjection until ready should see effect in 10min
83
counselling for intranasal triptan
do not prime 2.5mg in one nostril only onset in 10 min
84
ODT triptan counselling
``` may be taken without water keep in foli dont split may repeat after 2hr onset 30 min has aspartame ```
85
migranal nasal spray counseling
pump 4x into the air before first use 5.mg in each nostril may repeat in 15 minutes max4 sprays per attack
86
signs and symptoms of MOH
``` AM symptoms poor sleep quality neck pain poor response to acute meds using meds for 3 months >15 hedaache days per month ```

Clinical 2.0 winter (28 decks)

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