Migraine/headache Flashcards
migrain is more a ___ disorder than a vascular
neurological
what is cortical spreading depression phenomenom
self propagating wave of enuronal and glial depol that spreads across the cerebral cortex
suppression of brain activity across the cortex
what does cortical spreading depression cause
migraine aura
activate trigeminal nerve afferents
disrupt BBB permeability
how does sensitization contribute to migrains
nerves becomes more responsive to stimuli
peripheral vs ccentral sensitization
peripheral occurs in primary afferent neurons causing greater migrain symptoms
central in 2nd order neurons resulting in greater conversion of episodic to chornic migrain?
what role does serotonin have in migrains
just know activation of serotonin receptors is important for acute migraines
migrain subtypes
acute episodic chronic vestibular menstrual retinal hemiplegic (paralysis of one side of body)
signs of migrain headache
stable pattern positive fmaily history normal neurologic exam food triggers menstrual association improve with sleep long standing history
prodrome features
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
migrain aura time frame and symptoms
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
describe a typical migrain headache
unilateral throbbing, pulsating attack progressively and worsens NV photophobia/phonophobia osmophobia(sensitive to smell) and cutaneous allodynia mod - sev pain intensity
red flags
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)
symptoms warranting meuroimaging
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
what is migrainous infarction
rare complication of migrain
mostly occurs in the posterior circulation in younger women with a history of migraine with aura
ischemic stroke??
risk of ischemic stroke significantly increased in which type of people with migraines
women <45yoa smokers who have aura oral contraceptives who have aura previous hostory of stroke >12 headaches per year
examples of migrain triggers
stress hormones weather sleep disturbance odor heat food
non pharms
avoid triggers rest in dark quiet room headache diary relaxation techniques cbt cold/heat packs hydration routine regular meals caffiene balance
goals of acute therapy
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
reasons to treat the headache early
reduce overal burden of migrain
reduce likelihood of central sensitization
challenges to treating headaches early
some avoid meds unless headache is severe
fear of overuse
drugs for acute and when to take them
triptan ergot derivative nsaids acetaminopehn domperidone, metoclopramide best taken at onset of head pain
role of triptans
mod-sev migraines first line
reduce NV, photo and phonophobia
if dont respond is there a benefit in switching
yes
space 24h
triptans CI in
CAD
severe liver disease
some caution in renal
triptan MOA
vasoconstrictor
inhibits neurogenic inflammation peripherally prevents central sensitization
most common triptan coverage
EDS2
when would you use subcutaneous sumatriptan
use if headache builds rapidly or is accompanied by early NV
which formulations are good in NV
ODT
intranasal
SC
oral triptan onset and duration
start working in 30-60min
last 2-4 hr
which triptans have a slower onset (better tolerated) and longer duration
naratriptan
frovatriptan
use if have long migraines
triptans with sulfonamide moiety
suma
nara
triptans with sulfonyl group
ele
frova
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
triptan common SE
paresthesia fatigue dizzy fatigue warm somnolence
triptan sensations are
mild transient burning, tingling, tightness, pressure, heaviness, pain
serious rare triptan SE
MI, cornoary vasospasm with ischemia
serotonin syndrome
see doctor if lasts more than 20 min
triptan contraindications
cerebrovascular disease IHD uncontrolled HTN PVD hemiplegic or basilar migraine
ergot actions
non selectiv serotonin agonist
alpha and beta agonist
dopamine D! and D2 agonist
dihydroergotamine dosage forms
SC
IM
IV
common ergot SE
NV - pretreat with antiemetic ab pain weak, fatigue paresthesias muscle pain diarrhea chest tightness NAUSEA!!
serious ergot SE
severe peripheral ischemia - cold numb, pain, claudication
gangerenous extremities
MI
bowel and brain ischemia
ergot CI
cardiac/cerebrovascular disease
uncontrolled HTN
pregnant
hemiplegic or basilar migrani
role of acetaminopehn
acute treatment fo mild to mod
contraidications to nsaids
best if taken early
better than placebo
acetaminophen MOA
may block prostaglandin synthesis in CNS and pain impulse generation in the periphery
NSAIDs role
acute migrain treatment of mild-mod severity
nsaids MOA
prevent inflammation in the trigeminovascular system via prostaglandin synthesis inhibition
why avoid fiorinal
contains butalbital which causes rebound headaches
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
what is medication overuse headache
acute meds used lots over several months
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**
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
treatmetn algorithm for mild-mod
mod-sev start at 2
- asa, ibuprofen, diclofenac, naproxen, acetaminophen
- triptan (try at least 3 diff triptans)
- triptan +nsaid
- DHE + antinauseant
- acet + codiene/tramadol
of nausea occurs or to improve efficacy use
metoclopramide or domperidone 10mg
treatment in pregnancy
non pharm acet metrocolopramide sumtriptan sometimes breast feeding the same except can use nsaids
when to consider prophylaxis
frequent, long lasting, severe
CI or failure to acute therapu
>2attacks per week (risk of MOH)
goals of migraine prophylaxis
reduce frequency by 50%
prevent transition from acute to chronic
prophylaxtic treatments
beta blockers
antidepressant
antiepileptic
butterbur
beta blocker MOA
raises migrain threshold by modulating adrenergic system and serotonin transmission in cortical pathways of brain
first line beta blockers
propranolol 80-160mg
metoprolol
timolol
beta blocker SE and CI
fatigue, bradycardia, hypotension, cold, vivid dreams, bronchospasm
asthma, heart block, heart failure, peripheral vascular disease
antidepressant MOA
downregulate central serotonin receptors
increase synaptic NE
enhances endogenous opioid receptor action
consider antidepressants in
comorbidities
depression, insomnia, neuropathic pain, tension headache
first line antidepressant
amitriptyline
venlafaxine
TCA SE
anticholinergic sedation weight gain orthostatic hypotension cardiac toxicity
TCA CI
heart block CVD urinary retention glaucoma prostate disease mani
avoid venlafaxine in
hypertension
kidney failure
serotonin syndrome risk
serotonin syndrome symptoms
agitation rapid HR confusion dilated pupils muscle rigid diarrhea shivering
effective anticonvulsant drugs
valproate
topiramate
gabapentin maybe
anticonvulsant MOA
enhance GAB
modulate glutamate
inhibit Na/Ca ion channel activity
role for anticonvulsants
second line prophylaxis
pateitns with bipolar, seizures, anxiety
valproic acid safety
NV alopecia tremor weight gain avoid in liver disease, bleeding disorder, pregnancy, obesity
topiramate safety
weight loss, paresthesia , fatigue, memory impairment
avoid in kidney problem, pregnancy, cognitive impairment, glaucoma
NHP with low-mod quality evidence for efficacy
butterbur - long term safety unknown coenzyme q10 magnesium riboflavin not a lto of SE
prophylactic treatment algorithm
beta blocker or antidepressant
if one doesnt work try the other
combo BB with anticonvulsant or TCA
pregnant prophylaxis
non drug magnesium propranolol nortriptyline lactation same but can use valproate
initiation of prophylactic treatment
start low and titrate to max dose
prodrome stage occurs when
24-48 hours before onset of headache
prodrome symptoms
neurological - difficulty concentraion anxiety, depression, fatigue food cravings, anorexia NVD just feel off
women with migraine with aura should be encouraged to
stop smoking
control their BP
use alternative method of contraception
migraine triggers
stress hormones weather sleep odor lights alcohol smoke heat food or no food sexual activity exercise
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
counseling for SC triptan
to outside of thigh/upper arm
do not load autoinjection until ready
should see effect in 10min
counselling for intranasal triptan
do not prime
2.5mg in one nostril only
onset in 10 min
ODT triptan counselling
may be taken without water keep in foli dont split may repeat after 2hr onset 30 min has aspartame
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
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
