Migraine Headaches Flashcards
What is the proposed mechanism of Migraine Development?
Potent vasodilators (ie. CGRP, NO) released, inflammatory reactions also take place in the brain & induces pain.
How do Triptans work?
Selective Serotonin Agonists; Act as Potent Vasoconstrictors!!!
Auras occur in what percentage of migraine patients?
30%
What can trigger a migraine?
-Stress
-Skipping Meals
-Cheese / Chocolate
-Alc (espec. Red Wine)
-Dehydration
-Scents
-Barometric Pressure
-Caffeine (can be both withdrawal / overuse)
What is the “POUND” pneumonic?
P - Pulsatile Headache
O - One Day Duration
U - Unilateral Headache
N - Nausea & Vomiting
D - Disabling Pain
-0 to 2pts = 17% likelihood of migraine.
-3pts = 64% likelihood of migraine.
-4 to 5pts = 92% likelihood of migraine.
What NSAID demonstrates the best efficacy for acute pain relief in mod - severe migraines?
Ibuprofen
Order the following Triptan dosage forms by efficacy:
IN
SC
Oral
SC > IN > Oral
Is there a statistical difference in efficacy for migraine pain relief between Ace 1000mg + Metoclopramide vs. Oral Sumatriptan?
NOPE
Is it necessary to follow ordered step-up therapy advancements in those with migraines?
Nope… Can jump straight to Sc Sumatriptan (ie. Step 4) if attacks are extremely rapid & early vomiting.
KEY IS TO INDIVIDUALIZE
Is Naproxen Base (ie. Apo-Naproxen or other Generics) or Naproxen Sodium (ie. Aleve) better?
Naproxen Sodium… Quicker OOA (30mins).
NSAIDs with or without food: Which is preferred for migraines?
Without… Usually TWF, but this would delay OOA (faster OOA on an empty stomach means quicker migraine pain relief).
Which Triptans have a slow OOA & long DOA?
Naratriptan, Frovatriptan
All others are fast OOA!
What is the benefit of combining Metoclopramide with Triptans / NSAIDs / Acetaminophen?
Is an anti-emetic (so helps with nausea via Dopamine Receptor Antagonism), speeds up GI motility (enhances the speed & degree of SI absorption of the other drugs).
If a patient is prone to water-induced vomiting upon taking oral agents for migraine treatment, what can we do?
-IN Triptans
-ODTs
What are the primary benefits of migraine prophylactic treatments?
-Migraine frequency reduced.
-Decrease in migraine intensity (drugs don’t have to work as hard).
How does Dihydroergotamine (DHE) work?
Serotonin Receptor Agonist (similar to Triptans induces vasoconstriction)… However, is dirty (hits many others).
Why do we avoid Opioids in migraine treatment?
Doubled risk of Medication Overuse Headaches, increased OD risk.
Why do T3 tablets suck ass for treating migraines?
-2x Med Overuse Headaches.
-Subtherapeutic Caffeine (15mg «< 100mg), Ace Doses (300mg «< 1000mg).
-Codeine Metabolism is unpredictable (2D6 polymorphisms).
Even though T3s suck ass, why do Doctors love them so much?
Very cheap (9 cents per pill).
When would Triptans be contraindicated?
-Uncontrolled HTN
-Previous MI / Stroke
-Generalized CVD
-Ergot use within 24hrs
-MAOIs
Side effects of Triptans?
-Chest Tightness
-Palpitations
-Dizziness
-Facial Flushing
-Nausea
How are Triptans dosed?
100mg at onset of migraine; Repeat in 2hrs PRN (200mg = Daily Limit).
Note that this is for Sumatriptan… Rizatriptan more commonly 10mg at onset & repeat in 2hrs with daily limit of 20-30mg.
Is nausea completely avoided by using an injectable Triptan?
Nope… But definitely reduced.
Which Triptan has the longest t1/2?
Frovatriptan (25hrs)
-Naratriptan is 6hrs… Fast Acting ones are 2-3hrs.
What other add-on therapy in migraine treatment works in the same manner as Metoclopramide?
Domperidone
What added benefit does Domperidone have over Metoclopramide?
Cannot cross BBB… Dopamine Blockade in the brain unachievable, so we avoid Pseudo-Parkinsonism symptoms (ie. Tremor, Movement Disorders).
What is the 3x3 Triptan rule?
-Try for three migraines, try three different Triptans before giving up on the class! These drugs are highly individualized, so a particular Triptan may work well for one person & not at all for another.
ODT Triptans take _____ (more or less) time to work than Regular Oral Triptans.
More; ODTs are not SL in nature, so lots of drug lingers around in the mouth (thus increasing absorption time).
The rule of thumb (in terms of days per month) for likely diagnosis of Medication Overuse Headaches is what?
> 15d / mth
Give the max number of drug days (not doses) per month that you can use these meds without worry of MOH:
Triptans
Opioids
NSAIDs / Ace
Triptans: 9d
Opioids: 9d
NSAIDs / Ace: 14d
What options do we have for Menstrual Migraine pre-treatment?
-Naproxen 500mg BID x 6d
-Naratriptan 1mg BID x 6d
-Frovatriptan 2.5mg BID x 6d
-Estradiol Gel 1.5mg OD x 7d
Of the four provided Menstrual Migraine pre-treatment strategies, which one demonstrates greatest efficacy?
Frovatriptan (but also $$$).
Ubrogepant dose?
50-100mg
Atogepant dose?
10-60mg
What advantage do CGRP Receptor Antagonists (ie. ‘gepant’ drugs) have over Triptans?
CAN BE USED SAFELY IN CVD!!!
Who should consider migraine prophylaxis?
- > 6 headache days / mth.
- > 3 severely disabling attacks / mth.
-Acute treatments don’t work well or are CI.
What four drugs demonstrate best efficacy in migraine prophylaxis?
Amitriptyline, Propranolol, Metoprolol, Topiramate
If a patient is put onto Amitriptyline for migraine prophylaxis, when would we expect to see tolerance development to nuisance anti-cholinergic side effects?
3 - 10d
Which prophylactic migraine agents demonstrate the fewest adverse effects?
Candesartan, Magnesium, Riboflavin
If a patient desires migraine prophylaxis & additionally smokes, what would be a suitable product?
Nortriptyline
If a patient desires migraine prophylaxis & is an Insomniac, what would be a suitable product?
Amitriptyline
If a patient is hypertensive and experiences migraines, what would be a suitable ACEi or Ca2+ Channel Blocker to use for prophylaxis?
Lisinopril (ACEi) or Verapamil (Ca2+ Channel Blocker)
If a patient wants migraine prophylaxis & also has concurrent depression, what would be suitable agents?
Venlafaxine, Duloxetine, Amitriptyline (potentially)
What is the proposed theory behind using Beta Blockers (ie. Propranolol, Metoprolol) in migraine prophylaxis?
Precursor vasodilation relaxes vessels prior to migraine onset… Less capacity for dilation = Less blood rushing suddenly into the brain.
Why are Propranolol & Metoprolol considered the best Beta Blocker agents for migraine prophylaxis?
Most lipophilic = Better BBB Penetrance.
What pneumonic describes the difficult discontinuation process of SNRIs?
“FINISH”
F - Flu-Like Symptoms
I - Insomnia
N - Nausea
I - Imbalance
S - Sensory Disturbances
H - Hyperarousal
Does it make sense to combine Verapamil with a Beta Blocker for strengthened prophylaxis against migraines?
NOOOOO… Can precede Heart Block & Conductance issues!
When utilizing herbals (ie. Magnesium Citrate / Oxide, Riboflavin) for migraine prophylaxis, do we need to titrate doses?
Nope… Can jump straight to target dose!
With long-term use, what is the proposed MOA in migraine prophylaxis for TCAs?
Downregulation of Serotonin Receptors = Less likely migraine cascade!
If initiating someone on a Biologic for migraine prophylaxis (ie. Fremanezumab, Eptinezumab, Erenumab, Galcanezumab, “Gepant” drugs), how long does it usually take for full effects?
24wks
What “Gepant” drug is indicated in Canada for Acute Migraines? Migraine Prophylaxis?
Ubrogepant - Acute
Atogepant - Prophylaxis
Target Beta Blocker doses for migraine prophylaxis?
Propranolol: 80mg BID, 160mg (if LA Tablet).
Metoprolol: 100mg BID, 200mg (if SR Tablet).
Target Amitriptyline dose for migraine prophylaxis?
75mg HS (jump to 100mg if it’s tolerated).
Target Nortriptyline dose for migraine prophylaxis?
50mg HS (jump to 100mg HS if tolerated)
Target Topiramate dose for migraine prophylaxis?
50mg BID
Target Candesartan dose for migraine prophylaxis?
16mg OD
Target Magnesium Oxide dose for migraine prophylaxis? Magnesium Citrate dose?
Oxide: 500mg OD Elemental (2T OD)
Citrate: 300mg BID (2T BID)
Target Fremanezumab dose for migraine prophylaxis?
225mg Sc q4wks
OR
675mg Sc q12wks
Target Riboflavin dose for migraine prophylaxis?
400mg OD
Does Botox help with Episodic Migraines (< 15d / mth)?
Nope… But, seems to help with Chronic Migraines (> 15d / mth).
Propranolol slows Rizatriptan metabolism & thus increases its levels by ____%.
70%
If a patient is on both Propranolol & Rizatriptan, what Rizatriptan dose should they take?
5mg (NOT 10mg too much).
What’s one concern with CGRP MABs?
Development of resistance to the drug (via AB generation against the drug itself due to long windows between doses).
Provincial Drug Plan / NIHB coverage of certain CGRP MABs is limited to who?
Those who have failed at least two oral prophylactic agents.
What is the average patient response rate to CGRP MABs?
40%
CGRP Receptor Antagonists are good to use in those with CVD (are not a CI). However, are CGRP MABs good to use in CVD?
Probably not… Can invoke HTN & CV patients were excluded from trials!
What are some adverse effects of the “gepant” drugs?
Nausea & Somnolence
Provide some red flag symptoms of Acute Headache that warrant calling an ambulance.
-Impaired Speech
-Fever / Neck Stiffness
-Thunderclap Headache
-Ocular Symptoms
-Loss of strength or fading in out of consciousness
Provide some red flag symptoms of Acute Headache that warrant physician referral.
-1st ever intense headache
-Headache from sex / exercise
-Over 50yrs age
-HIV / Cancer / Lyme Dx / Pregnant
-Papilledema
-Old & Cognitive Disturbances
Describe what a migraine headache is.
-4 to 72hr duration
-Unilateral (40% bilateral)
-Pulsating, Mod to Sev Pain
-NV / Photo or Phonophobia
-Can be aggravated by routine activities
-Potential Aura presence
-Potential Speech Disturbance
Describe a Tension Headache.
-30mins to 7d duration
-Typically bilateral
-Pressing / Tightening (BUT NOT PULSATING) Pain; Mild - Mod intensity
-Photo / Phonophobia
-Absence of NV
-Typically not aggravated by routine activity
Describe a Cluster Headache.
-15mins to 3hrs Duration
-Behind the Eyes Origin
-Stabbing Pains; Sev - Excruciating Intensity
-Frequency of Occurrence Bi-Yearly
-Eyelid Tearing / Swelling, Facial Sweating, Pupillary Constriction, Eyelid Drooping
Acute treatments for Tension Headaches? Prophylaxis?
-NSAIDs (Acute)
-Acetaminophen (Acute)
-TCAs (Pro)
Acute treatments for Cluster Headaches? Prophylaxis?
-Sc Suma (Acute)
-Verapamil (Pro)
In Medication Overuse Headaches, how long can withdrawal symptoms last?
Generally 2-10d, but can last up to 2-4wks in some.
When is meaningful headache frequency improvement demonstrated in those who have MOHs?
4-8wks after drug discontinuation.
Three main strategies for addressing MOHs?
1) Stop overused meds abruptly.
2) Stop / taper overused meds & start prophylaxis.
3) Start prophylaxis only & do nothing to overused meds.
On average, the three MOH treatment strategies reduce headache frequency by how many days per month?
8 - 12d / mth
