Migraine headaches Flashcards by Christine Hsu

migraine with brainstem aura or Basilar type migraine

history of migraine who presents with an occipital headache and brainstem symptoms and a normal MRI .

rare subset of migraine characterized by aura with brainstem symptoms (vertigo dysarthria and ataxia) without motor symptoms

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basilar aura symptoms that can be seen in migraine with brainstem aura

vertigo

dysarthria

tinnitis

diplopia

bilateral visual symptoms

hypacusis - impaired hearing

ataxic gait or speech

impaired consciousness

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typical migraine aura symptoms presentation

visual (flickering light diagonal lines)

sensory numbness

aphasia

(don’t give OCP’s to pts with migraine with aura due to increased risk for stroke and cerebral vein thrombosis)

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migraine headache location

occipital

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diagnosis of migraine with brainstem aura

must have 2 basilar aura symptoms to be considered basilar type migraine or migraine with brainstem aura

these symptoms must be fully reversible and negative MRI

also occipital headaches may suggest diagnosis but do not need to be present

Need a MRI of brain and MR angiography of head and neck to rule out posterior vascular lesions. (like aneurysm)

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differential for migraine with brainstem aura

mimics dysfunction of posterior cerebral circulation so need to consider:

TIA,

basilar aneurysm,

temporal lobe epilepsy

benign paroxysmal positional vertigo.

Need a MRI of brain and MR angiography of head and neck to rule out posterior vascular lesions.

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how to treat migraine with brainstem aura

after vascular lesions have been ruled out, treat with antiemetics, non vasoconstricting agents (NSAIDS) NO triptans (ergotamine derivatives) , beta blockers in migraine with brainstem aura because can lead to vasoconstriction and ischemia in the vertebral basilar system.

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what is contraindicated in treatment of basilar migraine or migraine with brainstem aura

NO triptans (ergotamine derivatives), beta blockers in migraine with brainstem aura

they can lead to vasoconstriction and ischemia in the vertebral basilar system.

only use NSAIDS and anti emetics

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what can be used for chronic prevention of migraine with brainstem aura?

verapamil and alternatives include lamotrigine and amitriptyline and topiramate

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what is contraindicated in women with migraine with aura

no OCPs, increases their risk for stroke and cerbral vein thrombosis

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treatment of pregnant woman with migraine headache?

tylenol.

Can give hydration, massage, ice packs if not responding to tylenol can get antiemetic Metoclopramide, codeine, caffeine and butalbital.

(try to avoid given risk for overuse headache.)

Naproxen - end line - can be used in short bursts but have severe toxicity in 1st and 3rd trimesters

Stronger opioids 3rd line- not picked because habit forming and can worsen N/V and constipation in pregnancy.

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what medications for migraine headaches are contraindicated in pregnant women?

ergotamine (risk for inducing hypertonic uterine contractions and vasoconstriction which can lead to adverse fetal effects)

triptans (sumatriptan) can be considered for refractory dx in pregnant pts but contraindicated due to increased risk for vasoconstriction of uteroplacental vessels, increased uterotonic activity and preterm delivery and low birth weight.

topiramate is absolutely contraindicated in pregnancy.(depending on source)

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can we use topiramate for pregnant pts with migraine?

no. absolutely contraindicated.

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preventative medications for migraine?

topiramate,

divalproex sodium (vaproic acid)

tricyclic antidepressants

beta blockers (propranolol)

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what medications or therapies stop/abort migraine headaches once they start?

abortives are:

triptans (sumatriptan)

acetaminophen

NSAIDS (naproxen)

Antiemetics (metoclopramide, prochlorperazine) ergotamines (dihydroergotamine)

better to treat sooner as opposed to during the peak of pain.

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when to provide migraine prophylaxis or preventative meds for migraines?

recurrent migraines >4 per month, lasting 12 hrs, or significant impairment with migraine headaches

what is 1st line for prevention of migraine headaches?

topiramate is best choice for young pt because of mild side effect profile good for people who have concurrent seizures

helps with weight loss

what are the side effects of topiramate for migraine prophylaxis?

paresthesia,

fatigue,

weight loss.

best though for people who have depression or mood disorders, low risk for hyponatremia and lower risk for fetal teratogenicity.

topiramate should be used cautiously in pts with

kidney stones

women who could be pregnant (category D) drug

can we use propranolol in migraine prophylaxis?

who should we avoid using propranolol in?

yes

try to avoid in pts >60 yrs old

those with existing lung dx or those who smoke (for risk of bronchospasm)

when do we use verapamil for headache?

can use with migraine with basilar aura

meant for prophylaxis for cluster headache not really used in migraine prophylaxis except in women of childbearing or pregnant due to safety in pregnancy.

migraine headaches

have photophobia, phonophobia, nausea - these are not seen in paroxysmal hemicrania migraines also tend to switch side of head and migrate and last 4-72 hrs.

chronic migraine headache is:

headache for 15 or more days per month

acute migraine management:

try to eliminate pain and restore function lots of variation in response and symptoms so most pts benefit from two or more acute migraine therapies. Better to take medication early as opposed to when there’s moderate to severe headache.

Treatment of migraine headache should be limited to

\<10 days a month to medication overuse headache

1st line treatment for migraine headaches:

combination of analgesic agents - tylenol with metoclopramide aspirin alone or with combo tylenol and caffeine NSAIDS also help

when do we start to use triptans for treatment of acute migraine headache?

when there's been at least 3 migraine headaches that don't respond to NSAIDs or tylenol can use oral triptans (all have similar clinical efficacy) Nasal sprays have fastest onset to working.

Contraindications to use of triptans:

anyone with CAD, CVA, or PAD uncontrolled HTN migraine with brainstem or hemiplegia auras (due to blood vessel spasms) vasculitis pregnant pt

are triptans ok to use with someone who is on a SSRI?

yes it's ok

we don't like opioid and butalbital containing compounds for acute migraine because of

**potential for dependence** and also risk for transformation of e**pisodic migraines to chronic migraine headaches**

status migraninosus is defined as

**migraine headache that is \>72 hrs long** need to be treated with several days of steroids may need ED or inpatient management. There they can get a dopamine antagonist **(metoclopramide or prochlorperazine) IV +** IV **diphenhydramine** and IV ketorolac and hydration.

when do we consider migraine prophylaxis and when do we start migraine prophylaxis what if there's \<15 headache/month what if there's \>15 headache/month

when at least \>5 headaches a month or \>2 headaches per week **start migraine prophylaxis when there's \>10 days per month with migraine** _if headaches \<15 days a month_ use **beta blockers, topiramate, sodium valproate, amitriptyline** _if \>15 days a month_ use **topiramate** or **botox** and if this doens't work **use erenumab**

how long does it take for migraine prophylaxis to work? How long to keep pt on migraine prophylaxis?

it can take several weeks to months to start working Keep them on medication for 6 to 12 months before considering to stop or taper it down

migraine prophylaxis drugs are:

3 beta blockers: propranolol, timolol, metoprolol two antiepileptic drugs **: divalproex sodium** and **topiramate** 2nd line **atenolol amitriptyline** and **venlafaxine** and several NSAIDs. some say you can use riboflavin or coenzyme Q10

when to hospitalize a patient for migraine headache

for **severe acute migraine** or **status migrainosus** (attacks \>72 hrs) Need to give **IV dopamine antagonists**, prochlorperazine or metoclopramide. Can combine with **IV benadryl and ketorolac** or hydration. can see MRI findings of acute punctate white matter lesions.

fastest relief for migraine headache

subcutaneous sumatriptan serotonin receptor agonist binds to 5hT1d receptor

status migraninosus treatment:

IV dopamine antagonist (**metoclopramide or prochlorperazine)** + **IV diphenhydramine** (to prevent acute dystonic reactions) If last sumatriptan was \>24 hrs then can give IV dihydroerphtamine.

treatment of migraines in pregnant woman?

**tylenol** if not working then can give **metoclopramide or chlorpromazine or ondansetron** (zofran)

Who is topiramate a good choice for in terms of migraine prophylaxis?

good for pts who hare overweight (it can cause weight loss)