Migraine Kaakeh Exam 4

Question 1

What headaches fall into the vascular headaches category?

Answer 1

Migraines, cluster, non-migraine vascular and vascular

Question 2

What are some causes of secondary headache?

Answer 2

Trauma, aneurysm, neoplasm, systemic disorders, medication-induced

Question 3

What type of headache can wake people up at night with intense pain?

Answer 3

Cluster HA

Question 4

What type of headaches tend to be bilateral?

Answer 4

Tension headaches (can stem from chronic myositis and cervical osteoarthritis as well)

Question 5

True or false: It is common for migraine headaches to be preceded by an aura.

Answer 5

False – only 15% migraines

Question 6

What type of headache presents in a hangover?

Answer 6

Non-migraine vascular

Question 7

Why should caffeine be used cautiously in treating a migraine?

Answer 7

Sleep is often required to terminate migraines.

Question 8

What are the three theories of migraine pathophysiology?

Answer 8

Vasodilation, neurological (abnormal firing), and neurogenic dural inflammation theory (CGRF, substance P, NKA, NO)

Question 9

What gender is at higher predisposition for migraines? Cluster headaches?

Answer 9

Migraine – women

Cluster – men

Question 10

What are the five criteria for migraine with aura diagnosis? How many are needed for a diagnosis?

Answer 10

Gradual onset, mild-severe intensity
Reversible, aura lasts 5-60 mins
HA follows aura within 60 mins
Normal neurologic exam
Nausea/vomiting, photophobia, phonophobia
Need 3 of 5 and minimum 2 attacks ever

Question 11

What are the criteria for diagnosing migraine without aura? (minimum 5 attacks lasting 4-72 hours)

Answer 11

2 of: 
Unilateral, pulsating, moderate-severe intensity, aggravated by routine physical activity
1 of:
Nausea and vomiting
Phototobia and phonophobia

Normal neurologic exam too.

Question 12

What are prodrome migraine symptoms?

Answer 12

Fatigue and dizziness

Question 13

What are the positive and negative visual aura symptoms?

Answer 13

Photopsias, teichopsia (positive) and scotomas, heimaopias (negative)

Question 14

True or false: Sensory auras can be treated with OTC products.

Answer 14

False

Question 15

If a patient experiences an aura, when should migraine treatment be started?

Answer 15

At first sign of aura symptoms

Question 16

What are the two scoring systems for assessing migraine?

Answer 16

MIDAS (IV is high) and HIT-6

Question 17

True or false: Stratified care, where treatment agents are considered based on severity, is preferred in migraines.

Answer 17

True

Question 18

Acute migraine abortive therapy should be limited to ____ times per month.

Answer 18

2 times/month

Question 19

How does metoclopramide help in migraine?

Answer 19

Stimulates gastric emptying which helps with nausea and improves absorption of antimigraine agents. Metoclopramide + aspirin may even be more effective than triptans in some patients.

Question 20

How is metoclopramide dosed in migraine?

Answer 20

10mg PO at first sign of attack

Question 21

How should aspirin be used for migraine?

Answer 21

One 325-1000mg PO dose at first sign of attack then a6h prn. Do not use enteric coated (liquid/effervescent better). MAX 4 grams daily. Not for PUD patients.

Question 22

How is acetaminophen dosed in migraine?

Answer 22

1000mg PO at first sign of attack then 500mg PO q4-6 hours prn

Question 23

What is an IV NSAID used for migraine? Dosing?

Answer 23

Ketorolac 30-60mg IV/IM initially

Question 24

What is in excedrin migraine?

Answer 24

APAP 250mg, ASA 250mg, caffeine 65mg (max 4 tabs per day)

Question 25

Which combination product contains acetaminophen--fiorinal or fioricet?

Answer 25

Fioricet (aCETaminophen) | Fiorinal contains aspirin and is schedule III

Question 26

What opioid nasal spray can be used for migraine?

Answer 26

Butorphanol -- 1 spray in 1 nostril. Limit 4/day

Question 27

What pregnancy category are triptans?

Answer 27

C -- use only if potential benefits outweigh potential risk

Question 28

What triptan has the longest duration of action?

Answer 28

Frovatriptan (but slower onset)

Question 29

What triptan has especially good efficacy with low side effects?

Answer 29

Almotriptan

Question 30

Treximet is a combination product with sumatriptan and ______ synergistically.

Answer 30

Naproxen

Question 31

What conditions make triptans contraindicated?

Answer 31

CVD, CAD, PVD, uncontrolled HTN, hemiplegic/basilar migraines.

Question 32

What are the side effects for triptans?

Answer 32

Somnolence, nausea, dizziness, weakness, potential pain or pressure in chest, rare coronary artery vasospasm, angina, ventricular tachycardia or fibrillation, MI

Question 33

What major psychiatric drugs do triptans interact with?

Answer 33

MAOIs and SSRIs | In general, messing with 3A4.

Question 34

What triptan interacts strongly with propranolol?

Answer 34

Rizatriptan

Question 35

What are side effects of the ergotamines?

Answer 35

Cyanotic extremeties, ischemic bowel disease, renal dysfunction, N/V. CI: same as triptans plus renal impairment, hepatic disease, glaucoma, pregnancy Pregnancy X!

Question 36

What compound is added to every oral ergotamine product?

Answer 36

Caffeine | *not in SL products*

Question 37

How is dihydroergotamine dosed?

Answer 37

IV, IM, or SQ | 1-2 mg initially, increase to max 2-3mg/day. Max 6mg/week.

Question 38

How are the ergotamine SL tablets dosed?

Answer 38

1 2mg tab SL at first sign then 2mg q30 min PRN, max 6mg/day and 10mg/week

Question 39

What acute migraine treatment can be used in pregnant and breast feeding women?

Answer 39

Isometheptene + APAP + dichloralphenazone (sedative) (Midrin)

Question 40

What is one an advantage of isometheptene?

Answer 40

Advantage -- much safer than triptans and safe for pregnant women May try Midrin after NSAID and before triptan.

Question 41

How long must a headache last to be considered status migrainosus?

Answer 41

Headache for >72 hours

Question 42

How do you treat status migrainosus?

Answer 42

Sumatriptan SQ, accompanied with anti-emetic and IVF

Question 43

What is second line for status migrainosus after triptan failure?

Answer 43

DHE 1mg SQ or ketorolac 30mg IV with or without corticosteroid Haloperidol may be used. Avoid narcotics.

Question 44

When should migraine prophylaxis be considered?

Answer 44

If abortive therapies are used >2x/month or if vasoconstrictors contraindicated

Question 45

What are the four first line agents for migraine prophylaxis?

Answer 45

B-blockers, topiramate, tricyclic antidepressants, valproic acid

Question 46

What are first line agents for menstrual migraines?

Answer 46

Extended cycle oral contraceptive, intermitten estrogenn or NSAIDs

Question 47

What are the two beta blockers approved to reduce migraine severity?

Answer 47

Propraolol LA 80mg PO daily | Timolol 10mg PO BID

Question 48

How is topiramate dosed for migraine prevention?

Answer 48

25mg PO daily increased by 25mg every week to 100mg total. Risk of metabolic acidosis.

Question 49

What are the potential tricyclic antidepressants for migraine prevention?

Answer 49

Amitriptyline, doxepin, imipramine, nortriptyline, protriptyline, desipramine, trazodone Normally a lower dose than used for depression.

Question 50

TCAs are the drug of choice for...

Answer 50

Mixed headache syndrome (chronic daily headache) | 2-8 migraine attacks/month plus daily low grade tension headache

Question 51

What SSRIs prevent migraine?

Answer 51

Fluoxetine, sertraline, paroxetine

Question 52

What are characteristics of cluster headache?

Answer 52

Constant, unilateral pain in one eye orbit, nightly for weeks, same eye, extreme pain, autonomic symptoms (tearing, drooping, draining of nasal passage)

Question 53

What is the only approved treatment for cluster headaches?

Answer 53

Sumatriptan | Oxygen, meperidine, cocaine, DHE may be used

Question 54

What is another name for a medication-overuse headache?

Answer 54

Analgesic rebound headache.