Migraine Kaakeh Exam 4 Flashcards
What headaches fall into the vascular headaches category?
Migraines, cluster, non-migraine vascular and vascular
What are some causes of secondary headache?
Trauma, aneurysm, neoplasm, systemic disorders, medication-induced
What type of headache can wake people up at night with intense pain?
Cluster HA
What type of headaches tend to be bilateral?
Tension headaches (can stem from chronic myositis and cervical osteoarthritis as well)
True or false: It is common for migraine headaches to be preceded by an aura.
False – only 15% migraines
What type of headache presents in a hangover?
Non-migraine vascular
Why should caffeine be used cautiously in treating a migraine?
Sleep is often required to terminate migraines.
What are the three theories of migraine pathophysiology?
Vasodilation, neurological (abnormal firing), and neurogenic dural inflammation theory (CGRF, substance P, NKA, NO)
What gender is at higher predisposition for migraines? Cluster headaches?
Migraine – women
Cluster – men
What are the five criteria for migraine with aura diagnosis? How many are needed for a diagnosis?
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
What are the criteria for diagnosing migraine without aura? (minimum 5 attacks lasting 4-72 hours)
2 of: Unilateral, pulsating, moderate-severe intensity, aggravated by routine physical activity 1 of: Nausea and vomiting Phototobia and phonophobia
Normal neurologic exam too.
What are prodrome migraine symptoms?
Fatigue and dizziness
What are the positive and negative visual aura symptoms?
Photopsias, teichopsia (positive) and scotomas, heimaopias (negative)
True or false: Sensory auras can be treated with OTC products.
False
If a patient experiences an aura, when should migraine treatment be started?
At first sign of aura symptoms
What are the two scoring systems for assessing migraine?
MIDAS (IV is high) and HIT-6
True or false: Stratified care, where treatment agents are considered based on severity, is preferred in migraines.
True
Acute migraine abortive therapy should be limited to ____ times per month.
2 times/month
How does metoclopramide help in migraine?
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.
How is metoclopramide dosed in migraine?
10mg PO at first sign of attack
How should aspirin be used for migraine?
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.
How is acetaminophen dosed in migraine?
1000mg PO at first sign of attack then 500mg PO q4-6 hours prn
What is an IV NSAID used for migraine? Dosing?
Ketorolac 30-60mg IV/IM initially
What is in excedrin migraine?
APAP 250mg, ASA 250mg, caffeine 65mg (max 4 tabs per day)
Which combination product contains acetaminophen–fiorinal or fioricet?
Fioricet (aCETaminophen)
Fiorinal contains aspirin and is schedule III
What opioid nasal spray can be used for migraine?
Butorphanol – 1 spray in 1 nostril. Limit 4/day
What pregnancy category are triptans?
C – use only if potential benefits outweigh potential risk
What triptan has the longest duration of action?
Frovatriptan (but slower onset)
What triptan has especially good efficacy with low side effects?
Almotriptan
Treximet is a combination product with sumatriptan and ______ synergistically.
Naproxen
What conditions make triptans contraindicated?
CVD, CAD, PVD, uncontrolled HTN, hemiplegic/basilar migraines.
What are the side effects for triptans?
Somnolence, nausea, dizziness, weakness, potential pain or pressure in chest, rare coronary artery vasospasm, angina, ventricular tachycardia or fibrillation, MI
What major psychiatric drugs do triptans interact with?
MAOIs and SSRIs
In general, messing with 3A4.
What triptan interacts strongly with propranolol?
Rizatriptan
What are side effects of the ergotamines?
Cyanotic extremeties, ischemic bowel disease, renal dysfunction, N/V.
CI: same as triptans plus renal impairment, hepatic disease, glaucoma, pregnancy
Pregnancy X!
What compound is added to every oral ergotamine product?
Caffeine
not in SL products
How is dihydroergotamine dosed?
IV, IM, or SQ
1-2 mg initially, increase to max 2-3mg/day. Max 6mg/week.
How are the ergotamine SL tablets dosed?
1 2mg tab SL at first sign then 2mg q30 min PRN, max 6mg/day and 10mg/week
What acute migraine treatment can be used in pregnant and breast feeding women?
Isometheptene + APAP + dichloralphenazone (sedative) (Midrin)
What is one an advantage of isometheptene?
Advantage – much safer than triptans and safe for pregnant women
May try Midrin after NSAID and before triptan.
How long must a headache last to be considered status migrainosus?
Headache for >72 hours
How do you treat status migrainosus?
Sumatriptan SQ, accompanied with anti-emetic and IVF
What is second line for status migrainosus after triptan failure?
DHE 1mg SQ or ketorolac 30mg IV with or without corticosteroid
Haloperidol may be used. Avoid narcotics.
When should migraine prophylaxis be considered?
If abortive therapies are used >2x/month or if vasoconstrictors contraindicated
What are the four first line agents for migraine prophylaxis?
B-blockers, topiramate, tricyclic antidepressants, valproic acid
What are first line agents for menstrual migraines?
Extended cycle oral contraceptive, intermitten estrogenn or NSAIDs
What are the two beta blockers approved to reduce migraine severity?
Propraolol LA 80mg PO daily
Timolol 10mg PO BID
How is topiramate dosed for migraine prevention?
25mg PO daily increased by 25mg every week to 100mg total. Risk of metabolic acidosis.
What are the potential tricyclic antidepressants for migraine prevention?
Amitriptyline, doxepin, imipramine, nortriptyline, protriptyline, desipramine, trazodone
Normally a lower dose than used for depression.
TCAs are the drug of choice for…
Mixed headache syndrome (chronic daily headache)
2-8 migraine attacks/month plus daily low grade tension headache
What SSRIs prevent migraine?
Fluoxetine, sertraline, paroxetine
What are characteristics of cluster headache?
Constant, unilateral pain in one eye orbit, nightly for weeks, same eye, extreme pain, autonomic symptoms (tearing, drooping, draining of nasal passage)
What is the only approved treatment for cluster headaches?
Sumatriptan
Oxygen, meperidine, cocaine, DHE may be used
What is another name for a medication-overuse headache?
Analgesic rebound headache.
