Migraine Rx Flashcards
MTS Activity aggravates Pain Location Photo/phono
Y, N, Y
Mod to s, mild to mod, mild to sev
Uni, bi, uni
Usually, rarely, rarely
MTS Duration Congestion Positional sensitivity Nausea
3 hr to 3 days, as long as 7 days, infection
Sometimes, rarely, always
No, No, Yes
Usually, rarely, rare
Migraine cause/quality and novel
Idiopathic recurring and 4-72 hrs/attack
Mod to severe pain, unilateral pulsating
Photophobia, nausea, aggrevated by activity, alleviated by sleep
Migraine diagnosis
Severe enough to affect daily life
> 5 attack w/o aura or >2 with
2 or more: unilaterla, pulsating, mod to severe pain, aggravation
At least 1: N, V, photo, phono
3 questions for migraines
Do your headaches limit daily activitive or cause diabilities for a day or more? Has this happened in last 3 months?
Do you feel N/V when HA?
Does light bother you?
POUND
Pulsatile Ongoing duration (4-72) unilateral location N/V Disabling intensity
Women and migraine
Is with aura, increased stroke risk…contraceptive further inceases risk
Comorbidities of migraines
Depression and epilepsy
also more in women
Vascular pathophys
Initial vasoconstriction leads to early aura…responsive vasodilation leads to pain
Spreading depression pathophys
Hyperactive activity release to release/stimulation of trigeminal nerve
Spreads across surface (aura) as a wave
Vascular changes that lead to localized hypovolemia/hypoxia and pain driven by neuronal changes
unifying sterile neurogenic inflammation pathphy
BS hyperexcitiability drives trigeminovascular system
Reelease of substance P, CGRP, and other noxious signals…stimulated nociceptors become sensitized, responding to all sensory input as pain
Affarnets are stretch nocicpetors on meningeal BV
Efferents release agents
Why does light increase pain
Non imaging formaing retinal ganglion cells
Modulate dura sensitive posterior thalamic neurons that innervate somatosensory, visual, and association cortixes
Vascular hypothesis as related to triptans
Unique 5HT receptors localized to carotid AVAs…triptans squeeze the precapillary sphincters to prevent blood flow back
Sumatriptan
Good in 75%
Almost exclusively for migraines
Selevtive vasoconstrictor for meninges and inhibits 5HT release from neurons
Triptan action on neurons
In addition to constriction
Presynaptci autoreceptor agonist…reduces 5HT release (main anti-migraine effect)
On trigeminal nerve may reduce release of pro-inflam agents
In CNS, may facilitate anti-nociceptive input from BS to cortex
Sumatriptan, when to take, side effects, contra
As soon as possible after HA detected
Chest pressure and tightness
Strong with coronary artery dz…weak with MAOI or SSRI
Frovatriptan
Super long 1/2 life compared to others
Ergotamine dosing, complications, mech
Oftne with caffeine…tx as early as possible and is abortive
Narrow therapeutic window
Variable GI absorption
O/D
Toxocivity
Through 5HT system…D2 receptor agonist so need metoclopromide to counter the N/V
DHE
Admin ASAP
Better than ergotamine
Erratic absorption
Triptan, ergot, MOH side effects
Triptans - chest tightening
Ergot - vasospasm/gangrene, hallucinations, abortion
MOH - often with opiodids
Chronic migraine
> 15 migraines per months
Look ofr med overuse
Withdraw
Transition therapy to support during detox
INitiate prophylaxis
intractable migraine
Resistant to tx
24-72 prior to ER
Longer is harder to tx
Intractable migraine tx
1st line is what was best in the pat
Could use sumatriptan or DHE
Prophylaxis of migraine
B blockers (propanolol) Anti-epileptic (valproic acid/topiramate) TCA Antidepressants (amitriptyline)
Prophy vs. acute
Prophy - start low and go high
Acute- start high and go low…tx early not often
Serotonin syndrome
Hypertension, hyperreflexia, tremor, clinus, diarrhea, mydriasis, agitation
Discontinue agents and 5HT2 block
For triptans, headache society says SSRI/SNRI plus triptan has not greater risk than SSRI/SNRI alone
