Migraine tx Flashcards
Migraine types
-without aura (common)
-with aura (classic)
Migraine without aura
->5 attacks
-4-72 hour HA
-unilateral pulsating, mod-severe pain, aggravation
-NV
-photo/phonophobia
migraine w Aura
->2 attacks
-at least one fully reversible aura
-no aura lasting more than 60 min
-HA follows within 60 min
-visual, sensory, speech/language, motor, brainstem, retinal
Migraine phases
- Prodrome
- Aura
- Migraine
- Postdromal
Prodrome
-hours/days before onset
-euphoria, depression, irritability, appettite, constipation, eck stiffness, yawning
- Aura
-mostly visual
-before or during migraine
-<60min
-phatopsia (floater/flash of light)
-Scotoma (blind spot)
-zigzag lines, numbness/tingling in arms, legs, face
- Migraine
-dull ache that worsens
-unilateral, throbbing
-phono/photophobia
- Postdromal
-may last several days
-tired, head pain, GI distress, mood changes, weakness, cognitive difficulties
Migraine Triggers
-med overuse (analgesics, ergots, triptans): rebound headaches
-meds (oral contraceptives, hydralazine, nitroglycerin, nifedipine, cocaine)
-diet: chocolate, oranges, tomatoes, onions, alc, caffeien, aspartame and MSG
-weather, alt, tobacco, lights
-irreg sleep and eating, stress, hromones
Limit analgesic use
-try to use abortive tx only 2-3x week
Abortive tx
-acute tx
-educate on med overuse
-mild-mod: analgesic
-mod-severe: triptans and ergots
-triptans
-ergots
-CGPR (-gepant) also preventative
-lasmiditan
-butorphanol nasal spray
Preventative tx
-for 4+ attacks/month w disabilities 3 days/month
-use of abortive meds >2x week
-adequate trial of at least 8 weeks preventative tx for partial response
Abortive tx guidelines
- triptans and NSAIDs
- NSAIDs
Preventative tx guidelines
- valproate, topiramate, metoprolol, propranolol, frovatriptan
- amitriptylline
3…
Non-pharma migraine tx
-biofeedback/relaxation therapy
-CBT
-diet
-sleep
-transcutaneous electrical nerve stimulation device
-exercise/accupuncture
-headache diary
Triptan MOA
-ABORTATIVE only
-selective 5-HT1b and 5-HT1D receptor agonists
triptan contraindications
-use of ergot or other triptan within 24h
-MAO-A in last 2 weeks(frova, rizatriptans)
-IHD, angina, hx stroke
-hemiplegic.basilar migraine
-arrhythmias
-uncontrolled HTN
-IBD
-severe hepatic impairment
Triptan warnings
-MI tightness in chest up to jaw
-CVA, HTN
-GI rxn
-peripheral vasospasm
-med overuse headache
-serotonin syndrome
-sulfa allergy
-corneal opacities
-sz
Triptan side effects
-tingling
-dizziness
-drowsiness
-fatigue
-chest pressure
-flushing
Triptan drug interactions
-SSRI/SNRI risk of serotonin syndrome (rare)
-AVOID 3A4 inhibitors w eletriptan
Eletriptan warning
0AVOID strong 3A4 inhibitors
Ergot MOA
-stimulate a receptor
-dec vasc tone via vasoconstriction
Ergot contraindications
-risk of CHD
-avoid 3A4 inhibitors
-uncontrolled HTN
-hepatic/renal impairment
-peripheral vasc disease
Ergot warnings
-box warning for peripheral ischemia
-cardiac valvular fibrosis
-vasospasms/constriction
-CVasc events
-ergotism
Ergotism
-OD of ergot
-cramps, spasms, dry gangrene from vasoconstriction
Ergot side effects
-retroperitoneal, pleuropulmonary, valvular fibrosis
-ergotism
-vasoconstrictive complications
Ergot drug interactions
-3A4 inhibitors inc toxicity risk
Calcitonin Gene-Related Peptide (CGRP) ANTAgonist drugs
-rimegepant
-ubrogepant
-Zavegepant
Calcitonin Gene-Related Peptide (CGRP) ANTAgonist use
-abortative
CGRP antagonists drug interactions
-AVOID 3A4 inhibitors
-interactions w 3A4 inducers too and p-gcp inhibitors
CGRP side effects
-all Nausea
-rimegepant: rash and dyspnea
-ubrogepant: somnolence, xerostomia
-zavaegepant: salty or loss of taste, nasal discomfort
Lasmiditan
-abortative
-monitor LFT, BP, HR
Lasmiditan warnings
-med overuse HA
-sedation
-dizziness
-serotonin syndrome
-driving impairment (avoid 8h)
Lasmiditan side effects
-dizziness
-fatigue
-paresthesia
-sedation
Lasmiditan drug interactions
-caution CNS depressants and serotonergic meds
-avoid p-gp or BCRP substrates and other meds that can dec HR
Other abortive therapies
-butorphanol nasal spray as rescue medication
Abortive agents
-triptans
-ergots
-NSAIDs
-CGRP
-Lasmiditan
-butorphanol nasal spray
Preventative agents
-B-blockers
-Tricyclic antidepressants (amitriptylline)
-CGRP antagonists (abortive too)
-valproate
-topiramate
-Butterbur/petasites 150mg qd
Beta blockers as preventative tx
-propranolol 80-240mg/day
-metoprolol 100-200mg/day
-CI in asthma and Raynaud’s
Tricyclic antidepressants for preventative tx
-not FDA approved
-amitriptylline 25-150mg/day (mixed migraine/tension type)
Preventative CGRP antagonists
-atogepant: N, constipation, fatigue
-rimegepant: N, rash, dyspnea
Antisz drugs for migraine prevention
-valproate 500-1500mg/day
-topirimate 50-100mg/day
-pt should be on contraception if preg risk
Migraine tx in pregnancy
-AVOID ergot, valproate
-triptans ok (pros v cons)
-CRGP unknown
-topiramate may cause fetal harm (cleft lip and reduced birth wt), monitor metabolic acidosis during and after preg
-avoid or caution all meds breastfeeding
Migraine tx in children
->12: almotriptan (abortive), zolmatriptan nasal spray, sumatriptan/naproxen combo, topiramate for prevention
->6: rizatriptan
-sumatriptan nasal spray not approved in children but studies have show efficacy
