Migraines

Question 1

Migraine Diagnosis

Answer 1

2 Features must occur

• Unilateral head pain
• Throbbing pain
• Worsens with activity
• Moderate/severe pain

And 1 of these

• N/V
• Photophobia
• Phonophobia

Question 2

Migraine classifications

Answer 2

1. Aura present
2. Aura Not present (most common)
3. Chronic migraine
   - 15 day/month for 3 months

Question 3

Migraine Risk factors

Answer 3

• Family Hx
• Estrogen and progesterone
• Genetic and environmental factors

Question 4

Migraine Triggers

Answer 4

Fatigue
Oversleeping
Missed meals
Overexertion
Weather change
Stress
Hormonal changes
Bright lights or strong smells

Question 5

Pathophysiology

Answer 5

1. Changes in neurotransmitter levels in CNS

2. Blood vessel tone (blood flow)

Question 6

Clinical Phases

Answer 6

Premonitory phase

• 1/3 have:
• fatigue
• irritability
• loss of concentration
• stiff neck
• food cravings

Migraine Aura
-up to 1/3 have aura symptoms lasting up to [1 hr]
(Bright spots or flashed, usually visual)

Headache phase

• Throbbing pain
• Fatigue, N/V/D, hypersensitivity to touch on head
• Lasts [4-72 hrs]

Recovery Phase
-Irritability, fatigue, depression

Question 7

Abortive (symptomatic) Therapy

Answer 7

1. Aspirin-like drugs
   (ASA, acetaminophen, NSAIDS)
2. Serotonin 1B/1D Receptor Agonists (triptans)
   - sumatriptan (Imitrex)
3. (CGRP) Calcitonin Gene-related Peptide Antagonist

Question 8

Serotonin 1B/1D Receptor Agonists

Answer 8

sumatriptan (Imitrex)

MOA:

• constricts intracranial blood vessels
• suppresses release of inflammatory neuropeptides
• Block brain pathways for pain

Route:
-Sub-Q, PO, Intranasal

SE:
-Injection site reaction (SQ), chest pressure, flushing, weakness, headache, bad taste (nasal)

Considerations
-Avoid with ischemic stroke or heart disease and angina

Question 9

Calcitonin Gene-related Peptide (CGRP) Antagonist

Answer 9

rimegepant (Nurtec)

MOA: mediates pain transmission

Route: PO

SE: GI upset

Considerations: CYP substrate

Question 10

Preventive Therapy

Answer 10

**>4 per month or last >12 hrs

1. Beta-Blockers
   - Propranolol (Inderal)
2. Tricyclic antidepressants
3. Antiepileptic drugs
   - divalproex (Depakote)
   - topiramate (Topamax)
4. Estrogens
   - Mensural migraine

Question 11

Preventative Therapy Goals

Answer 11

1. Reduce attack frequency, severity, and duration
2. Improve responsiveness to treatment of acute attacks
3. Improve function and reduce disability
4. Prevent progression or transformation of episodic migraine to chronic migraine