Migraines Flashcards
Who generally get migraines more?
young, women
What is the suspected mechanism of a migraine?
Sensitive neurons, trigger causes release of vasodilators (CGRP and NO), this causes inflammation that begets more inflammation
IN regards to time to treat migraine what is important?
faster=better
What are some potential migraine triggers?
stress, food(chocolate or cheese), alcohol (red wine), skip meals
What is the POUND pneumonic?
Pulsate headache
One day duration
Unilateral
Nausea
Disabling
*for diagnosing
What is the simplified steps of treatment for Migraines?
NSAID
Triptan
Both
SQ SUma
Is opioids a good option for migraines?
NO
How can we increases the efficacy of drugs for migraines? WHy does this work?
metoclopramide increases motility of stomach= faster onset
With regards to NSAIDs how can we get faster onset?
NO food, Liquid gels diclo potassium, Naproxen sodium
What form of naproxen is faster and by how much?
Naproxen sodium
20 min faster
If a triptan fails what is next step?
switch to a different one (try 3), add a combo, if low absorb go with SQ or nasal
Which triptans are slower?
naratriptan and frovatriptan
Which triptans are better tolerated?
Nara and frova
What is most efficacious triptan?
SQ sumatriptan
Why do we avoid opioids for migraines?
causes headaches, Acet and caffiene dose is subtherapeutic
What level of caffiene is needed for headaches?
100 mg
MOA of triptans?
vasoconstrictors b y seratonin agonists
True or false injection triptans do not cause nausea?
FALSE
S/e of triptans?
chest tightness, palpitations, dizzy, nausea
Who should NOT get triptans?
CVD, if ergot in 24 hours= vasospasm, MAO
What is potential s/e of metoclopramide?
parkinsons like because stopping dopamine
Which riptan is the cheapest?
Almotriptan
Which is better NSAIDs or acet for migraine?
NSAIDs but acet worth an add on
I am a patient with bad nausea from triptans. WHat are my options?
Add antiemetic, nasal, SQ or nava or frova
Are disintegrating triptans faster than regular?
NO it is only absorbed in SI
What is max days a month for triptans?
9
What is max days a month for opioids?
9
What is max days a month for NSAIDs/acet?
14
What is max days a month for combos?
9
How many migraines a month indicates med over use?
> 15
What should we do if menstrual migraines
start 2 days before
What is an interesting prvention method for menstual induced migraines?
Hormonal contraception but IF THEY HAVE NO AURA
What are the two CGRP antagonists?
Ubrogepant and Atogepant
Which CGRP is approved for treat which one is only for prophylaxis?
Treat= ubro
prevent=atog
How do CGRPs work?
stops dilations!!!!!!
What are s/e of CGRPs
nausea, somnolence
Is it okay to give CGRP in CV patients?
YES
IS CGRP more effective than triptans?
NO because its too slow
Are CGRPs at risk of medication induced headache?
NO
Why can you not be on an ergot and triptan?
TOO MUCH constriction
What patients could use prophylaxis?
> 6 attacks a month or severe 3x a month, or difficult to treat migraines
How long should you remain of prophylaxis regimine for?
8-12 weeks
What are the best agents for prophylaxis? What is rate of help?
amitriptyline, propanolol, metoprolol, topiramate
60%
What agents are second line if adverse reaction is an issue for prophylaxis? What is rate that it helps?
candesartan, magnesium and riboflavin
40%
When do side effects of prophylaxis tend to stop?
10 days
What is a realistic expectation for prophylaxis?
decrease by 50%
Which prophylaxis agent is best if smoking is comorbidity?
nortiptyline
Which prophylaxis agent is best if insomnia is comorbidity?
amitriptyline
Which prophylaxis agent is best if HTN is comorbidity?
B blocker, ARB
Which prophylaxis agent is best if chronic pain is comorbidity?
amitriptyline, topiramate, SNRI
Which prophylaxis agent is best if MDD is comorbidity?
SNRI, Amitriptyline,
Are SSRIs a good option for prophylaxis?
NO
What is the best beta blocker for prophylaxis?
propanolol
What is a bad side effect of b blocker that is bad for younger people?
exercise intolerance
What is the anti CGRP antibody drug and its dose and onset?
Fremanezumab 225 mg SQ q4weeks
days to to up to 6 months
What is s/e of fremanezumab?
hypeternsion
What are red flag signs of headache?
impaired speech, eye sx, headache with sex, >50 preg and other
Duration of migraine, Tension, Cluster?
M= 4-72
T=7 day
C= 3 hours
location of migraine, Tension, Cluster?
M=Unilat but bi possible
T=bilat
C=unilat
type of pain of migraine, Tension, Cluster?
M=pulse
T=pressing
C=stabbing
SX of migraine, Tension, Cluster?
M=Aura, nausea
T=Light, NO nausea
C=clusters
Treatment of migraine, Tension, Cluster?
M=DUH
T=NSAIDs/acet
C=SQ sumatriptan
Which TCA is tertiary?
Amitriptyline
Of the first line prophylaxis meds which is the least tolerable?
Topiramate>TCA>Bblocker
What is dose of propanolol?
80 mg BID
What is dose of Metoprolol?
100 mg BID
What is dose of Amitriptyline?
75 mg Hs
What is dose of Nortriptyline?
50 mg hs
What is dose of Topiramate?
50 mg BID
What is dose of Candesartan?
16 mg