Migraines

Question 1

Who generally get migraines more?

Answer 1

young, women

Question 2

What is the suspected mechanism of a migraine?

Answer 2

Sensitive neurons, trigger causes release of vasodilators (CGRP and NO), this causes inflammation that begets more inflammation

Question 3

IN regards to time to treat migraine what is important?

Answer 3

faster=better

Question 4

What are some potential migraine triggers?

Answer 4

stress, food(chocolate or cheese), alcohol (red wine), skip meals

Question 5

What is the POUND pneumonic?

Answer 5

Pulsate headache
One day duration
Unilateral
Nausea
Disabling
*for diagnosing

Question 6

What is the simplified steps of treatment for Migraines?

Answer 6

NSAID
Triptan
Both
SQ SUma

Question 7

Is opioids a good option for migraines?

Answer 7

NO

Question 8

How can we increases the efficacy of drugs for migraines? WHy does this work?

Answer 8

metoclopramide increases motility of stomach= faster onset

Question 9

With regards to NSAIDs how can we get faster onset?

Answer 9

NO food, Liquid gels diclo potassium, Naproxen sodium

Question 10

What form of naproxen is faster and by how much?

Answer 10

Naproxen sodium
20 min faster

Question 11

If a triptan fails what is next step?

Answer 11

switch to a different one (try 3), add a combo, if low absorb go with SQ or nasal

Question 12

Which triptans are slower?

Answer 12

naratriptan and frovatriptan

Question 13

Which triptans are better tolerated?

Answer 13

Nara and frova

Question 14

What is most efficacious triptan?

Answer 14

SQ sumatriptan

Question 15

Why do we avoid opioids for migraines?

Answer 15

causes headaches, Acet and caffiene dose is subtherapeutic

Question 16

What level of caffiene is needed for headaches?

Answer 16

100 mg

Question 17

MOA of triptans?

Answer 17

vasoconstrictors b y seratonin agonists

Question 18

True or false injection triptans do not cause nausea?

Answer 18

FALSE

Question 19

S/e of triptans?

Answer 19

chest tightness, palpitations, dizzy, nausea

Question 20

Who should NOT get triptans?

Answer 20

CVD, if ergot in 24 hours= vasospasm, MAO

Question 21

What is potential s/e of metoclopramide?

Answer 21

parkinsons like because stopping dopamine

Question 22

Which riptan is the cheapest?

Answer 22

Almotriptan

Question 23

Which is better NSAIDs or acet for migraine?

Answer 23

NSAIDs but acet worth an add on

Question 24

I am a patient with bad nausea from triptans. WHat are my options?

Answer 24

Add antiemetic, nasal, SQ or nava or frova

Question 25

Are disintegrating triptans faster than regular?

Answer 25

NO it is only absorbed in SI

Question 26

What is max days a month for triptans?

Answer 26

9

Question 27

What is max days a month for opioids?

Answer 27

9

Question 28

What is max days a month for NSAIDs/acet?

Answer 28

14

Question 29

What is max days a month for combos?

Answer 29

9

Question 30

How many migraines a month indicates med over use?

Answer 30

>15

Question 31

What should we do if menstrual migraines

Answer 31

start 2 days before

Question 32

What is an interesting prvention method for menstual induced migraines?

Answer 32

Hormonal contraception but IF THEY HAVE NO AURA

Question 33

What are the two CGRP antagonists?

Answer 33

Ubrogepant and Atogepant

Question 34

Which CGRP is approved for treat which one is only for prophylaxis?

Answer 34

Treat= ubro prevent=atog

Question 35

How do CGRPs work?

Answer 35

stops dilations!!!!!!

Question 36

What are s/e of CGRPs

Answer 36

nausea, somnolence

Question 37

Is it okay to give CGRP in CV patients?

Answer 37

YES

Question 38

IS CGRP more effective than triptans?

Answer 38

NO because its too slow

Question 39

Are CGRPs at risk of medication induced headache?

Answer 39

NO

Question 40

Why can you not be on an ergot and triptan?

Answer 40

TOO MUCH constriction

Question 41

What patients could use prophylaxis?

Answer 41

>6 attacks a month or severe 3x a month, or difficult to treat migraines

Question 42

How long should you remain of prophylaxis regimine for?

Answer 42

8-12 weeks

Question 43

What are the best agents for prophylaxis? What is rate of help?

Answer 43

amitriptyline, propanolol, metoprolol, topiramate 60%

Question 44

What agents are second line if adverse reaction is an issue for prophylaxis? What is rate that it helps?

Answer 44

candesartan, magnesium and riboflavin 40%

Question 45

When do side effects of prophylaxis tend to stop?

Answer 45

10 days

Question 46

What is a realistic expectation for prophylaxis?

Answer 46

decrease by 50%

Question 47

Which prophylaxis agent is best if smoking is comorbidity?

Answer 47

nortiptyline

Question 48

Which prophylaxis agent is best if insomnia is comorbidity?

Answer 48

amitriptyline

Question 49

Which prophylaxis agent is best if HTN is comorbidity?

Answer 49

B blocker, ARB

Question 50

Which prophylaxis agent is best if chronic pain is comorbidity?

Answer 50

amitriptyline, topiramate, SNRI

Question 51

Which prophylaxis agent is best if MDD is comorbidity?

Answer 51

SNRI, Amitriptyline,

Question 52

Are SSRIs a good option for prophylaxis?

Answer 52

NO

Question 53

What is the best beta blocker for prophylaxis?

Answer 53

propanolol

Question 54

What is a bad side effect of b blocker that is bad for younger people?

Answer 54

exercise intolerance

Question 55

What is the anti CGRP antibody drug and its dose and onset?

Answer 55

Fremanezumab 225 mg SQ q4weeks days to to up to 6 months

Question 56

What is s/e of fremanezumab?

Answer 56

hypeternsion

Question 57

What are red flag signs of headache?

Answer 57

impaired speech, eye sx, headache with sex, >50 preg and other

Question 58

Duration of migraine, Tension, Cluster?

Answer 58

M= 4-72 T=7 day C= 3 hours

Question 59

location of migraine, Tension, Cluster?

Answer 59

M=Unilat but bi possible T=bilat C=unilat

Question 60

type of pain of migraine, Tension, Cluster?

Answer 60

M=pulse T=pressing C=stabbing

Question 61

SX of migraine, Tension, Cluster?

Answer 61

M=Aura, nausea T=Light, NO nausea C=clusters

Question 62

Treatment of migraine, Tension, Cluster?

Answer 62

M=DUH T=NSAIDs/acet C=SQ sumatriptan

Question 63

Which TCA is tertiary?

Answer 63

Amitriptyline

Question 64

Of the first line prophylaxis meds which is the least tolerable?

Answer 64

Topiramate>TCA>Bblocker

Question 65

What is dose of propanolol?

Answer 65

80 mg BID

Question 66

What is dose of Metoprolol?

Answer 66

100 mg BID

Question 67

What is dose of Amitriptyline?

Answer 67

75 mg Hs

Question 68

What is dose of Nortriptyline?

Answer 68

50 mg hs

Question 69

What is dose of Topiramate?

Answer 69

50 mg BID

Question 70

What is dose of Candesartan?

Answer 70

16 mg