Migraines Flashcards

1
Q

What are some simplified pathophysiologies for migraines?

A
  1. Some people have sensitized neurons (unclear why)
  2. A migraine trigger comes along
  3. The brain releases potent vasodilators (CGRP, NO) and inflammation reactions
  4. Vasodilation = big pain, inflammation begets for more inflammation (positive feedback loop)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is a migraine aura?

A

An aura occurs in around 30% of patients

Visual symptoms (flickering bright lights, blindspots)

Sensory Disturbances (tingling, numbness, pins and needles)

Speech Disturbances (difficulty word-finding)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are some migraine triggers?

A
  • Stress
  • Meal-skipping
  • Certain foods (chocolate or soft cheese)
  • Alcohol (especially red wine)
  • Caffeine withdrawal
  • Dehydration
  • Obesity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What pharmacological options showed the highest efficacy in migraine treatment?`

A

Combination products (ex. NSAID+oral triptan) and triptans showed the highest response rates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the treatment ladder for migraine treatment ranked by first-line to last line?

A
  1. NSAIDs (affordable, response in 4 to 5 patients per 10)
  2. Triptans (response in 5 to 6 patients per 10)
  3. NSAID + triptan (response in 6 to 7 patients per 10)
  4. Subcutaneous Sumatriptan (early attack on inflammation, best single product
  5. Refractory Patients (try other alternative combination products, start migraine prophylaxis, DHE nasal spray)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When are NSAIDs taken in migraine treatment?

A

Taken on the earliest onset of migraine pain and an empty stomach (food delays onset, minutes count in migraine treatment)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When are triptans taken in migraine treatment?

A

Take triptan at the earliest onset of migraine pain (fast acting triptans are preferred)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How can triptan therapy be optimized with adjunct therapies?

A

Add acetaminophen, an NSAID, or metoclopramide (improves GI motility and increases the speed at which migraine drugs reach small intestine for absorption)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the fast-acting triptans?

A

Almotriptan
Eletriptan
Rizatriptan
Sumatriptan
Zolmatriptan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the only slow-acting triptans?

A

Naratriptan or frovatriptan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Why are T3s avoided in migraine treatment?

A

They contain opiates (codeine) and they double the risk for medication overuse headache compared to other agents

Caffeine dose is subtherapeutic (only has 15mg, need 100mg for migraine efficacy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are some side effects associated with triptans?

A

They are potent vasodilators (chest discomfort/tightness, palpitations, dizziness, facial flushing)

They are also potent serotonin agonists (nausea)

Injection site reactions and bad taste with nasal spray

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are some contraindications for triptans?

A

Contraindicated in the following situations:
- CVD (uncontrolled HTN, previous MI, previous stroke)
- Within 24 of taking an ergot (ex. DHE) due to additive coronary vasospasm
- MAOIs (risk of serotonin syndrome especially when used with other serotonergic drugs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What triptans provide the quickest relief?

A

10-15 minutes for any subcut or nasal formulations; however these have higher cost

ex. Sumatriptan subcut, Suma nasal, Zolmitriptan nasal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What triptans provide the best efficacy at 2 hours after administration?

A

Likely sumatriptan subcut (works in 80% of patients)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What triptans are best tolerated?

A

The slow onset triptans (nara or frova). they have lower nausea and other adverse effects

But have lower efficacy than faster onset agents in migraine treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the effect of a high metoclopramide dose?

A

Can cause decreased dopamine activation in the brain (can cause pseudo-Parkinson’s). These patients show tremors, issues with movement

An alternate is using Domperidone to avoid experiencing pseudo-Parkinson’s but also have the benefit of increasing oral absorption of migraine drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What triptans are best for long-acting migraine attacks?

A

Naratriptan and Frovatriptan (long half-life)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What triptans are best for privacy (discretely administered)?

A

Any ODT product (Rizatriptan and Zolmitriptan)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Rank oral dosage form triptans by cost (most expensive to least expensive)

A

Almo PO, Suma PO, Zolmi PO, Riza PO

21
Q

What are the best triptans if the patient experiences vomiting during their migraine attacks?

A

Any subcut or nasal option avoids the GI tract and eliminates risk of loosing drug in vomit

OR

add anti-emetic like metoclopramide or domperidone

22
Q

Will an effective triptan show benefit for the first migraine attack?

A

Not always, so try a triptan for 3 migraines before giving up, and try 3 triptans before giving up on the drug class

23
Q

Do ODT triptans have faster onset compared to regular tabs?

A

No, ODT triptans are no faster than regular tabs

24
Q

How many days can a patient use triptans before medication overuse headaches become a concern?

A

9 days

25
Q

What is the maximum number of days that opioids can be taken without medication overuse heachaches?

A

9 days

26
Q

What is the maximum number of days that NSAIDs or acetaminophen can be used before medication overuse headaches become a concern?

A

14 days

27
Q

How many days can a patient use combination migraine products before risking medication overuse headaches?

A

9 days

28
Q

What are menstrual migraines?

A

In some patients, migraines increase during menstruation (perhaps due to changing hormone levels)

Often requires pretreatment (start 2 days before anticipated menstruation)

29
Q

What pharmacological options are used in menstrual migraines?

A

Naproxen 500mg BID
Naratriptan 1mg BID
Frovatriptan 2.5mg BID
Estradiol gel 1.5mg (can use combined birth control, but officially contraindicated if patient has migraine with aura, but used off-label)

30
Q

What is the newest migraine treatment drug class?

A

anti-CGRPs (CGRP receptor antagonists)

ex. Ubrogepant used for treatment and Atogepant used for prevention

31
Q

What are some characteristics of CGRP receptor agonists?

A

ADRs: Nausea and somnolence(drowsiness)

Not contraindicated in CV disease, unlike caution for triptans

Very low risk for medication overuse headaches

32
Q

Review slide 23 for summary of testable content

A
33
Q

Who should get migraine prophylaxis?

A
  • Patient preference
  • Frequent attacks (more than 6 headache days per month)
  • Severely disabling attacks (especially if more than 3 per month)
  • Difficult to treat attacks (acute treatment doesn’t work well)
34
Q

How should migraine prophylactic therapy be initiated?

A
  1. Start a headache diary
  2. Start a migraine prevention drug at low dose (beta-blockers, ACEi/ARB, TCA, SNRIs)
  3. Increase dose gradually, every 1 to 2 weeks as guided by target dose range
  4. Remain at that dose for 8 to 12 weeks to assess effectiveness and tolerability
  5. Assess and decide whether to continue, increase dose, or taper or d/c the drug
35
Q

What migraine prophylactic agents have the best efficacy (need to know doses)?

A

Amitriptyline 75mg/day
Propranolol 160mg/day
Metoprolol 200mg/day
Topiramate 100mg/day

36
Q

What migraine prophylactic agents have the fewest adverse effects (need to know doses)?

A

Candesartan 16mg/day
Magnesium 600mg/day
Riboflavin 400mg/day

37
Q

If the patient smokes, what is the best migraine prophylactic agent?

A

Nortriptyline

38
Q

If the patient has insomnia, what is the best migraine prophylactic agent?

A

Amitriptyline

39
Q

If the patient has HTN, what is the best migraine prophylactic agent?

A

Beta-blocker, candesartan, lisinopril, or verapamil (240mg/day) are good choices

40
Q

If the patient has chronic pain, what is the best migraine prophylactic agent?

A

Amitriptyline, venlafaxine, duloxetine, topiramate, or even gabapentin

41
Q

If the patient has depression, what is the best migraine prophylactic agent?

A

Venlafaxine (150mg/day) , duloxetine, amitriptyline

Optimize non-drug options (CBTi)

42
Q

How long should migraine prophylactic trial last before switching agents?

A

At least 8-12 weeks before deciding if prophylaxis is helping

43
Q

What migraine prophylactics pose risk for fetal defects?

A

Topiramate
Divaloprex
Candesartan
Lisinopril
Flunarizine

44
Q

What are some significant drug interactions between migraine prophylaxis and other commonly used drugs?

A

Propranolol slows rizatriptan metabolism (increases levels by 70%
- Increases risk for coronary vasospasm

Therefore use rizatriptan 5mg, if a patient is also using propranolol for prophylaxis

45
Q

What are some emergency red flags for acute headache?

A
  • Worst headache
  • Impairment of speech, strength, consciousness
  • Fever or neck stiffness
  • Eye symptoms (acute angle closure glaucoma)
  • Head trauma
46
Q

What are some urgent red flags for acute headaches?

A
  • First ever headaches
  • Headache with exercise or sex
  • New headache if age over 50
  • HIV
  • Cancer
  • Lyme disease
  • Pregnancy
  • Older adult with cognitive changes
47
Q

Review slide 30 to help differentiate migraines, tension type, and cluster headaches (will be on exam)

A
48
Q

Review slides 34 to 40 for migraine cases

A