Migraines Flashcards
What are some simplified pathophysiologies for migraines?
- Some people have sensitized neurons (unclear why)
- A migraine trigger comes along
- The brain releases potent vasodilators (CGRP, NO) and inflammation reactions
- Vasodilation = big pain, inflammation begets for more inflammation (positive feedback loop)
What is a migraine aura?
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)
What are some migraine triggers?
- Stress
- Meal-skipping
- Certain foods (chocolate or soft cheese)
- Alcohol (especially red wine)
- Caffeine withdrawal
- Dehydration
- Obesity
What pharmacological options showed the highest efficacy in migraine treatment?`
Combination products (ex. NSAID+oral triptan) and triptans showed the highest response rates
What is the treatment ladder for migraine treatment ranked by first-line to last line?
- NSAIDs (affordable, response in 4 to 5 patients per 10)
- Triptans (response in 5 to 6 patients per 10)
- NSAID + triptan (response in 6 to 7 patients per 10)
- Subcutaneous Sumatriptan (early attack on inflammation, best single product
- Refractory Patients (try other alternative combination products, start migraine prophylaxis, DHE nasal spray)
When are NSAIDs taken in migraine treatment?
Taken on the earliest onset of migraine pain and an empty stomach (food delays onset, minutes count in migraine treatment)
When are triptans taken in migraine treatment?
Take triptan at the earliest onset of migraine pain (fast acting triptans are preferred)
How can triptan therapy be optimized with adjunct therapies?
Add acetaminophen, an NSAID, or metoclopramide (improves GI motility and increases the speed at which migraine drugs reach small intestine for absorption)
What are the fast-acting triptans?
Almotriptan
Eletriptan
Rizatriptan
Sumatriptan
Zolmatriptan
What are the only slow-acting triptans?
Naratriptan or frovatriptan
Why are T3s avoided in migraine treatment?
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)
What are some side effects associated with triptans?
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
What are some contraindications for triptans?
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)
What triptans provide the quickest relief?
10-15 minutes for any subcut or nasal formulations; however these have higher cost
ex. Sumatriptan subcut, Suma nasal, Zolmitriptan nasal
What triptans provide the best efficacy at 2 hours after administration?
Likely sumatriptan subcut (works in 80% of patients)
What triptans are best tolerated?
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
What is the effect of a high metoclopramide dose?
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
What triptans are best for long-acting migraine attacks?
Naratriptan and Frovatriptan (long half-life)
What triptans are best for privacy (discretely administered)?
Any ODT product (Rizatriptan and Zolmitriptan)