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migraines Flashcards

1
Q

Why should a general dentist care about headaches?
Because:
1. The same nerve pathway?
2. Being able to diagnose referred pain from
headaches will allow you to?

A
  1. The same nerve pathway (Trigeminal) is involved and may show up as a toothache,
    gingival pain or facial pain in your patient.
  2. Being able to diagnose referred pain from headaches will allow you to refer your patient to the proper specialist AND AVOID UNNECCESARY DENTAL TX (i.e. RCTs,
    extractions, restorative)
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2
Q

Why should a general dentist care about headaches?
Because:
Headaches occur Most frequently when during the day?

A

Headaches occur Most frequently on arising in the morning therefore the
DDS must differentiate if the head/facial pain is from migraine, bruxism or
obstructive sleep apnea

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3
Q

Headaches can mimic acute dental disease
 If located in?
 what forms can mimic dental disease and cause tooth pain?

A

 If located in the lower half of the face (V2-3)
 Migraine, cluster headache, or paroxysmal hemicrania can mimic dental
disease and cause tooth pain

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4
Q

Dental Pain vs Headache?
1. Acute dental pain distribution?
2. Dental pain clinical characteristics:
 sensation
 location?
 Generally provoked by ?

A
  1. Acute dental pain may spread unilaterally but (unlike headache) rarely crosses the midline of the face.
  2. Dental pain clinical characteristics:
     Intense, throbbing
     Poorly localized
     Generally provoked by stimulation of the offending tooth (i.e. pressure, hot/cold)
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5
Q

Headache attributed to temporomandibular disorder (TMD)
Diagnostic Criteria:
A. Any headache fulfilling?
B. Clinical and/or imaging?
C.Evidence of causation demonstrated by ≥2 of:

A

A. Any headache fulfilling criterion C
B. Clinical and/or imaging reveals evidence of TMD
C. Evidence of causation demonstrated by ≥2 of:
1.headache has developed in temporal relation to onset of TMD
2. either or both of:
a) headache has significantly worsened in parallel with progression of TMD;
b) headache has significantly improved or resolved in parallel with improvement in or resolution of TMD
3. headache produced or exacerbated by active jaw movements, passive movements through range of motion of jaw and/or provocative maneuvers such as pressure on TMJ
and surrounding muscles of mastication
4. headache, when unilateral, is ipsilateral to TMD
D. Not better accounted for by another ICHD-3 diagnosis

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6
Q

Primary Headache Disorders

A
  1. Migraine
  2. Tension-type headache
  3. Trigeminal-autonomic cephalgias (TAC’s)
     Cluster headache
     Paroxysmal hemicrania
     Hemicrania continua
     SUNCT syndrome
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7
Q

Orofacial pains resembling presentations of primary headaches

A

 5.1 Orofacial migraine:
 5.1.1 Episodic orofacial migraine
 5.1.2 Chronic orofacial migraine

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8
Q

Episodic orofacial migraine Diagnostic criteria:
A. At least ? attacks fulfilling criteria?
B. Facial and/or oral pain, without head pain, lasting ? hours (untreated or
unsuccessfully treated)
C. Pain has at least two of the following four characteristics:
D. Pain is accompanied by one or both of the following:
E. Not better accounted for by another ICOP or ICHD-3 diagnosis?

A

A. At least five attacks fulfilling criteria B–D
B. Facial and/or oral pain, without head pain, lasting 4–72 hours (untreated or
unsuccessfully treated)
C. Pain has at least two of the following four characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe intensity
4. aggravation by, or causing avoidance of, routine physical activity (e.g. walking or climbing stairs)
D. Pain is accompanied by one or both of the following:
1. nausea and/or vomiting
2. photophobia (light sensitivity) and phonophobia (noise sensitivity)
E. Not better accounted for by another ICOP or ICHD-3 diagnosis

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9
Q

Chronic orofacial migraine Diagnostic Criteria:
 A. Facial and/or oral pain, without head pain, on ? days/month for >? months and fulfilling criteria?
B. Occurring in a patient who has had at least ? attacks fulfilling criteria ? for ?
C. On ? days/month for >? months, fulfilling either of the following:
1. criteria ? for ?
2. believed by the patient to be ? at onset and relieved by?
 D. Not better accounted for by?
 Comment: ?

A

 A. Facial and/or oral pain, without head pain, on 15 days/month for >3 months and fulfilling criteria B and C below
 B. Occurring in a patient who has had at least five attacks fulfilling criteria B–D for 5.1 Episodic orofacial migraine
 C. On 8 days/month for >3 months, fulfilling either of the following:
1. criteria C and D for 5.1.1 Episodic orofacial migraine
2. believed by the patient to be orofacial migraine at onset and relieved by a triptan or ergot derivative
 D. Not better accounted for by another ICOP or ICHD-3 diagnosis.
 Comment: A Pain Diary must be kept to track headache frequency

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10
Q

are migraine unilateral or bilateral

A

either

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11
Q

Pain sensitive intracranial
structures

A

 Include: the skin and blood vessels of the scalp; the
head and neck muscles; the venous sinuses; thea rteries of the meninges;
the larger cerebral
arteries; the pain-carrying
fibers of the fifth, ninth,
and tenth cranial nerves;
and parts of the dura
mater at the base of the
brain.
 The brain itself is insensitive to pain

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12
Q

Impact of Migraines
 ? million Americans are estimated to have severe migraine headaches.
 Migraine will affect ?% of women over a lifetime.
 Annual lost productivity in the U.S. due to migraine costs over?

A

 36 million Americans are estimated to have severe migraine headaches.
 Migraine will affect 30% of women over a lifetime.
 Annual lost productivity in the U.S. due to migraine costs over $ 1 billion per year

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13
Q

Migraines:
 Severe type of headache that affects approximately % of the world
population or?
 Gender Prevalence:
 Episodes may occur when?

A

 Severe type of headache that affects approximately 10% of the world population or 1 Billion
 Gender Prevalence: 2-3F: 1M
 Episodes may occur at any time of the day or night

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14
Q

onset of migraine in lifetime

A

Onset of migraine occurs in the first four life decades, then the frequency decreases. Childhood gender distribution is equal
sharp increase in females may be due to estrogen

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15
Q

migraines
 Clinical Characteristics:
 what occurs in 2/3 of the patients during or after the headache?
 genetics role?
 More than 50% of migraineurs have how many attacls per month?

A

 Scalp tenderness occurs in 2/3 of the patients during or after the headache
 A genetic factor or familial history is present in most migraineurs
 More than 50% of migraineurs have less than two attacks per month

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16
Q

migraine Pathophysiology
 Migraines & trigeminal autonomic cephalgias cause activation of? causing release of?
 what gets activated? what is released? actions of this? found where?
 what is believed to play a MAJOR role in migraine pathogenesis?

A

 Migraines & trigeminal autonomic cephalgias cause activation of the
Trigeminovascular system causing release of inflammatory chemical
mediators in the brain known as neuropeptides.
 The serotonin receptor (5-HT) gets activated. Serotonin acts as a
neurotransmitter in the CNS & is a potent vasoconstrictor. It is found in
the brain, platelets & intestine.
 Calcitonin gene related peptide (CGRP) is believed to play a MAJOR role in
migraine pathogenesis

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17
Q

A small group of migraineurs transform into?

A

A small group of migraineurs transform into CHRONIC daily headache which is now classified as daily persistent migraine- Headaches occur ≥ 15 times per Month

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18
Q

previous classification of chronic daily migraines

A

Previous classification was Medication Overuse or Rebound Headache since use of analgesics and migraine abortive medications >2days/week can trigger daily headaches in some individuals)

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19
Q

what can be an effective tx in daily migraines

A

Onabotulinum A is effective for treatment
of daily persistent migraines.

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20
Q

Family History of migraines>?
 % of migraineurs have a parent with the disorder and up to % have
at least one first-degree relative with migraine
 chromosome ? is linked to migraines
 cluster headaches genetics?
 % of tension-type headaches sufferers have family members with
similar headaches

A

 50-60% of migraineurs have a parent with the disorder and up to 80% have
at least one first-degree relative with migraine
 chromosome 19 is linked to migraines
 cluster headaches rarely occur within the same family
 40% of tension-type headaches sufferers have family members with
similar headaches

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21
Q

 Migraine is Comorbid with:

A

Comorbidity of Migraine
 Migraine is Comorbid with:
1. stroke
2. epilepsy
3. depression
4. anxiety disorders
 In patients with migraine, anxiety disorders & major depression, the onset of anxiety generally precedes the onset of migraine, whereas the onset of major depression usually follows the onset of migrain

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22
Q

International Headache Society (IHS) Classification of Migraines

A
  1. Migraine with aura (Classic Migraine)
  2. Migraine without aura (Common Migraine)
    * Many patients have both forms
  3. EPISODIC MIGRAINE < 15 migraine days/month
  4. CHRONIC MIGRAINE >15 migraine days/month
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23
Q

Psychiatric Comorbidity of Migraine odds ratios:
 Major depression
 Manic episode
 Anxiety disorder
 Panic disorder

A
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24
Q

when can aura occur relative to migraine

A

Aura can precede, accompany, or follow the actual
headache attack

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25
Q

aura sex prevalence

A

Aura prevalence is: Male-female ratio of 1:2

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26
Q

Migraine without aura Diagnostic Criteria
A. At least 5 attacks fulfilling criteria?
B. Headache attacks lasting?
C. Headache has 2 of the following characteristics:
D. During headache 1 of the following:
E. Not better accounted for by?

A
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27
Q

Migraine Attack Phases

A
  1. Prodrome - occurs hours to days before the headache.
  2. Aura - immediately precedes or accompanies the headache.
  3. Headache
  4. Headache Resolution- may take days
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28
Q

Prodrome
 Change in ?
 Neurological ?
 General ?

A

 Change in mood or behavior (i.e. depressed, hyperactive, euphoric, talkative, drowsy,
restless, or irritable).
 Neurological (i.e. sensitivity to light & noise, difficulty concentrating, yawning,&
hypersomnia).
 General (i.e. stiff neck, food cravings, cold feeling, anorexia, sluggish & thirsty)

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29
Q

Aura
 Approximately % of migraine attacks are “with aura”.
 Many patients have?
 The aura consists of?
 Most common symptoms are ?

A

 Approximately 30% of migraine attacks are “with aura”.
 Many patients have both forms
 The aura consists of gradually spreading neurological symptoms that usually precede the headache by 5-60 minutes
Most common symptoms are visual disturbances such as flashing lights
(scotoma) or a zigzag pattern (fortification spectra)

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30
Q

Sensory Aura

A
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31
Q

Sensory Auras
 ? symptoms) - % prevalence
 hyperkinetic?
 speech? % prevalence?

A

 motor symptoms (i.e. weakness or atonia) - 18% prevalence
 hyperkinetic movement disorders (i.e. chorea)
 speech abnormalities (i.e. aphasia- absence of language or dysarthria- poorly articulated speech) 17-20% prevalence

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32
Q

Migraine with typical aura diagnostic criteria
A. At least 2 attacks fulfilling?
B. what is present>?
C. 2 or more of the following 4 characteristics:
D. Not better accounted for by ?

A
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33
Q

typical aura without headache
A. Fulfils criteria for?

A

A. Fulfils criteria for 1.2.1 Migraine with typical aura
B. No headache accompanies or follows the aura within 60 min

34
Q

Headache Phase
 Location:
 Pain:
 what behavior is common?
 GI signs?
 lights?
 Exercise will?

A

 Location: may be bilateral (40%) or start on one side and become generalized
 Pain: intensity varies ,however, average rating reported is 5/10 on Numeric Rating
Scale (0=no pain, 10=worst pain)
 anorexia is common although food cravings may occur
 nausea (90%), vomiting (33%)
 photo/phonophobia cause patient to seek a dark, quiet room
 Exercise will typically worsen migraine

35
Q

Headache Phase
Systemic Symptoms

A
36
Q

Headache Phase
Affective Alterations Include:

A

 impairment of concentration (common)
 impairment of memory (less common)
 depression
 fatigue
 anxiety
 nervousness
 irritability

37
Q

Resolution Phase
 pain?
 what may occur?
 some migraine sufferers report what following attacks?

A

 pain diminishes
 fatigue, irritability, listlessness, impairment of concentration, or mood change may occur
 some migraine sufferers report euphoria following an attack
while others report depression and malaise

38
Q

Aggravating or Precipitating
Factors for Headache

A
39
Q

Food Triggers for Migraines

A
40
Q

Past Headache History
 Ask patient about:
 Previous ?
 Non-pharmacological ?
 Current?
 Withdrawal or rebound?

A

 Ask patient about:
 Previous medications prescribed (dose & length of time taken)
 Non-pharmacological therapies (biofeedback, psychotherapy, acupuncture & chiropractic)
 Current medications
 Withdrawal or rebound headache - produced by excessive use of NSAIDS,
barbiturates, triptans, narcotics & ergots. Limit usage to 2 days/week

41
Q

Social History for migraines
1. Identify source of ?
2. Recent major ?
3. Job?
4. Exposure to ?
5. Habit ?
6. Sleep ?

A
  1. Identify source of stress
  2. Recent major life changes
  3. Job satisfaction
  4. Exposure to drugs/toxins in workplace
  5. Habit history (i.e. alcohol, tobacco, caffeine & recreational drugs)
  6. Sleep habits (i.e. keep bedtime and awakening time the same each day. Depression, anxiety, sleep apnea produces morning headaches)
42
Q

Migraine Management flow chart

A
43
Q

Non-Pharmacologic Methods (Behavioral Modifications) for migraine prevention

A
44
Q

Non-pharmacologic Methods of migraine prevention: sleep

A
45
Q

Non-pharmacologic Methods of migraine prevention: stress

A

Stress management
 Decreases autonomic nervous
system responsiveness

46
Q

psychotherapy for migraines

A
  1. Relaxation training
  2. Biofeedback
  3. Hypnosis
  4. Cognitive behavior therapy
47
Q

Migraine Medications roles

A
  1. Abortive medications: treat Acute phase.
  2. Prophylactic medications: preventive- recommended if headache frequency is 2 or more headaches per week
48
Q

Pharmacologic Methods
 Migraines that occur less than twice a week are managed with?
 Treatment is provided during the?
 Migraines that occur more frequently should be managed with?

A

 Migraines that occur less than twice a week are managed with abortive medications
 Treatment is provided during the onset of the attack (within 20 minutes of onset for optimal outcome)
 Migraines that occur more frequently should be managed with both preventive and abortive medications

49
Q

Effective Migraine Treatment based on pain levels

A
50
Q

Abortive migraine medications

A

 Acetaminophen
 Aspirin
 Butalbital, caffeine & analgesics
 Caffeine adjuvant
 Isometheptene
 Narcotics
 NSAIDs
 Ergotamine
TRIPTANS:
5-HT 1B/1D Agonists:
 Sumatriptan (Imitrex)
 Zolmitriptan (Zomig)
 Naratriptan (Amerge)
 Rizatriptan (Maxalt)
 Eletriptan (Relpax)

51
Q

Ergot derivatives:
indications?
what can be the action of these rx?
forms?

A

abortive medication

52
Q

Abortive Medications
 Examples of Ergot derivatives

A

 Cafergot suppositories / tablets
 Wigraine suppositories / tablets
 Ergostat sublingual tablets
 Dihydroergotamine: DHE-45 SC and IV
Migranal nasal spray

53
Q

All ergotamine preparations
are capable of producing what ADEs

A
  • Nausea, vomiting, paresthesias, muscle cramps, HTN and angina in sensitive individuals
54
Q

ergot dependency

A

Frequent use of ergotamine tartrate–more than two days per week–
can result in ergot dependency

55
Q

Abortive medications: Analgesics
 In a small number of patients what can be useful?
 When these medications are helpful they should be used because of?
 safety?
 Potential for ?

A

 In a small number of patients analgesic medications (i.e. aspirin, acetaminophen, and
NSAIDs) can be useful in aborting migraine
 When these medications are helpful they should be used because of their low toxicity and side effects
 Generally safe when used infrequently
 Potential for overuse

56
Q

Other rx treatments for migraines

CGRP antag name? used for?

A

 Rimegepant (PO): CGRP Receptor Antagonist
 Both preventative and acute pain reilief
 Take 75mg q 2 days
 Lasmotodine

56
Q

Abortive Medications:
Triptans

A
57
Q

Zolmitriptan (Zomig)
 onset/efficacy?
 forms?

A

 Fast onset of action and early efficacy
 Available in tablet and nasal spray

58
Q

Rizatriptan (Maxalt) (more rapid Tmax)
 Available in?
onset/efficacy?

A

Rizatriptan (Maxalt) (more rapid Tmax)
 Available in tablet and wafer oral
disintegrating tablet
 Fast onset of action and early efficacy

59
Q

Abortive Medications: Triptans
therapeutic effect?

A
  • Restores vascular integrity
  • Inhibits neuropeptide release/inflammation
  • Restores central inhibition of pain pathway
60
Q

triptans forms

A

many available and doses

61
Q

triptans can also control what other effect of migraines?

A

Have particular beneficial influence in
controlling nausea as well as headache

62
Q

For patients with early or significant nausea
or vomiting what route of admin should be considered

A

For patients with early or significant nausea
or vomiting select a non-oral route of
administration

63
Q

Triptans
(5-HT Serotonin Agonists)
 Cause what vasculature changes;

A

 Cranial vasoconstriction
 Coronary vasoconstrictio

64
Q

triptans contraindications

A

Contraindications:
 Coronary artery disease
 Heart disease & uncontrolled hypertension
 Stroke

65
Q

Preventive Migraine
Medications

A
66
Q

Preventive
Medications
 Frequent migraine attacks are best
managed with ?
 Provide antagonist activity at ?

A

 Frequent migraine attacks are best managed with medications that, when taken regularly, decrease the likelihood of the next attack
 Provide antagonist activity at the 5-HT2 and the 5-HT1c receptors

67
Q

Beta adrenergic Blockers use for prevention
 Beta blocker effect on ?
 Act to?

A

 Beta blocker effect on the 5-HT receptors
 Act centrally to inhibit the central beta receptors and decrease the enhancing adrenergic pathway

68
Q

Calcium channel blockers for prevention
* Act o?
* Inhibit?
* Inhibit formation of?
* Prevent ?

A
  • Act on 5-HT receptors
  • Inhibit contraction of vascular smooth muscle
  • Inhibit prostaglandin formation
  • Prevent hypoxia of cerebral neurons
69
Q

Serotonin antagonists
* Examples
* Blocks development of?

A
  • Methysergide (Sansert)
  • Periactin
  • Blocks the development of neurogenic inflammation
70
Q

Divalproex (Depakote)
* Inhibits?
* Enhanced post-synaptic response to?

A
  • Inhibits firing of 5-HT neurons
  • Enhanced post-synaptic response to GABA
71
Q

Topiramate (Topamax)
* Blocks>?
* Does not affect?
* Causes what additional effect?

A
  • Blocks voltage-dependent sodium and calcium channels
  • Does not affect reuptake or binding of neurotransmitters
  • Causes weight loss
72
Q

Gabapentin
Structurally related to?
* Identify and function?

A

Structurally related to GABA but does not interact
with GABA receptors
* Identify and function remain to be elucidated

73
Q

Preventive Migraine Medications INDICATIONS :

A
  • 2 or more attacks per month that produce disability > 3 days
  • Abortive medications not effective
  • Use of abortive medications > 2x/week
  • Special circumstances i.e. hemiplegic migraine
74
Q

Calcitonin Gene Related Peptide (CGRP)Receptor Inhibitors
 CGRP is widely expressed in?
 αCGRP is highly expressed in?
 Inhibits?
 form? do not cause?
 use for migraineS?

A

 is widely expressed in the peripheral and central nervous systems
 αCGRP is highly expressed in sensory neurons
 Inhibits inflammatory pathways
 These Monclonal Antibodies Used for cancer treatment do Not cause immunosuppression
 For prevention of acute migraine ONLY (prophylaxis)

75
Q

Calcitonin Gene Related Peptide Antagonists
provide what for migraine tx?

A

provide effective, differentiated therapy for acute migraine treatment and prevention of frequent episodic and chronic migraine
injected once per month and used as prophylaxis

76
Q

CGRP antagonist names

A

Ab’s (mab suffix)

77
Q

Onabotulinum toxin type A
 Potent?
 mm effect?
 Inhibits?
 FDA treatment option for?
 moa?

A

 Potent neurotoxin
 Weakens painful muscles
 Inhibits muscle contractions
 FDA treatment option for Chronic
Migraines >15 days/month
 Interrupts pain cycle & may alter neurotransmitter secretory function in both afferent & efferent motor nerves

78
Q

onabotulinum toxin duration

A

Therapeutic injections have an average
duration of 12 weeks before re-injection is
necessary

79
Q

Onabotulinum A Toxin
1. Used for?
2. # Injection sites
3. how often?
4. Research has demonstrated effectiveness in?
5. Advantages:
6. Potential Side Effects:

A

Onabotulinum A Toxin
1. Used for Chronic Migraine Headache NOT responsive to medications
2. Injected at 32 sites
3. Repeated every 3 Months
4. Research has demonstrated effectiveness in treatment of
headaches and muscle pain
5. Advantages: no drug-drug interactions and no systemic side effects
6. Potential Side Effects: are risk of weakness at injection site

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