migraines Flashcards
primary versus secondary headache
primary: tension headache, cluster headache, migraine with or without aura
secondary: head/neck trauma, vascular disorders, seizures, tumor, substance withdrawal (MEDICATION OVERUSE HEADACHE), infection, psych disorder
migraine: location?
unilateral
migraine: type of pain?
throbbing, pulsating
migraine: onset and duration?
onset gradual, duration 4-72 hours
other symptoms with migraines
nausea, vomiting, photosensitivity, phonosensitivity
risk factors for migraines
female (more common than men)
age
genetics (50% chance if 1 parent has migraines, 75% chance if both parents have migraines)
depolarization theory for the pathophysiology of migraines
vasoactive peptides like CGRP and neurokinin A and substance P are released. then interact with dural blood vessels to cause vasodilation, neurogenic inflammation, activation of sensory neurons in trigeminal nerve, pain
what are the phases of a migraine?
premonitory, aura, headache, postdromal
what are some food triggers of migraines
alcohol, caffeine or caffeine withdrawal, chocolate, MSG, nitrate or tyramine containing foods, yeast productsw
what are some environmental triggers of migraines
glare/flickering lights, high altitude, loud noises, strong smells/fumes, tobacco smoke, weather changes
what are some behavioral/physiologic triggers of migraines
excess or not enough sleep, fatigue, menstruation, menopause, skipped meals, strenuous physical activity, stress or post stress
what is the premonitory phase?
a prodrome/warning signs experienced by ~80% of patients hours-days before migraine onset. can consist of neurologic, psychologic, autonomic, and constitutional symptoms. ex: photophobia, anxiety, diarrhea/constipation, stiff neck, etc…
what is an aura
+ and - neurologic symptoms that precede or accompany a migraine attack including visual, sensory, and motor symptoms
migraines with aura increase ________
risk of ischemic stroke 2.4x higher than migraine without aura
(2nd highest risk factor for stroke, after hypertension)
what are some symptoms of aura
visual: scintillating scotomas, fortification spectrum
sensory: paresthesias
motor: dysphasia, weakness
what is the postdrome phase
resolution phase, can consist of fatigue, irritability, impaired concentration and mood
some patients report mild euphoria/feeling refreshed
what is the acronym that describes migraines?
SULTANS
Severe
Unilateral
Location (unilateral)
Throbbing
Activity provokes pain
Nausea
Sensitivity to light/sound
what is the acronym that describes concerning symptoms/red flags?
SNOOPS
Systemic s/sx (fever, myalgia, wt loss)
Neurologic s/sx (confusion, AMS)
Onset (sudden, abrupt, split second)
Older patient with new onset (40, 50 yo)
Pattern change
Secondary risk factors (HIV, cancer)
diagnostic criteria for migraine without aura
at least 5 attacks
headache 4-72 hrs
not better accounted for by another diagnosis
at least 2 of the following: unilateral, pulsating, moderate-severe, aggravation by activity
and at least 1: n/v, photophobia, phonophobia
diagnostic criteria for migraine with aura
at least 2 attacks
not better accounted for by another diagnosis
at least 1 fully reversible aura symptoms
at least 3 characteristics: aura spreads gradually over 5 minutes, 2 aura symptoms occur in succession, at least one is unilateral, at least one is positive, aura is accompanied by headache within 60 minutes
what drug classes can be used for acute treatment of migraines?
analgesics like NSAIDs and APAP
triptans
ergot alkaloids
CGRP receptor antagonists (gepants)
5-HT1F receptor agonists (ditans)
general treatment algorithm for MILD migraine symptoms
1st line: oral NSAIDs, APAP
2nd line: combo: acetaminophen/aspirin/caffeine
3rd line: triptans, ergots, gepants, ditans
general treatment for SEVERE migraine symptoms
triptans
ergots
gepants
ditans
limit for analgesics such as NSAIDs and APAP?
3 days/week or 15 days/month to avoid MOH
which combination analgesics should be AVOIDED
products containing butalbital: abuse potential
mechanism of triptans
selective agonists at 5HT1B and 5HT1D
limit for triptans
3 days/week or 10 days/month to avoid MOH
which triptans have the best outcomes
sumatriptan SQ
rizatriptan ODT
zolmitriptan ODT
eletriptan tablets
considerations for failed triptans
try a different triptan if unsuccessful for 3 attacks. consider different class after failed TWO triptans.
timing of administering triptans
give within 1 hour of onset, effective if within 4 hours
side effects from triptans
dizziness, fatigue, flushing, paresthesias, n/v
local injection site inflammation
taste perversion, nasal discomfort
angina/coronary ischemia
drug interactions with triptans
SSRIs/SNRIs, ergots, other triptans, MAOI (2 weeks), CYP4A4 inhibitors, propranolol, cimetidine
contraindications to triptans
cerebrovascular disease like stroke, TIA
CV: uncontrolled HTN or ischemic heart disease
hemiplegic or basilar migraine
which drugs are ergot alkaloids
ergotamine
dihydroergotamine
place in therapy for ergot alkaloids
moderate to severe migraines in patients failing triptans
mechanism of ergots
nonselective 5HT1 agonists that activate other types of serotonin receptors, alpha adrenergic, and DA
preferred routes of administration for ergots
IV>IM>Inhaled>SQ>PO (GI absorption erratic)
administer ______ with parenteral dihydroergotamine
antiemetic (mitigate nausea)
common side effects from ergots
n/v, muscle cramps & abd pain, numb/tingling figers/toes
serious side effects from ergots
sustained generalized vasoconstriction, HTN, MI, CVA, gangrene, bowel ischemia, coronary ischemia
drug interactions with ergots
triptans, CYP3A4 inhibitors
contraindications with ergots
PREGNANCY or breastfeeding, CV Disease (HTN, etc), impaired renal/hepatic function, hemiplegic or basilar migraine
which drugs are CGRP receptor antagonists
ubrogepant
rimegepant
zavegepant
place in therapy for CGRP receptor antagonists
for patients with insufficient response to triptans
MOA of CGRP receptor antagonists/gepants
decrease activity of CGRP
lacks direct vasoconstrictive activity
side effects from CGRP receptor antagonists/gepants
nausea, somnolence, dry mouth
contraindications for CGRP receptor antagonists/gepants
concomitant use of strong CYP3A4 inhibitors
not rec in pregnancy
which drug is a selective serotonin 5-HT1F receptor agonist
lasmiditan
lasmiditan place in therapy
in lack of response or contraindication to triptans
lasmiditan MOA
selective 5-HT1F agonist that lacks vasoconstrictor (5HT1B/D) activity
side effects of lasmiditan
dizziness, somnolence, paresthesia, fatigue, nausea
CV
do NOT drive within 8 hours of administration!!
place in therapy for antiemetics in migraines
monotherapy for migraine treatment, adjunct to simple analgesics/triptans when nausea/vomiting limit the absorption of oral medications
preferred antiemetics in migraine treatment
parenteral dopamine antagonists
metoclopramide, prochlorperazine, chlorpromazine
administer with IV diphenhydramine to prevent akathisia and acute dystonic reactions
candidates for migraine prophylaxis
recurrent attacks producing significant disability, frequent attacks, ineffective or contraindicated to acute treatment, uncommon migraine variants with risk for severe neuro injury, patient preference
what is an adequate therapeutic trial for migraine prophylaxis
2-3 months for oral agents
3-6 months for monoclonal antibodies
maximum effects take 6 months
which agents are level A for migraine prophylaxis (established efficacy)
Oral: antiepileptics- divalproex, valproate, topiramate; beta blockers- metoprolol, propranolol, timolol; ARB- candesartan
Parenteral- CGRP mAbs, onabotulinumtoxin A
which agents are level B for migraine prophylaxis (probably effective)
oral: antidepressants- amitriptyline, venlafaxine; beta blockers- atenolol, nadolol; ACEi lisinopril
parenteral: onabotulinumtoxin A + CGRP
migraine prophylaxis for patients whose headaches recur in a predictable pattern (ex menstrual migraines)
NSAID or triptan at time of vulnerability
migraine prophylaxis for healthy patients or comorbid hypertension, angina
B-adrenergic antagonist (verapamil if contraindicated)
migraine prophylaxis for patients with comorbid depression or insomnia
TCA
migraine prophylaxis for patients with comorbid seizure disorder or bipolar illness
anticonvulsant
contraindications for divalproex, valproate
pregnancy, liver disease
precaution: pancreatitis, thrombocytopenia
precautions for topiramate
history of kidney stones, cognitive impairment, pregnancy
contraindications for beta blockers
asthma, diabetes, CHF, depression
contraindications for candesartan
pregnancy
precautions for amitriptyline
BPH, glaucoma, elderly (Beer’s)
precautions for venlafaxine
abrupt withdrawal, concomitant triptan use
contraindications for lisinopril
pregnancy
CGRP is a _____ that does _____
a neuropeptide that is expressed in the trigeminal ganglia nerve that leads to vasodilation
MOA of CGRP mAbs
antagonize CGRP receptor preventing vasodilation during migraine attacks
FDA approved CGRP mAbs for migraine prevention
Erenumab (Aimovig)
Fremanezumab (Ajovy)
Calcanezumab (Emgality)
Eptinezumab (Vyepti)
place in therapy for CGRP mAbs
benefits patients who did not respond to other prophylaxis classes
decreases migraine frequency in 3-6 months
reauthorization for CGRP mAbs depends on what criteria
reduction in monthly headaches of at least moderate severity of >50%
or
a clinically meaningful improvement in validated scale
botox MOA
inhibits acetylcholine release at motor nerve terminals
indication/ADEs/contraindications to botox for migraine prophylaxis
FDA approved for chronic migraines
ADEs: neck pain and muscle weakness
contraindications: infection at injection site
supplements that may be beneficial for migraines?
magnesium oxide– ADEs diarrhea
riboflavin (B2)– ADEs yellow/orange urine
general features of tension headaches
bilateral
mild to moderate pain
dull, aching, non-pulsating, headband-like
other symptoms are STRESS
can last 30 min-7 days
treatment for tension headaches
1st: analgesics, NSAIDs
2nd: combination analgesics containing caffeine
general features of cluster headaches
unilateral, supraorbital, SEVERE pain
sharp, stabbing
commonly occurs at night
15-180 minutes, up to 8 attacks/day
can also cause unilateral autonomic symptoms, restlessness
treatment for cluster headaches
oxygen, triptans for ACUTE treatment
prevention with verapamil (1st line), lithium, corticosteroids
causes of medication overuse headaches
withdrawal due to regular overuse of headache medications. more than 15 days/month for 3 months of simple analgesics. more than 10 days/month for 3 months of combination, triptans, ergots.
treatment of medication overuse headaches?
avoid stopping treatment altogether- start prophylactic regimen to decrease reliance on acute therapy
risk factors for medication overuse headaches
age <50 years
female
smoking
physical inactivity
high daily caffeine intake >540 mg
medication overuse headache prevention
no more than 3 days per month of butalbital
no more than 9 days per month of combination analgesics
no more than 15 days per month of NSAIDs
features of menstrual related migraines
occurs immediately before monthly cycles (~3 days), oral contraceptives and hormone replacement therapy may change frequency or severity of migraine
what is the root cause of menstrual related migraines
decline in estrogen immediately prior to menstruation
treatment of menstrual related migraines
triptans 1-2 days before menses
NSAIDs 1 week before
