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neurology/psychiatry > migraines > Flashcards

migraines Flashcards

1
Q

primary versus secondary headache

A

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

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2
Q

migraine: location?

A

unilateral

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3
Q

migraine: type of pain?

A

throbbing, pulsating

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4
Q

migraine: onset and duration?

A

onset gradual, duration 4-72 hours

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5
Q

other symptoms with migraines

A

nausea, vomiting, photosensitivity, phonosensitivity

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6
Q

risk factors for migraines

A

female (more common than men)
age
genetics (50% chance if 1 parent has migraines, 75% chance if both parents have migraines)

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7
Q

depolarization theory for the pathophysiology of migraines

A

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

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8
Q

what are the phases of a migraine?

A

premonitory, aura, headache, postdromal

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9
Q

what are some food triggers of migraines

A

alcohol, caffeine or caffeine withdrawal, chocolate, MSG, nitrate or tyramine containing foods, yeast productsw

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10
Q

what are some environmental triggers of migraines

A

glare/flickering lights, high altitude, loud noises, strong smells/fumes, tobacco smoke, weather changes

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11
Q

what are some behavioral/physiologic triggers of migraines

A

excess or not enough sleep, fatigue, menstruation, menopause, skipped meals, strenuous physical activity, stress or post stress

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12
Q

what is the premonitory phase?

A

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…

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13
Q

what is an aura

A

+ and - neurologic symptoms that precede or accompany a migraine attack including visual, sensory, and motor symptoms

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14
Q

migraines with aura increase ________

A

risk of ischemic stroke 2.4x higher than migraine without aura

(2nd highest risk factor for stroke, after hypertension)

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15
Q

what are some symptoms of aura

A

visual: scintillating scotomas, fortification spectrum
sensory: paresthesias
motor: dysphasia, weakness

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16
Q

what is the postdrome phase

A

resolution phase, can consist of fatigue, irritability, impaired concentration and mood
some patients report mild euphoria/feeling refreshed

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17
Q

what is the acronym that describes migraines?

A

SULTANS
Severe
Unilateral
Location (unilateral)
Throbbing
Activity provokes pain
Nausea
Sensitivity to light/sound

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18
Q

what is the acronym that describes concerning symptoms/red flags?

A

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)

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19
Q

diagnostic criteria for migraine without aura

A

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

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20
Q

diagnostic criteria for migraine with aura

A

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

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21
Q

what drug classes can be used for acute treatment of migraines?

A

analgesics like NSAIDs and APAP
triptans
ergot alkaloids
CGRP receptor antagonists (gepants)
5-HT1F receptor agonists (ditans)

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22
Q

general treatment algorithm for MILD migraine symptoms

A

1st line: oral NSAIDs, APAP
2nd line: combo: acetaminophen/aspirin/caffeine
3rd line: triptans, ergots, gepants, ditans

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23
Q

general treatment for SEVERE migraine symptoms

A

triptans
ergots
gepants
ditans

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24
Q

limit for analgesics such as NSAIDs and APAP?

A

3 days/week or 15 days/month to avoid MOH

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25
Q

which combination analgesics should be AVOIDED

A

products containing butalbital: abuse potential

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26
Q

mechanism of triptans

A

selective agonists at 5HT1B and 5HT1D

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27
Q

limit for triptans

A

3 days/week or 10 days/month to avoid MOH

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28
Q

which triptans have the best outcomes

A

sumatriptan SQ
rizatriptan ODT
zolmitriptan ODT
eletriptan tablets

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29
Q

considerations for failed triptans

A

try a different triptan if unsuccessful for 3 attacks. consider different class after failed TWO triptans.

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30
Q

timing of administering triptans

A

give within 1 hour of onset, effective if within 4 hours

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31
Q

side effects from triptans

A

dizziness, fatigue, flushing, paresthesias, n/v
local injection site inflammation
taste perversion, nasal discomfort
angina/coronary ischemia

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32
Q

drug interactions with triptans

A

SSRIs/SNRIs, ergots, other triptans, MAOI (2 weeks), CYP4A4 inhibitors, propranolol, cimetidine

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33
Q

contraindications to triptans

A

cerebrovascular disease like stroke, TIA
CV: uncontrolled HTN or ischemic heart disease
hemiplegic or basilar migraine

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34
Q

which drugs are ergot alkaloids

A

ergotamine
dihydroergotamine

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35
Q

place in therapy for ergot alkaloids

A

moderate to severe migraines in patients failing triptans

36
Q

mechanism of ergots

A

nonselective 5HT1 agonists that activate other types of serotonin receptors, alpha adrenergic, and DA

37
Q

preferred routes of administration for ergots

A

IV>IM>Inhaled>SQ>PO (GI absorption erratic)

38
Q

administer ______ with parenteral dihydroergotamine

A

antiemetic (mitigate nausea)

39
Q

common side effects from ergots

A

n/v, muscle cramps & abd pain, numb/tingling figers/toes

40
Q

serious side effects from ergots

A

sustained generalized vasoconstriction, HTN, MI, CVA, gangrene, bowel ischemia, coronary ischemia

41
Q

drug interactions with ergots

A

triptans, CYP3A4 inhibitors

42
Q

contraindications with ergots

A

PREGNANCY or breastfeeding, CV Disease (HTN, etc), impaired renal/hepatic function, hemiplegic or basilar migraine

43
Q

which drugs are CGRP receptor antagonists

A

ubrogepant
rimegepant
zavegepant

44
Q

place in therapy for CGRP receptor antagonists

A

for patients with insufficient response to triptans

45
Q

MOA of CGRP receptor antagonists/gepants

A

decrease activity of CGRP
lacks direct vasoconstrictive activity

46
Q

side effects from CGRP receptor antagonists/gepants

A

nausea, somnolence, dry mouth

47
Q

contraindications for CGRP receptor antagonists/gepants

A

concomitant use of strong CYP3A4 inhibitors
not rec in pregnancy

48
Q

which drug is a selective serotonin 5-HT1F receptor agonist

A

lasmiditan

49
Q

lasmiditan place in therapy

A

in lack of response or contraindication to triptans

50
Q

lasmiditan MOA

A

selective 5-HT1F agonist that lacks vasoconstrictor (5HT1B/D) activity

51
Q

side effects of lasmiditan

A

dizziness, somnolence, paresthesia, fatigue, nausea
CV
do NOT drive within 8 hours of administration!!

52
Q

place in therapy for antiemetics in migraines

A

monotherapy for migraine treatment, adjunct to simple analgesics/triptans when nausea/vomiting limit the absorption of oral medications

53
Q

preferred antiemetics in migraine treatment

A

parenteral dopamine antagonists
metoclopramide, prochlorperazine, chlorpromazine
administer with IV diphenhydramine to prevent akathisia and acute dystonic reactions

54
Q

candidates for migraine prophylaxis

A

recurrent attacks producing significant disability, frequent attacks, ineffective or contraindicated to acute treatment, uncommon migraine variants with risk for severe neuro injury, patient preference

55
Q

what is an adequate therapeutic trial for migraine prophylaxis

A

2-3 months for oral agents
3-6 months for monoclonal antibodies
maximum effects take 6 months

56
Q

which agents are level A for migraine prophylaxis (established efficacy)

A

Oral: antiepileptics- divalproex, valproate, topiramate; beta blockers- metoprolol, propranolol, timolol; ARB- candesartan

Parenteral- CGRP mAbs, onabotulinumtoxin A

57
Q

which agents are level B for migraine prophylaxis (probably effective)

A

oral: antidepressants- amitriptyline, venlafaxine; beta blockers- atenolol, nadolol; ACEi lisinopril

parenteral: onabotulinumtoxin A + CGRP

58
Q

migraine prophylaxis for patients whose headaches recur in a predictable pattern (ex menstrual migraines)

A

NSAID or triptan at time of vulnerability

59
Q

migraine prophylaxis for healthy patients or comorbid hypertension, angina

A

B-adrenergic antagonist (verapamil if contraindicated)

60
Q

migraine prophylaxis for patients with comorbid depression or insomnia

A

TCA

61
Q

migraine prophylaxis for patients with comorbid seizure disorder or bipolar illness

A

anticonvulsant

62
Q

contraindications for divalproex, valproate

A

pregnancy, liver disease
precaution: pancreatitis, thrombocytopenia

63
Q

precautions for topiramate

A

history of kidney stones, cognitive impairment, pregnancy

64
Q

contraindications for beta blockers

A

asthma, diabetes, CHF, depression

65
Q

contraindications for candesartan

A

pregnancy

66
Q

precautions for amitriptyline

A

BPH, glaucoma, elderly (Beer’s)

67
Q

precautions for venlafaxine

A

abrupt withdrawal, concomitant triptan use

68
Q

contraindications for lisinopril

A

pregnancy

69
Q

CGRP is a _____ that does _____

A

a neuropeptide that is expressed in the trigeminal ganglia nerve that leads to vasodilation

70
Q

MOA of CGRP mAbs

A

antagonize CGRP receptor preventing vasodilation during migraine attacks

71
Q

FDA approved CGRP mAbs for migraine prevention

A

Erenumab (Aimovig)
Fremanezumab (Ajovy)
Calcanezumab (Emgality)
Eptinezumab (Vyepti)

72
Q

place in therapy for CGRP mAbs

A

benefits patients who did not respond to other prophylaxis classes
decreases migraine frequency in 3-6 months

73
Q

reauthorization for CGRP mAbs depends on what criteria

A

reduction in monthly headaches of at least moderate severity of >50%
or
a clinically meaningful improvement in validated scale

74
Q

botox MOA

A

inhibits acetylcholine release at motor nerve terminals

75
Q

indication/ADEs/contraindications to botox for migraine prophylaxis

A

FDA approved for chronic migraines
ADEs: neck pain and muscle weakness
contraindications: infection at injection site

76
Q

supplements that may be beneficial for migraines?

A

magnesium oxide– ADEs diarrhea
riboflavin (B2)– ADEs yellow/orange urine

77
Q

general features of tension headaches

A

bilateral
mild to moderate pain
dull, aching, non-pulsating, headband-like
other symptoms are STRESS
can last 30 min-7 days

78
Q

treatment for tension headaches

A

1st: analgesics, NSAIDs
2nd: combination analgesics containing caffeine

79
Q

general features of cluster headaches

A

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

80
Q

treatment for cluster headaches

A

oxygen, triptans for ACUTE treatment

prevention with verapamil (1st line), lithium, corticosteroids

81
Q

causes of medication overuse headaches

A

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.

82
Q

treatment of medication overuse headaches?

A

avoid stopping treatment altogether- start prophylactic regimen to decrease reliance on acute therapy

83
Q

risk factors for medication overuse headaches

A

age <50 years
female
smoking
physical inactivity
high daily caffeine intake >540 mg

84
Q

medication overuse headache prevention

A

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

85
Q

features of menstrual related migraines

A

occurs immediately before monthly cycles (~3 days), oral contraceptives and hormone replacement therapy may change frequency or severity of migraine

86
Q

what is the root cause of menstrual related migraines

A

decline in estrogen immediately prior to menstruation

87
Q

treatment of menstrual related migraines

A

triptans 1-2 days before menses
NSAIDs 1 week before

neurology/psychiatry (22 decks)

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