migraines

Question 1

migraine

Answer 1

very common
episodic neurologic disorder
HA lasting 4- 72hr

Question 2

dx

Answer 2

need 2 of following: unilateral head pain, throbbing pain, worse with activity, mod/severe pain
+1 of the following: n/v, photophobia, phonophobia (sound)

Question 3

classification

Answer 3

aura present: visual, sensory, motor
aura not present: most common
chronic: usually episodic and increase in freq over time, 15 days/mo for 3 mo

Question 4

rf

Answer 4

fam hx
estrogen and progesterone: F!, more freq before/during menstruation, decrease in preg and menopause therefore cyclic withdrawal may be trigger
genetic and env factors

Question 5

triggers

Answer 5

fatigue, sleep disturbance (too much/little), missed meals, overexertion, weather change, stress, hormonal change, OH (red wine), bright lights, strong smells

Question 6

patho

Answer 6

not really identifiable, complex
change in excitatory NT levels in CNS: increase neuronal depol -> hyperactivity -> vasodilate
change in brain met and BF

Question 7

clinical phases: premonitory

Answer 7

hrs - days before onset
1/3 have fatigue, irritability, decreased [], stiff neck, food cravings

Question 8

clinical phases: migraine aura

Answer 8

1/3 have aura S lasting up to 1 hr

Question 9

clinical phases: HA

Answer 9

throbbing (1 sides and spread to both)
fatigue
n/v
dizzy
hypersensitivity to head touch
4-72hr

Question 10

clinical phases: recovery

Answer 10

can linger hrs - days
irritable, fatigue, depression

Question 11

pharm: abortive

Answer 11

more effective early
aspirin like: asa, acetaminophen, NSAID
serotonin receptor agonist (triptans): sumatriptan - usually in addition to aspirin like, combo more effective than either alone
calcitonin gene related peptide (CGRP) antagonist (if cant tolerate triptans)
antiemetics if severe n/v

Question 12

pharm: preventative

Answer 12

> 4 migraines/mo, or >12hr, or chronic
BB: propanolol
tricyclic antidep: divalproex, topiramate
estrogens: menstrual migraine

Question 13

pharm: preventative - goals

Answer 13

decrease attack freq, severity, duration
improve responsiveness to tm of acute attack
improve function and decrease disability, prevent progression or transformation of episodic migraine to chronic migraine

Question 14

Sumatriptan

Answer 14

Serotonin receptor agonists
Constrict intracranial blood vessels
Suppress release of inflammatory neuropeptides
Block brain pathways for pain migraine
Injection site rxn (SQ), chest pressure, flushing, weakness, HA, bad taste (nasal)
SQ, PO, intranasal
Avoid with ischemic stroke or HD and angina

Question 15

Rimegepant

Answer 15

CGRP antagonists
Mediate pain transmission
Migraine
GI upset PO
CYP substrate – watch for interactions, get good med hx
Used to treat acute migraine where triptans aren’t effective or CI