Migraines Flashcards
Diagnosing migraines without aura
- at least five attacks
- last 4-72 hours
- two of the following s/sx: unilateral pain, throbbing, aggravation on movement, moderate to severe pain
- one of the following s/sx: n/v, or photophobia/phonophobia
Diagnosing migraines with aura
- At least 2 attacks
- aura s/sx are at least three of the following: completely reversible; develop gradually over more than 4min, or more than 2 symptoms in succession; no symptom for more than sixty minutes; headache follows in less than an hour, or may precede or be simulataneous
- no evidence of organic brain disease
Migraines versus Cluster HA
Cluster HA: predominantly affect men, short in duration (15-90min average), frequent (up to 1-3/day), not assoc with n/v or visual symptoms; assoc with lacrimation
Midas Questionnaire
Scores based on how much loss of productivity in last three months due to HA; rates disability
Migraine triggers
lack of or too much sleep irregular meals, diet (inc caffeine, ETOH, tyramine, chocolate, etc) irregular exercise strong odors stress menstrual cycle environmental (noise, lights) medications (trazadone, BCP, hydralazine, H2 blocker)
Migraine pathophysiology
migraine trigger, to primary neural dysfunction, to activation of trigeminal nerve (pain can affect many areas of face/neck), to vasodilation of intracranial blood vessels (pain due to cerebral hypoxia and ischemia and inflammatory response), to stimulation of nerve pain pathways
therefore, anti-inflammatories and vasoconstrictors may help with migraines
Abortive versus Preventative care
abortive: take meds as needed, treats an acute attack
preventative: taken daily; reduces frequency and severity of future attacks
Preventative therapy indicated for:
greater than two HA per month substantial disability with HA patient preference contraindication to, failure, or overuse of abortive treatments presence of uncommon migraine condition take cost into consideration
Med options for acute attacks: NSAIDS
analgesic/anti-inflammatory OTC, cheap response is individual overuse can cause rebound HA SE: GI bleed, RF, fluid and salt retention (avoid in CHF, HTN)
Med options for acute attacks: Triptans
ex: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan
MOA: seratonin 5-HT (1B/1D) receptor agonist
*prescription only
SE: coronary vasoconstriction (avoid use in CVA/TIA/MI/PVD hx)
DDI: interact with MAO-Is
Misc: prescription only, available in nasal spray or SQ formulations
Medication options for acute attacks: Ergotamines
ex: dihydroergotamine (DHE), cafergot
MOA: agonist at serotonin receptors causing vasoconstriction; centrally mediated vasoconstriction
SE: tachy, HTN, nausea (tx with anti emetic), long term toxicity (n/v, malaise, gangrene, rebound HA)
Misc: ergotamine dependence with misuse- can cause severe withdrawal/rebound HA
Medication options for acute attacks: Opioids
ex: butorphanol nasal spray (only one proven efficacious)
*reserved for use when other medications fail
*chance for dependence/rebound HA with misuse
SE: drowsy/dizzy/constipation
Med options for acute attacks: Other agents
- anti-emetics (metoclopramide, prochlorperazine)
- isometheptene and combinations (borderline efficacy)
- corticosteroids (be careful with SE)
Med options for preventing attacks: general principles
likely not effective if HA is med-induced
gradual dose adjustments, with 2mo titration period minimum
consider concurrent medical conditions
goal: raise threshold for onset of migraine
Med options for preventing attacks: antihypertensive agents
Beta blockers proven most effective (propanolol and timolol)
calcium channel blockers (nicardipine, verapamil, nicardipine; show limited efficacy)
Alpha 2 antagonists (clonidine and guaifinisen; show limited efficacy)
