Migraines Flashcards
Migraine pathophysiology
neurovascular, Trigeminal nucleus caudalis, serotonin neurotransmission, calcitonin gene related peptide
5HT receptors
5HT1 agonists: migraine treatment, 5HT2 antagonists: migraine prevention, 5HT antagonists: treatment of N/V
Phases of the migraine
irritable, depressed, neck stiffness, fluid retention, thirst, drowsiness
Migraine aura
neurologic symptoms, visual and somatosensory most common, speech, language, sx evolve slowly, 20-60 min before migraine
Migraine attack
moderate to severe intensity, unilateral, throbbing pain, N/V, photophobia, phonophobia; sleep will alleviate
Primary vs secondary headaches
primary: 90%, migraine, tension, cluster; secondary: tumor, meningitis, alcohol-induced
Red flags of headache history
age of onset, time form onset to peak, intensity, pain level, aggravating factors, associated sx
Post headache sx
fatigue, mood changes, decreased appetite, muscle weakness
Diagnosis of migraine
at least 5 attacks meeting criteria of +/- aura, lasts 4-72 hours, pain 2 of 4 (moderate to severe intensity, unilateral, pulsatile/throbbing, aggravated with activity, N/V, photo/phonophobia
Diagnosis episodic tension-type headache
bilateral, 30 min-7 days, pain 2 of 4 (bilateral, pressing/tightening, intensity mild-moderate, not aggravated by activity), no nausea/vomiting, +/- photo/phonophobia
variable headache presentations
migraine +/- aura, episodic/chronic tension-type headache, menstrual migraines, sinus headache
migraine treatment strategies
all pts diagnosed w/ migraine follow similar med ladder, simple analgesics, combo treatment, specific migraine therapies
Non-pharm treatment
hydration, biofeedback, relaxation training, behavioral therapy, cold compress, sleep, cool, dark and quiet room, ha diary,
Complementary treatments
feverfew, magnesium oxide, vit B2, coenzyme Q-10, valerian root, Omega 3
Migraine prophylaxis
BB, CCB, TCA, anticonvulsants
Acute apisodes
Nonspecific treatment: NSAIDs, antiemetics, Specific treatments: triptans, dihydroergotamine
Lower need options
low-end therapy, NSAIDs, analgesics, triptans
Moderate need options
combo analgesic/NSAIDs, antiemetics, triptans, prophylactic therapy
high end need options
opiods, ergots, triptans, prophylactic therapy, consultation
Acute migraine meds
triptans, ergotamine/dihydroergotamine, NSAIDs, opiods, anti-emetics
Triptans MOA
serotonin (5HT) agonists, inhibit CGRP gene transcription, prevent release of neuropeptides which cause vasodilation/pain
Triptans
DOC for acute attacks, not best for tension HA, take as soon as possible to onset, not for prevention
Triptans metabolism
hepatic CYP450, avoid in hepatic
Triptan interactions
MAOI: avoid use within 2 weeks of discontinuing MAOI, oral contraceptive potentially increase in [triptan], avoid use of ergot within 24 hours of triptans
Triptans contraindication and precautions
concern for developing serotonin syndrome, concurrent admin of MAOIs, SSRIs; concern with vasoconstriction, MI, angina, silent ischemia, CAD, uncontrolled HTN, pregnancy cat C
Serotonin syndrome interaction
rare, potential w/ SSRIs, & SNRIs, S/SX: agitation, confusion, muscle spasms, tachy, BP changes, N/D, diaphoresis
Triptans ADRs
tingling, warmth, flushing, dizziness, somnolence, abnormal taste, pain at injection site, CX pain, neck pressure or discomfort may be serious sx
Triptan drugs
Sumatriptan (Imitrex), Rizatriptan (Maxalt), Zolmitriptan (Zomig), Naratriptan (Amerge), Almotriptan (Axert), Frovatriptan (Frova), eletriptan (Relpax)
Triptan drug with fastest onset
Sumatriptan (Imitrex), injectable
Triptan drug given nasal spray
Sumatriptan (Imitrex),, Zolmitriptan (Zomig)
Triptan given orally disintegrating tabs
Rizatriptan (Maxalt), Zolmitriptan (Zomig)
Triptan with best tolerability and duration
Naratriptan (Amerge), Frovatriptan (Frova)
Ergot derivatives
Ergotamine and dihydroergotamine, most affective at first sign of a migraine, all are sedating
Ergot derivatives MOA
high affinity for serotonin 1 receptors, also interact with alpha adrenergic, dopaminergic, and serotonin 3 receptors
Ergot derivatives ADRs
Severe sx, nonoral route preferred, N/V/D, vasoconstriction of systemic and coronary arteries
Ergot derivatives FDA Boxed warning
risk of stroke and/or gangrene when taken with certain antibiotics, antiviral and antifungal drugs
Antiemetics
Chlorpromazine (Thorazine), Metoclopramide (Reglan), Prochlorperazine (Compazine)
symptomatic migraine medication
acetaminophen, caffeine, isometheptene (Prodrin), Acetaminophen, isometheptene, dichloralphenazone (Midrin)
Isometheptene
a sympatomimetic, vasoconstrictor
Dichloralphenazone
a sedative, prodrug converted to chloral hydrate
NSAIDs drugs
naproxen, ibuprofen, aspirin
NSAIDs pearls
beneficial in menstrual migraines, use for pt with infrequent, mild-moderate severity migraines
Rescue medication
Opioids, APAP w/ codeine/hydrocodone or butorphanol, meperidine and tramadol; risk of dependency
Prophylactic treatment
BB, CCBs, anticonvulsants
Indication for prophylaxis
rule of 2s, HA >2 days per week or 2-4 x per month, use of acute tx >2 days/week, use of rescue > 2 x/month
Approved prophylactic drugs
propranolol, topiramate, divalproex sodium, botulinum toxin A, also TCA (amitriptyline, nortriptyline), verapamil, gabapentin
BB for prophylaxis
first line for prevention, chronic daily HA, modulate vascular tone, also anti HTN, contraindicated in asthma and COPD, propranolol, Atenolol, metoprolol
Anticonvulsants drugs
topiramate (Topamax), Gabapentin (Neurontin), Divalproic acid (Depakote, Depakote ER)
Topiramate (Topamax)
blocks Na channels, potentiates GABA activity, dose titrate to response, risk of kidney stones, ADRs: somnolence, wt loss, psychomotor slowing, tingling in extremities, difficulty concentrating, avoid in preg
Gabapentin (Neurontin)
possibly effective, beneficial in pt with neuralgia
Divalproic acid (Depakote)
reduces frequency, not severity, reduces excitatory amino acids, increases GABA activity, nausea, weakness, somnolence, wt gain, hair loss, liver toxicity, avoid pregnancy
Botulinum toxin A (Botox)
Neurotoxin, muscle relaxant, anti-spasmotic, small doses injected in to neck every 3 months, starts working in 1 month, $$$$, droopy eyelid, anaphylactic rxn
TCA drugs
amitriptyline (Elavil), Nortriptyline (Pamelor)
TCA MOA, ADR, cautions
inhibition of peripheral sensitization, 5HT2 antagonism, increase GABA, sedation, anticholinergic, wt gain, glaucoma, urinary retention, no use in suicidal pts
CCB
verapamil, nifedipine, MOA unknown, nifedipine may worsen HA, CT in pt with CHF, hypotension, arrhythmias
