migraines Flashcards
tension type
-most prevalent form of HA; bilateral, 30 minutes – 7 days
vascular
migraines with and w/o aura, mixed HA syndrome
migraine symptoms
severe, recurrent, unilateral; sleep is required to terminate most attacks
migraine w aura
minimum of 2 attacks (ever) and 3 of the following:
- Gradual onset, mild to severe intensity
- Reversible, aura lasts 5-60 minutes
- HA follows aura within 60 minutes
- May or may not have N/V, photophobia, phonophobia
- Normal neurologic exam
migraine w/o aura
Common migraine, minimum 5 attacks lasting 4-72 hours
- Any 2: unilateral, pulsing, aggravated by routine physical activity, moderate to severe intensity
- And 1 of: N/V, Photophobia and Phonophobia
attacks
Prodrome (fatigue/dizziness), aura (visual, sensory), Headache (2/3 unilateral), Postdromal (washed out feeling)
goals of migraine therapy
reduce frequency, severity, and disability to improve patients QOL
step care of migraines
drug in sequential manner (i.e. everyone starts with Tylenol with no regards to severity)
stratified care of migraines
migraine specific agents based on symptom severity
non specific abortive agents
- Aspirin: at first sign of attack, do not use enteric coated, effective with metoclopramide
- Acetaminophen: at first sign of attack, APAP and metoclopramide as effective as triptan
- NSAIDs: at first sign of attack, Ibuprofen, Ketoprofen, Naproxen, Ketorolac (quick onset); usually very safe if used short term, but max doses are under care of a physician
- Combinations: Excedrin (APAP, ASA, Caffeine): difficult for patients who can’t tolerate caffeine to sleep, Fiorinal (Butalbital, ASA, Caffeine, w or w/o Codeine), Fioricent (Butalbital, APA, Caffeine w/ or w/o Codeine)
- Opiate Analgesics: Butorphanol Nasal Spray, PO Hydromorphone, Oxycoodone (avoid these 2 if possible)
triptans
specific abortive agents
- Moderate to severe migraine treatment or if mild not responsive to NSAIDs
- Naratriptan: long half-life
- Almotriptan: good efficacy and high tolerability, but short duration
- Frovatriptan: long DOA, patients who need low recurrence
- Sumatriptan: multiple dosage forms (PO, IN, SQ) with quick onset, but limited by adverse effects
- Rizatriptan: rapid and consistent relief, but short duration
- Eletriptan: high efficacy and low recurrence, but ADRs are common
- Zolmitriptan: PO and intranasal, high ADRs
triptan AE
somnolence, nausea, dizziness, asthenia
triptan CI
CV disease, cerebrovascular disease, PVD, uncontrolled HTN, hemiplegic or basilar migraines
triptan interactions
- MAOIs: increase blood triptan levels
- SSRIs and SNRIs: risk of serotonin syndrome = theoretically contraindicated
- propranolol and Rizatriptan: increase in triptan AUC
- CYP3A4 may increase triptan levels
ergotamine products
specific abortive agents
- Very effective at first sign of attack
- Potent vasoconstrictor
- Increased N/V = treatment with antiemetic
- Pregnancy Category X
- Less Expensive
- All oral products formulated with caffeine = sleep disruption
- Avoid using more than 2x per week
DHE
specific abortive agent
-very effective, lower SE than ergotamine; nasal spray and injection
isometheptene
specific abortive agent
- Midrin (IMH, APAP, and a sedative)
- May be used in pregnant or breast-feeding women
migraine treatment
- PO therapy with Sumatriptan 50-100mg, Rizatriptan 10mg, Almotriptan 12.5mg, Eletriptan 40mg, or Zolmitriptan 2.5mg
- Slower Effect or Better Tolerability: Naratriptan 2.5mg, Frovatriptan 2.5mg
- Infrequent HA: Ergotamine, DHE
- Early Nausea/Vomiting: Sumatriptan nasal spray or injection, Zomitriptan nasal spray or dispersible, Rizatriptan wafer
- HA Recurrence: Ergotamine, Naratriptan, Eletriptan, Frovatriptan, Almotriptan, DHE
- Menstrual-Related: Ergot at night, estrogen, patches, short-term NSAIDs; Acute= triptans, DHE, nasal spray
- Rapid Symptoms: Sumatriptan SC, DHE IM, Zolmitriptan nasal spray
migraine prophylaxis nonpharm
lifestyle, ice packs, avoiding triggers, HA journal
criteria for pharm migraine tx
2 or more attacks per month, or if vasoconstriction is contraindicated
1st line migraine prophylaxis
-Beta-blockers (propranolol, timolol), topiramate, TCAs, Valproic Acid
beta blockers in migraine prophylaxis
- Propranolol LA is drug of choice; 80mg PO daily -> 80mg PO BID -> 80mg PO TID
- Timolol also approved
- Caution in asthma d/t non-selective nature
- Others: Atenolol, Metoprolol, Bisoprolol (if needing selective block)
topiramate in migraine prophylaxis
- Mood stabilizer
- Slow titration: 25mg PO daily -> increase 25mg/week -> 100mg PO daily
TCAs in migraine prophylaxis
- Useful in no response to BB, or cannot tolerate BB side effects
- affective agents: Amitriptyline, Doxepin, Imipramine, Nortriptyline, Protriptyline, Desipramine, Trazodone
- Amitriptyline 25mg-300mg/day or Doxepin 10-150mg/day (Usually a lower dose than for depression)
- Given at bedtime to minimize daytime drowsiness
- DOC for Mixed Headache Syndrome (2-8 migraines/ month, daily low-grade tension HA)
SSRIs in migraine prophylaxis
fluoxetine, sertraline, paroxetine see a reduction in migraine attacks
2nd line migraine prophylaxis
-CCBs, ACE-Inhibitors, ARBs, Antiepileptics, ASA, Alpha-blockers, Trazodone, Botox, Quetiapine, Memantine, NSAIDs (use if 1st line were ineffective or contraindicated)
