Migraines/ Cluster headaches

Question 1

What medications could exacerbate migraines? (6)

Answer 1

oral contraceptives,

HRT,

nasal decongestants,

SSRIs,

PPIs,

regular opioids.

Question 2

Tx for acute migraine attack

Answer 2

Aspirin 900mg or

ibuprofen 400-600mg

or paracetamol 1g if can’t do aspirin/NSAIDs

followed up triptan if needed - take BEFORE aura.

note: prochlorperazine 10mg or metoclopramide 10mg can be considered for acute migraine even if NO nausea/ vomiting. NOTE risk of extrapyramidal side-effects.

Question 3

Triptan doses for migraine (before flare up)

Answer 3

sumatriptan 50-100mg, can follow by 50-100mg after at least two hours.

Max. dose 300mg daily.

Zolmitriptan 5mg/0.1ml nasal spray unit dose. Max 10mg daily

SPRAY 1 DOSE INTO ONE NOSTRIL AT THE ONSET OF MIGRAINE, REPEATED AFTER NOT LESS THAN 2 HOURS IF RECURS.

Question 4

Nausea and migraine - which anti-emetics? (2)

Answer 4

Prochlorperazine 5-10mg 2-3 times a day (prevention)

20mg, then 10mg after two hours (acute attack)

or Metoclopramide 10mg

Question 5

what would be a good outcome with prophylaxis drug treatment? And how long would you try drug before switching if ineffective?

Answer 5

50% reduction in migraines

Use maximum tolerated dose for 3m before switching to try something else.

Question 6

First line prophylaxis drug treatment for migraines

Answer 6

Propranolol 80-160mg/d target dose 80mg twice daily (not for asthmatics!!)

Question 7

If patient asthmatic, what 1st line prophylaxis drug would you use?

And name 4 others

Answer 7

Amitriptyline 25-150mg at night. Target dose 30-50mg

Topiramate 50-100 mg/d target dose 50mg BD

Others; sodium valproate 400-1500 mg/d. Target dose 600mg BD. TERATOGENIC

Candesartan 15mg/d; target dose 15mg/d

Riboflavin make work for some (400mg OD)

Flunarizine 10mg/d (secondary care decision?)

Question 8

What drugs would you NOT use for treating migraines?

Answer 8

gabapentin, pregabalin,

ACEi,

SSRI/ SNRIs,

antiepileptics,

pizotifen (causes weight gain/ drowsiness, and ineffective when migraine starts).

Question 9

When would you consider using prophylaxis drugs for migraines?

Answer 9

If severe prolonged attacks,

or >1/week attacks

Question 10

Migraine of TIA? What symptoms make migraine more likely? (3)

Answer 10

SLOW and gradual onset, often starting with visual changes.

POSITIVE symptoms, i.e. flashing lights, new tingling

Previous HISTORY

Question 11

Are you sure it’s a migraine? What other differentials?

Answer 11

TIA

Raised intracranial pressure

Giant Cell arteritis

retinal detachment