Migraines (detailed)

Question 1

Types (2)

Answer 1

1. Migraine with aura
2. Migraine w/o. aura
3. Menstrual-related migraines w/o aura

Question 2

Migraine with aura - diagnostic criteria

Answer 2

1. At least 5 attacks; duration: 4-72 hrs
2. At least 2 of the following:
   
   1. unilateral
   2. pulsating/throbbing
   3. moderate-severe
   4. agrravation of or causing avoidance of physical activity
3. At least 1 of the following
   
   1. nausea & vomiting
   2. photophobia
   3. phonophobia
   4. smell

Question 3

Migraine with aura

Answer 3

• Neurological disturbance precipitated by visual disturbance
• Might have speech/language and/or sensory disturbance
• DOES NOT always with assoc headache - Acephalic headaches
• Typically : 5-60mins (helps differentiate from a stroke); develops gradually
• Migraines

Question 4

Menstrually related migraines w/o aura

Answer 4

• attacks in menstruating women
• Diagnosis:
  
  • on 3 consecutive cycles on D1-2 of menstruation
• Can occur in other times of the cycle
• In PURE menstrual migraine w/o aura - doesn’t occur in any other part of the cycle

Question 5

Oestrogen withdrawal headaches

Answer 5

• Drop in exogenous oestrogen (been used or > 3 weeks) => triggers migraines

Question 6

Specific prohylaxis for menstrual migraines (non-hormonal + hormonal)

Answer 6

Non-hormonal

1. Mefenamic acid 500mg; starting 2-3days before the expected day of menstruation
2. Naproxen perimenstrually (NSAID, irreversible non-selective COX inhibitors)
3. Naratriptan premenstrually

Hormonal

1. Perimenstrual estrogen supplements of menstruation regular + predictable
2. Continuous combined OCP, particularly if other strategies are not tolerated/contraindicated

Question 7

Pathophysiology (4 stages - list?)

Answer 7

1. Prodrome (77%)
2. Aura (25%)
3. Heacache
4. Postdrome

Question 8

Describe each of the 4 stages of migraines

Answer 8

Prodrome:

• symptoms (e.g. yawning, euphoria, depression, irritability) around 24-48hrs prior to the headache

Aura:

• Completely reversible
• visual (bright lines/shapes), auditory (tinnitus, noises), somatosensory (burning pain, paresthesia), motor (jerking) & negative symptoms (loss of function)
• Mostly visual!

Headache:

• Often unilateral, throbbing, increasing intensity
• Assoc. symptoms
  
  • N&V, photophobia, phonophobia
  • Occasionally cutaneous allodynia = abnormal painful sensitisation of the skin to innocuous stimuli

Postdrome:

• Feeling drained/exhausted
• sometimes sudden head movement cause pain

Question 9

List the 5 ways for migraine treatment

Answer 9

1. Headache diary
2. Identification of migraine overuse
3. Identify & avoid triggers
4. Acute attack therapy
5. Prophylaxis

Question 10

List the 5 problems with acute attack therapy

Answer 10

1. No warning, no aura
2. Nocturnal onset attacks - already started before have time to treat
3. N&V - cannot take oral meds
4. Prolonged duration attacks - treating 1 day doesn’t prevent it the other days
5. High frequency of attacks

Question 11

List the 5 pharmacotherapies for migraines

Answer 11

1. Analgesics
2. Anti-emetics
3. NSAIDs
4. Ergot preparations
5. Triptans

Question 12

Give an example of an anti-emetic and its MOA

Answer 12

E.g. Domperidone (20-30 mg PO) - doesn’t cross BBB

MOA:

• Peripheral dopamine (D2) receptor blocking
• increase oesophageal peristalsis & lower sphincter pressure

Question 13

Examples of NSAIDs

Answer 13

diclofenac potassium, indomethacin, naproxen

Question 14

Give an ergot preparations example + MOA

Answer 14

Example: Dihydroergotamine

MOA: Partial agonist for triptaminergic, dopaminergic & alpha-adrenergic receptors

Question 15

What are triptans, give an example & outline the MOA

Answer 15

• Serotonin 1a/1d agonists
• Examples: naratriptan (PO) - least S/Es
• MOA:
  
  • vasoconstriction + reduced inflammation assoc. w/ antidromic (information travelling in the opposite direction of a neuron) neuronal transmission

Question 16

List 8 Prophylaxis agents used in migraines with an example of each

Answer 16

1. 𝛃 blockers- first-line drugs!!!
   
   • Non-selective→ propranolol
   • Relativelyselective→ atenolol, metoprolol
2. 5-HT2 antagonists
   
   • Pizotifen
3. 5-HT reuptake blocking agents
   
   • Tricyclicagents→ amitriptyline
4. SSRIs, SNRIs → much less effective, may cause or worsen headache
5. Anticonvulsants
   
   • Topiramate→ very effective; no weight gain
   • Sodium valproate
6. Calcium channel blockers:
   
   • Verapamil
7. Angiotensin II receptor antagonist:
   
   • Candesartan (-sartan)
8. Random → Magnesium, riboflavin

Question 17

What are the C/I and S/E for B-blockers?

Answer 17

C/I - cannot give to asthmatics & in depression

S/E: Weight gain

Question 18

What is the interactions of SSRIs, SNRIs?

Answer 18

Cannot give with triptans or will lead to serotonin syndrome

Question 19

What is topiramate?

Positives? S/Es?

MOA?

Answer 19

Anti-convulsant

Very effective; causes no weight gain but still many other S/Es

MOA = Blocks neuronal voltage-dependent sodium channels => increases GABA (A) activity => antagonises AMPA/kainate glutamate receptors

Question 20

List 5 complications of migraines?

Which one is the most common?

Answer 20

1. Chronic migraines
2. Status Migranosus
3. Persistant aura w/o infarction
4. Migranous infarction
5. Migraine triggered seizure

MOST COMMON: Chronic migraines