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Pain > Migraines/HA > Flashcards

Migraines/HA Flashcards

1
Q

What causes an aura phase?

A

Reduction in cerebral blood flow that beings in the occipital region and moves across the cerebral cortex

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2
Q

What causes migraines?

A

From fibers in the intracranial extra cerebral blood vessels, dura mater, and large venous sinuses
Could be related to dysregulation of serotonin release
Genetics

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3
Q

Are there any nociceptors in the brain?

A

No

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4
Q

What causes the release of neuropeptides in migraines?

A

Activation of the trigeminal sensory nerve

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5
Q

What neuropeptides are released during a migraine?

A

Calcitonin gene related peptide (CGRP)
Neurokinin A
Substance P

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6
Q

What do neuropeptides cause?

A

Vasodilation

Dura plasma extravasation

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7
Q

What parts of genetics can cause migraines?

A

Cause imbalances of the CNS which have a lower threshold for pain
Abnormalities in Ca and Na channels responsible for neurotransmitter
Low levels of serotonin, dopamine, and increased levels of glutamate

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8
Q

What is premonitory sx?

A

Occurs in the hours or days before the onset of the HA
Can vary greatly between individuals, but is consistent w/in the individual
Generalized throughout the body
Bothersome but not debilitating
Could be caused from something other than a migraine

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9
Q

What is an aura?

A

A complex of positive and negative focal neurologic sx that precedes or accompanies an attack
Evolves over 5-20 minutes
Lasts less than 60 minutes
Most often visual and affects half of visual field
Most often debilitating

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10
Q

What are positive sx of an aura?

A

Scintillations
Photopsia (flashes of light)
Teichopsia (shimmering colors)
Fortification spectrum (arc of light)

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11
Q

What are negative sx of an aura?

A

Scotoma (area of partial alteration in the field of vision)

Hemianopsia (decreased vision in half the field)

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12
Q

What are the sensory/motor sx of an aura?

A

Numbness in face and arms
Dysphasia
Weakness
Hemiparesis

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13
Q

What are the presentations of migraines?

A

Aura
Premonitory sx
Gradual onset, peaking in minutes, lasting 4-72 hours
Pain in face and head, most common in frontotemporal region
Unilateral initially, can become bilateral throughout the attack
Throbbing and pulsating
Common: nausea, GI SEs

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14
Q

What are common food triggers of migraines?

A 
Chocolate
Pickled foods
MSG
Aspartame
Tyramine
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15
Q

What environmental factors are triggers of migraines?

A 
Glare
Flickering lights
High altitude
Loud noises
Strong smells
Weather changes
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16
Q

What are behavioral factors that are triggers of migraines?

A 
excess or insufficient sleep
Fatigue
Menstruation
Sexual activity
Skipped meals
Prolonged exertion
Stress
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17
Q

What is a mild HA?

A

Aware of HA

Able to continue daily routine w/minimal alterations

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18
Q

What is a moderate HA?

A

HA inhibits daily activities

Not incapacitating

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19
Q

What is a severe HA?

A

Incapacitating

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20
Q

What patients should receive migraine tx?

A

Greater than 2 attacks/week

Attacks lasting longer than 48 hours

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21
Q

What is the maximum amount of days that HA medications should be taken?

A

9 days/month

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22
Q

What is the most common cause of daily HA?

A

Medication overuse

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23
Q

What is the HA medication cycle?

A

HA returns as soon as medication wears off

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24
Q

What are non-pharm migraine tx options?

A

Track HA/activities/triggers/sx to avoid/decrease potential

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25
Q

What are the most effective OTC analgesics for migraine?

A

NSAID or ASA/APAP/Caffeine

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26
Q

Which medications have higher risks of rebound HA?

A

Combination

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27
Q

When is APAP recommended?

A

HA monotherapy

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28
Q

Which NSAIDs have the most demonstrated benefit for migraines?

A

ASA
Ibuprofen
Naproxen
Tolfenamic acid

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29
Q

How do NSAIDs work in migraines?

A

Inhibits inflammation and pain by inhibiting PGs

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30
Q

What is the MOA of barbiturates in migraines?

A 
Depresses the sensory cortex
Decreased motor activity
Altered cerebellar function
Drowsiness and sedation
Respiratory depression
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31
Q

What are the concerns of butalbital use in migraines?

A

Overuse
Abuse
WD

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32
Q

What is midrin?

A

APAP
Isometheptene
Dochloraphenazone

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33
Q

What is the MOA of isometheptene?

A

Sympathomimetic that reduces stimuli leading to vascular HA via constriction of dilated cranial and cerebral arterioles

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34
Q

What is the MOA of dichloraphenazone?

A

Sedative and antipyrine that reduces the emotional response to painful stimuli

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35
Q

What is midrin useful for?

A

Mild to moderate HA

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36
Q

What is the MOA of butorphanol?

A

Mixed opioid agonist

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37
Q

How is butorphanol supplied?

A

Nasal spray

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38
Q

What are the ergot alkaloids?

A

Ergotamine

Dihydroergotamine

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39
Q

What is the MOA of ergot alkaloids?

A

Partial agonist and/or antagonist activity on a variety of receptors to cause constriction of peripheral and cranial blood vessels and inhibit inflammation

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40
Q

What are DDIs of ergot alkaloids?

A

Strong 3A4 inhibitors

Azoles, PI, macrolides

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41
Q

What are the AEs of ergot alkaloids?

A

Cardiac valvular fibrosis (avoid in patients w/AFib or valve disease)
Vasoconstriction
Most common: N/V/D, ab pain, weakness, fatigue, sweating, chest tightness

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42
Q

Which medication is not commonly recommended in the elderly for migraines?

A

Ergot alkaloids

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43
Q

What can enhance the absorption and potency of ergot analgesia?

A

Caffeine

44
Q

What are ergot alkaloids used for?

A

Moderate to severe HA

45
Q

What should not be used within 24 hours of ergot alkaloids?

A

Triptan

46
Q

What are contraindications for ergot alkaloids?

A 
Renal/hepatic failure
Coronary cerebral or peripheral vascular disease
Uncontrolled HTN
Sepsis
Pregnancy
47
Q

What is the MOA of triptans?

A

Selective agonists of the 5-HT1b and 5-HT1d receptors
Normalization of dilated intracranial arteries by vasoconstriction, neuronal inhibition, and inhibition of transmission through trigeminocervical complex

48
Q

Which medication is an appropriate first line choice for mild to severe migraines?

A

Triptans

49
Q

What are AEs of triptans?

A 
Paresthesias
Fatigue
Dizziness
Flushing
Warm sensations
Somnolence
Chest pain
50
Q

What are contraindications for triptans?

A

IHD
Uncontrolled HTN
Cerebrovascular disease

51
Q

How does botulinum toxin work in migraines?

A

Significant decrease in number of days

52
Q

What is petasites derived from?

A

Butterbur plant

53
Q

What is the use of petasites in migraines?

A

Decrease frequency

54
Q

What is the use of histamines in migraines?

A

Decreased attack frequency
Decreased intensity
Decreased rescue medication use

55
Q

What is the use of Co-Q10 in migraines?

A

Reduced attack frequency

Water soluble

56
Q

When are opioids used in migraines?

A

Reserved for patients with mod-severe sx whom have failed above treatments or contraindications to treatment

57
Q

What are drawbacks to using opioids for migraines?

A

Dependency and rebound HAs

58
Q

What is the most common anti-emetic for migraines?

A

Metoclopramide - can increase absorption of migraine medication

59
Q

When are corticosteroids used for migraines?

A

Status migrainous

Continuous migraine for up to 1 week

60
Q

Which medications are used for migraine prophylaxis?

A

B-blockers
Antidepressants
Anticonvulsants
CCBs

61
Q

How long can a prophylactic dose change take to reach maximal effectiveness?

A

2-4 weeks

62
Q

How long should monitor max doses to make sure the dose has had time to work before adding on additional medications?

A

4 weeks

63
Q

When do we give prophylactic migraine medications?

A

Substantial impact on daily life
Do not respond well to acute care
Frequency is great enough that acute care may lead to rebound HAs

64
Q

How do BB work in migraines?

A

Reduce frequency

65
Q

When are BB not effective for migraine prophylaxis?

A

With intrinsic sympathomimetic activity

66
Q

What is the most common antidepressant used for migraine prophylaxis?

A

Amitriptyline

67
Q

Which antidepressants should not be used for migraine prophylaxis?

A

SSRIs

68
Q

Which anticonvulsants have demonstrated efficacy in migraine prophylaxis?

A

VPA
Divalproex
Topamax
Gabapentin

69
Q

What is the MOA of anticonvulsants in migraine prophylaxis?

A

Enhancement of GABA inhibition
Modulation of glutamate
Inhibition of sodium and calcium ion channels

70
Q

When are anticonvulsants useful in migraine prophylaxis?

A

Comorbid conditions
Seizures
Anxiety
Manic-depressive disorder

71
Q

How do we monitor VPA?

A

Best tolerated

Monitor liver function

72
Q

How do we monitor Divalproex?

A

Wt gain

73
Q

What are AEs with divalproex/VPA?

A

Pancreatitis
Liver failure
Teratogenic risk

74
Q

When are CCBs used in migraine prophylaxis?

A

2nd or 3rd line

Verapamil is the most common

75
Q

How long until verapamil is effective?

A

8 weeks

76
Q

When should women start prophylaxis of migraines?

A

2-3 days prior to menses or usual start of HA

77
Q

How dow contraceptives work in migraines?

A

Decrease duration and severity

78
Q

When should contraceptives be avoided for migraine prophylaxis?

A

Aura

2-4 times more likely to have a stroke

79
Q

What is a cause of a tension HA?

A

Least studied

Thought to originate from myofascial factors and sensitization of nociceptors

80
Q

What are stimuli of tension HA?

A

Mental stress
Non-physiologic motor stress
Local myofascial release of irritants

81
Q

What is the presentation of tension HAs?

A

No premonitory sx/aura
Dull, non-pulsatile tightness or pressure
Bilateral pain is most common
Frontal or temporal pain most common regions
Mild photophobia or phonophobia may be reported

82
Q

How can tension HA be classified?

A

Episodic or chronic

83
Q

What are types of tx for tension HA?

A

Most are treated OTC by the patient, relatively poorly studied
Behavioral therapy
Non-pharm
Non-opioid analgesics

84
Q

What are behavioral therapies for tension HA?

A

Stress management
Relaxation
Counseling
Can reduce sx

85
Q

What are non-pharm tx for tension HA?

A 
Heat or cold packs
Ultrasound
Stretching
Exercise
Massage
Acupuncture
Ergonomic instruction
Trigger point injections
86
Q

How long can non-opioid therapy be used for tension HAs?

A

No more than 9 days per month to stop overuse/rebound HAs

87
Q

What is the most severe of the primary HA disorders?

A

Cluster HA

88
Q

What are the characteristics of cluster HAs?

A

Severe, unilateral head pain in series lasting for weeks or months separated by remission periods lasting months or years

89
Q

Are men or women more likely to have cluster HAs?

A

Men

90
Q

What is the pathophysiology of cluster HAs?

A

Cyclic nature implicates a pathogenesis of hypothalamic dysfunction with resulting alterations in circadian rhythms

91
Q

What hormones are out of sync in cluster HAs?

A 
Cortisol
Prolactin
Testosterone
Growth hormone
Luteinizing hormone
Endorphin
Melatonin
92
Q

How long can cluster HAs occur?

A

2 weeks to 3 months followed by pain free intervals (2 years)

93
Q

When is the most common time for cluster HA?

A

At night during season change

94
Q

What is the onset and duration of cluster HA?

A

Suddenly and last 15-180 minutes

95
Q

Which HA do not present with auras?

A

Cluster

Tension

96
Q

What is the pain like in cluster HAs?

A

Excruciating
Penetrating
Boring in intensity

97
Q

What are the locations of pain in cluster HAs?

A

Orbital
Supraorbital
Temporal unilateral locations

98
Q

What are cluster HAs accompanied by?

A 
Conjunctival injection
Lacrimation
Nasal stuffiness
Eyelid edema
Sweating
Miosis/ptosis
Restlessness
Agitation
99
Q

How often may cluster HA occur during an attack?

A

Once every other day to 8 times a day

100
Q

What positions might a patient with a cluster HA be in?

A

Sitting and rocking or pacing clutching their head

101
Q

Patients with cluster HA may use what?

A

Alcohol
Nicotine
Coffee

102
Q

What are the treatments of cluster HAs?

A

Oxygen
Ergotamine derivatives
Triptans

103
Q

What forms of triptans are most effective for cluster HAs?

A

SQ

Intranasal formulations

104
Q

What medications are used for cluster HA prophylaxis?

A

Verapamil (preferred)
Lithium (can be added to verapamil)
Ergotamine (prophylactis or abortive)
Corticosteroids (relief after 1-2 days)

105
Q

What is the monitoring for cluster HAs?

A

Number of HA
AE
HA cycle patterns
Triggers

Pain (5 decks)

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