Migraines & Headaches

Question 1

List some migraine triggers

Answer 1

stress
meal-skipping (consider food insecurity)
foods (e.g. chocolate or soft cheese)
alcohol (especially red wine)
caffeine withdrawal
dehydration
menstruation
lights/sunlight
erratic sleep / shift work
perfume/odour
obesity
change in barometric pressure

Question 2

Describe migraine aura

Answer 2

an aura occurs in around 30% pt. Most often it is a flickering bright line, blind spot or lightning bolts that warn pt they are about to have a migraine

Question 3

MOA of Triptans

Answer 3

selective serotonin agonists –> vasoconstrictors

Question 4

Contraindications of Triptans

Answer 4

CV disease
within 24 hours of ergots
MAOIs (risk of serotonin syndrome) and cautioned with other serotonin drugs

Question 5

Why ergots and triptans should not be combined

Answer 5

due to additive coronary vasospasm (could cause MI)

Question 6

List Triptan side effects

Answer 6

nausea, serotonin syndrome, chest tightness, poor taste with nasal sprays, injection site reactions with subcut injections

Question 7

Which triptans are slow acting and which are fast acting?

Answer 7

Slow - nara / frova
Fast - suma/riza/zolmi/almo/ele

Question 8

Why should opioids be avoided in migraines?

Answer 8

higher chance of medication overuse headache
subtherapeutic acet and caffeine
codeine metabolism is unpredictable

Question 9

Tx option for Menstrual migraine

Answer 9

Option for pre-treatment (starting ~2 days before mensturation):
Naproxen 500mg BID x ~6 days ($5)
Naratriptan 1mg BID x ~6 days ($100)
Frovatriptan 2.5mg BID x ~6 days ($200)
Estradiol gel 1.5mg daily x ~7 days ($40)

Question 10

What is the role of anti-emetics in migraines?

Answer 10

works to help reduce nausea and might get the GI tract moving faster getting the medication into body faster

Question 11

What is the role of CGRP antagonists in acute migraines?

Answer 11

for people with CV disease or have failed on triptans

Question 12

What is the role of CGRP antagonists in prophylaxis?

Answer 12

it is slower than needed for acute, work like a mop and clean up which is better for prophylaxis

Question 13

What is the max days/month for triptans to avoid medication overuse headache?

Answer 13

9

Question 14

What is the max days/month for opioids to avoid medication overuse headache?

Answer 14

9

Question 15

What is the max days/month for NSAIDs to avoid medication overuse headache?

Answer 15

14

Question 16

What is the max days/month for multiple classes to avoid medication overuse headache?

Answer 16

9

Question 17

What is the max days/month for acetaminophen to avoid medication overuse headache?

Answer 17

14

Question 18

What is the onset of action and target adult dosing for migraine prophylactic using propranolol

Answer 18

onset - 8-12 weeks
target doses - 40-80 mg BID

Question 19

What is the onset of action and target adult dosing for migraine prophylactic using metoprolol

Answer 19

onset - 8-12 weeks
target doses - 50-100 mg BID

Question 20

What is the onset of action and target adult dosing for migraine prophylactic using amitripyline

Answer 20

onset - 8-12 weeks
target doses - 50-75 mg HS

Question 21

What is the onset of action and target adult dosing for migraine prophylactic using nortripyline

Answer 21

onset - 8-12 weeks
target doses - 50-75 mg HS

Question 22

What is the onset of action and target adult dosing for migraine prophylactic using topiramate

Answer 22

onset - 8-12 weeks
target doses - 50 mg BID

Question 23

What is the onset of action and target adult dosing for migraine prophylactic using candesartan

Answer 23

onset - 8-12 weeks
target doses - 16 mg daily

Question 24

What is the onset of action and target adult dosing for migraine prophylactic using fremanezumab

Answer 24

onset - within days but give 3-6 months for adequate trial
target doses - 225 mg SC q4wk

Question 25

What is the general three criteria for when to consider migraine prophylaxis

Answer 25

patient preference/request frequent attacks - > 6 headache days/month severly disabling difficult to treat attacks

Question 26

How do you measure success for migraine prophylaxis

Answer 26

set realistic expection - decrease day/month by 50% or less severe headaches use headache diary be patient will help get to the proper dosage

Question 27

Explain some factors to consider when individualizing selection of a migraine prophylactic agent

Answer 27

There is a group for the best efficacy data, few adverse effects, presence of comorbidities (smoking, insomnia, hypertension, chronic pain, depression/anxiety)

Question 28

Know the MOA of CGRP antagonist

Answer 28

prevents/reduce vasodilation

Question 29

A/E of CGRP monoclonal antibodies

Answer 29

injection site reactions, hypertension. Patients with CV risk were excluded from trials

Question 30

What is the onset of action for CGRP antagonists in migraine prophylaxis

Answer 30

within a few days but need 3-6 months to be an adequate trial

Question 31

List a critical DDI with triptans

Answer 31

1. Propranolol slows rizatriptan metabolism and this increases levels by ~70% 2. For any pt on propranolol, use risa 5 mg tabs or switch to a different triptan or BB

Question 32

List all the flags for ER headache referral

Answer 32

worst headache impairment of speech, sensation, strength or consciousness fever or neck stiffness thunderclap headache ey sx head trama

Question 33

List all the red flags for referring headaches to a walk in clinic or MD assessment

Answer 33

first ever headache headache with exercise or sex new headache if age > 50 yo HIV, cancer, lyme dx or pregnancy papilledema older adult with cognitive changes

Question 34

What does POUND mnemonic

Answer 34

Pulsatile quality of headache one day duration of headache unilateral headache nausea or vomiting disabling intensity of headache

Question 35

List the duration, location, pain description for migraines

Answer 35

Duration - 4-72 hours Location - typically unilateral Pain Description - usually pulsating pain, moderate to severe intensity

Question 36

List the duration, location, pain description for tension type headaches

Answer 36

Duration - 30 minutes to 7 days Location - typically bilateral Pain Description - usually pressing or tightening pain; mild to moderate intensity

Question 37

List the duration, location, pain description for cluster headache

Answer 37

Duration - 15 min to 3 hours when untreated Location - unilateral orbital, supraorbital, temporal or a combo Pain Description - stabbing, non pulsating pain; severe to excruciating intensity

Question 38

Describe some common symptoms of migraines

Answer 38

During the headache patients experience at least one of: nausea, vomiting, photophobia, and/or phonophobia.   Can be aggravated by (or cause avoidance of) routine physical activity (e.g. walking or climbing stairs).   Aura (1 in 3 patients): may include reversible visual symptoms (e.g. flickering lights, spots, or lines; loss of vision), reversible sensory symptoms (e.g. pins & needles, numbness) or reversible dysphasic speech disturbance. Each aura symptom may last 5-60 minutes.

Question 39

Describe some common symptoms of tension type headaches

Answer 39

Either photophobia or phonophobia are present.   Nausea and vomiting are NOT present.   Usually not aggravated by routine physical activity such as walking or climbing stairs.

Question 40

Describe some common symptoms of cluster headaches

Answer 40

Occurs in clusters from every other day to up to 8 headaches per day.   May have the following ipsilateral symptoms: conjunctival injection or lacrimation, nasal congestion or rhinorrhea, eyelid edema, forehead and facial sweating, miosis or ptosis, restlessness or agitation

Question 41

List some acute and prophylaxis tx for migraine

Answer 41

acute - NSAID, triptan, acetam, anti-emetic, DHE, others prophylaxis - TCA, BB, topiramate, candesartan, venlafaxine, anti-CGRP, some herbals, others

Question 42

List some acute and prophylaxis tx for tension type headache

Answer 42

acute - NSAIDs, acet, IV/IM ketorolac, metoclopramide, chlorpromazine prophylaxis - TCA

Question 43

List some acute and prophylaxis tx for cluster headache

Answer 43

acute - subcutaneous sumatriptan (other triptans or O2) prophylaxis - verapamil, lithium, galcanezumab

Question 44

Describe the difference between infrequent and frequent tension type headache

Answer 44

Infrequent - less than 1 day per month on average Frequent - 1-14 days per month on average

Question 45

Describe episodic and chronic cluster headaches

Answer 45

Episodic - 2 cluster periods lasting 7-365 days and separated by pain free remission of > 1 month Chronic - episodes recur for more than 1 year without remission or with remission lasting < 1 month

Question 46

Which triptan is the fastest relief

Answer 46

SC or nasal formulation

Question 47

Best efficacy at 2 hr for triptans

Answer 47

subcut suma

Question 48

Best tolerated triptans is

Answer 48

nara or frova from their slow onset

Question 49

Best triptan for long lasting attacks

Answer 49

nara or frova

Question 50

lowest costing triptan

Answer 50

almo po

Question 51

Which triptan should be used if vomiting

Answer 51

subcut or nasal or can add antiemetic