Neuro chapter 11 Migraine Headaches Flashcards
1
Q
Description
A
Common primary headache disorder that can be disabling.
- Occurs with or without aura.
2
Q
Assessment findings
A
- anorexia, nausea and vomiting
- blurred and/or double vision
- photophobia, and/or phonophobia
- visual field abnormalities
- restlessness, irritability
- aphasia
- fatigue
- dizziness, numbness, tingling, weakness
- aura consisting of experiences such as flashing lights, blind spots, tunnel vision
3
Q
Prodrome
A
- may encompass changes in mental state, photophobia, stiff neck, food cravings, thirst, diarrhea, constipation, cold feeling, anorexia
4
Q
Diagnostic criteria / assessment
Migraine Without Aura
A
- At least 5 attacks meeting criteria B-D
B. Attacks last 4-72 hours.
C. At least two of the following characteristics present: - unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravated by routine physical activity and/or prompt avoidance of routine physical activity
D. At least one of the following occurs during headache: - nausea and/or vomiting
- photophobia and phonophobia
E. Not better accounted for by another headache classification
5
Q
Migraine with Aura
A
A. at least two attacks meeting criteria B-D
B. One or more fully reversible symptoms of aura:
- visual
- sensory
- speech and/or language
- motor
- brainstem
- retinal
C. At least two of the following:
- at least one aura symptom spreads gradually over at least 5 minutes, and two or more symptoms occur in succession
- each aura symptom lasts 5-60 minutes
- at least one aura symptom is unilateral
- aura is accompanied by headache or following within 60 minutes by headache
D. Not better characterized by another headache classification. TIA has been excluded.
6
Q
Complicated Migraine
A
A. Headache > or equal to 15 days per month or > or equal to 3 months
B. At least 5 attacks of migraine without aura
C. Headache > or equal to 8 days per month for > or equal to 3 months: criteria for migraine without aura are met and/or the headache is treated and relieved by a triptan or ergot.
D. No medication overuse or secondary cause.
7
Q
Status Migrainosus
A
- a debilitating migraine attack lasting > 72 hours.
8
Q
Chronic migraine
A
- migraine headaches > 15 days per month
9
Q
Incidence
A
- more common among women
- 1 in 4 women will experience migraine
- peaks between early and middle adulthood then declines
- inversely related to income and educational level
- fifth leading cause of ED visits
- pediatric migraines: 3-5% of all children in U.S; increases to 10-20% during second decade.
10
Q
Risk Factors
A
- > 80% have family h/x.
- menstrual/hormonal changes, estrogen replacement
- first headache in early childhood, underreported.
- excessive sleep, insomnia
- certain foods: tryptophan or tyramine-rich foods: ripe cheeses, red wine, chocolate. Alcohol.
- missing meals, long periods between eating
- low-pressure weather systems
11
Q
Differential
A
- headache disorders
- secondary headaches
- giant cell arteritis
- drug-seeking
- mental health disorder
12
Q
CT, MRI, and/or MRA
A
- Reserve for patients with neurological deficits, sudden onset of severe headache, or change in frequency and occurrence of headaches.
13
Q
Diagnostic studies
A
- consider sinus series
- CBC, CMP, TSH
- Cervical x-rays
- EEG
- Lumbar puncture
- sedimentation rate
- serum or urine drug screening
- UA
14
Q
Migraine headache
Prevention / Avoidance
A
- avoid precipitating factors
- avoid foods that may trigger/precipitate:
nitrite-containing foods (hot dogs)
monosodium glutamate-containing foods (chinese food)
tyramine-containing foods (chocolate, cheese, red wine, caffeinated beverages) - pharmacologic prophylaxis
15
Q
Nonpharmacologic Management
A
- application of ice or cool compresses to head, face, scalp, neck
- darkened room
- quiet atmosphere
- CBT
- relaxation techniques
16
Q
Pharmacologic Management
A
- acetaminophen, aspirin, and caffeine delivered in combination are as efffective as triptans for mild and moderate migraine, with fewer adverse events if administered at symptom onset
- consider antiemetics (metoclopramide, prochlorperazine)
- butalbital and opioids may cause medication overuse headaches and rebound headaches, leading to daily chronic migraines
- many prescription drug classes are off-label for prophylaxis
- magnesium or riboflavin supplementation may be beneficial
TREATMENT OF MIGRAINES IS MOST EFFECTIVE IF ADMINISTERED DURING THE EARLY HEADACHE PHASE.
17
Q
Migraine Headache Pharmacologic Management
A
- Abortive agents Serotonin 5HT1 receptor agonists (triptans)
- Abortive agents Ergotamine
- prophylactic agents - beta blockers
- prophylactic agents anticonvulsants
18
Q
Serotonin 5HT1 receptor agonists (Triptans)
General comments
A
Contraindicated in CV disease and HTN
- monitor for angina, CV events, GI ischemic events
- c/i in ischemic heart disease, vasospastic CAD, uncontrolled HTN, PVD, cerebrovascular disease, basilar or hemiplegic migraine
- do not use within 24 hours of ergotamine medications or other triptans
- C/I concurrent use of MAO-I
- Caution in concomitant use of SSRIs and SNRIs; monitor for possible signs of serotonin syndrome
- take as soon as possible after onset of migraine
- frequent use may lead to reduced efficacy
19
Q
Serotonin 5HT1 receptor agonist
Almotriptan (Axert)
A
- dosage adjustment for hepatin or renal impairment
- watch for drug interactions, especially with SSRIs
- cautious use in patients who are sensitive to sulfonamides
20
Q
Serotonin 5HT1 receptor agonist
Naratriptan (Amerge)
A
- Dosage adjustment for hepatic or renal
- consider ECG monitoring
21
Q
Serotonin 5HT1 receptor agonist
Sumatriptan (Imitrex)
A
- consider ECG monitoring
- watch for drug interactions, especially with SSRIs
22
Q
Serotonin 5HT1 receptor agonist
Sumatriptan/naproxen sodium (Treximet)
A
- take with food if GI upset occurs
- increased risk of serious and potentially fatal GI adverse events
- avoid if CrCl < 30
23
Q
Serotonin
Zolmitriptan (Zomig)
A
- consider ECG monitoring
- OK to break 2.5mg tablet in half if lower dose works.
24
Q
Serotonin
Frovatriptan (Frova)
A
- BP at baseline
- CV eval at baseline, then periodically
- Menstrual Migraine usage.
25
Ergotamine
| General Comments
- serious and/or life threatening peripheral ischemia has been associated with coadministration of potent CYP 3A4 inhibitors and ergotamines
- do not use in patients with documented or suspected ischemic or vasospastic CAD
- frequent use may lead to reduced efficacy
26
Ergotamine
| Dihydroergotamine (Migranal)
- not safe for use in pregnancy
- many drug interactions with CYP3A4
- other drug interactions
- c/i in patients with uncontrolled HTN, hemiplegic or basilar migraine
- prior to administration, pump must be primed before use; discard after 8 hours
- do not sniff after spraying
27
Beta Blockers
| general comments
- c/i in bradycardia, asthma
- may mask signs and symptoms of hypoglycemia in patients with diabetes
- cautious use in patients with impaired renal or hepatic dysfunction
- patients with history of severe anaphylactic reaction may be unresponsive to usual doses of epinephrine used to treat allergic reaction
- monitor for symptoms of ischemic heart disease after withdrawing
28
Beta blockers
| Propanolol (Inderal)
- if insufficient response after 4-6 weeks of optimal dose, discontinue gradually withdrawing drug over several weeks
- many possible drug interactions
29
Beta blockers
| Timolol
- if insufficient response after 4-6 weeks of optimal dose, discontinue gradually withdrawing drug over several weeks
30
Anticonvulsants
| Topiramate (Topamax)
- C/I in elevated intraocular pressure
- baseline and periodic measurement of serum bicarb
- depression and mood problems may occur
- increased risk of kidney stones
- monitor for drug interactions: oral contraceptives, metformin, lithium, carbonic anhydrase inhibitors
31
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Anticonvulsants
Divalproex sodium (Depakote ER)
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- not safe for migraine headache in pregnancy
- reliable contraception in childbearing women during therapy
- monitor LFTs at baseline and frequently
- CBC with diff at baseline and periodically
- serum drug levels
- monitor ammonia
- monitor for s/s of depression, behavior changes, increased risk of suicide
32
MEDICATIONS USED OFF LABEL FOR MIGRAINE PROPHYLAXIS:
Metoprolol, amitriptyline, feverfew, magnesium, riboflavin, venlafaxine, candesartan, coenzyme Q10, and cyproheptadine
33
Alternative therapies
- transcutaneous supraorbital stimulation
| - transcranial magnetic stimulation
34
Special considerations
- avoid triptans in patienbts with CAD, poorly controlled HTN
- avoid concomitant use of triptans and ergotamine within 24 hours
- narcotics not recommended
35
goals of preventive therapy
- decrease frequency by 50%, and intensity and duration
- improve responsiveness to acute therapy
- improve function and decrease disability
- prevent the occurrences of a medication overuse headache (MOH) and chronic daily headache.
36
Pregnancy / Lactation
- triptans - no fetal studies
- avoid use of ergotamine
- may improve in second and third trimesters
37
Consultation / referral
- neurologist for severe o unresponsive
38
Follow - up
- return to clinic or ED if unresolved after t/x, becomes more severe, or varies from usual pattern
39
Expected course
most resolve within 72 hours
40
Possible complications
- risk of addiction, iatrogenic complications from treatment (angina from triptans)
- medication overuse headache and/or transformed mgraine
- status migrainosus
- persistent aura without infarction
- migrainous infarction
- migraine-triggered seizures
- severre N/V may lead to shock
- potential for stroke (rare) should be considered in high risk populations: women taking estrogen replacement, smokers, patients who experience migraine with aura.
