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NURS 640 > Neuro chapter 11 Migraine Headaches > Flashcards

Neuro chapter 11 Migraine Headaches Flashcards

1
Q

Description

A

Common primary headache disorder that can be disabling.

- Occurs with or without aura.

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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
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3
Q

Prodrome

A
  • may encompass changes in mental state, photophobia, stiff neck, food cravings, thirst, diarrhea, constipation, cold feeling, anorexia
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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
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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.

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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.

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7
Q

Status Migrainosus

A
  • a debilitating migraine attack lasting > 72 hours.
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8
Q

Chronic migraine

A
  • migraine headaches > 15 days per month
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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.
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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
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11
Q

Differential

A
  • headache disorders
  • secondary headaches
  • giant cell arteritis
  • drug-seeking
  • mental health disorder
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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.
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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
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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
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15
Q

Nonpharmacologic Management

A
  • application of ice or cool compresses to head, face, scalp, neck
  • darkened room
  • quiet atmosphere
  • CBT
  • relaxation techniques
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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.
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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
Q

Ergotamine

General Comments

A
  • 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
Q

Ergotamine

Dihydroergotamine (Migranal)

A
  • 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
Q

Beta Blockers

general comments

A
  • 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
Q

Beta blockers

Propanolol (Inderal)

A
  • if insufficient response after 4-6 weeks of optimal dose, discontinue gradually withdrawing drug over several weeks
  • many possible drug interactions
29
Q

Beta blockers

Timolol

A
  • if insufficient response after 4-6 weeks of optimal dose, discontinue gradually withdrawing drug over several weeks
30
Q

Anticonvulsants

Topiramate (Topamax)

A
  • 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
Q 
Anticonvulsants
Divalproex sodium (Depakote ER)
A
  • 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
Q

MEDICATIONS USED OFF LABEL FOR MIGRAINE PROPHYLAXIS:

A

Metoprolol, amitriptyline, feverfew, magnesium, riboflavin, venlafaxine, candesartan, coenzyme Q10, and cyproheptadine

33
Q

Alternative therapies

A
  • transcutaneous supraorbital stimulation

- transcranial magnetic stimulation

34
Q

Special considerations

A
  • avoid triptans in patienbts with CAD, poorly controlled HTN
  • avoid concomitant use of triptans and ergotamine within 24 hours
  • narcotics not recommended
35
Q

goals of preventive therapy

A
  • 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
Q

Pregnancy / Lactation

A
  • triptans - no fetal studies
  • avoid use of ergotamine
  • may improve in second and third trimesters
37
Q

Consultation / referral

A
  • neurologist for severe o unresponsive
38
Q

Follow - up

A
  • return to clinic or ED if unresolved after t/x, becomes more severe, or varies from usual pattern
39
Q

Expected course

A

most resolve within 72 hours

40
Q

Possible complications

A
  • 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.

NURS 640 (12 decks)

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