1: Migraines

Question 1

What is the dose for topiramate (Topamax)?

Answer 1

25 mg BID.

200 mg doses max.

Question 2

Which tricyclic is used to prevent migraines?

Answer 2

Amitriptyline
Often used at bedtime.
10-25 mg qPM
Can titrate up to 150 mg daily (max 400 mg daily).

Question 3

Diagnostic criteria for migraines.

Answer 3

Repeated attacks lasting 4–72 hours
Normal neuro exam
No other reasonable cause for headache
At least two of the following:
-Unilateral pain (~60% of the time)
-Throbbing/pulsating pain
-Aggravation by movement or activity
-Moderate to severe intensity
Plus at least one:
-Nausea and vomiting
-Photophobia or phonophobia

Question 4

What is the #1 recommended preventative med?

Answer 4

Propanolol

Question 5

How long do auras typically last?

Answer 5

30-60 minutes

Question 6

What is the dose for valproic acid?

Answer 6

250 mg 2-3x daily.

Titrate up to effectiveness.

Question 7

What are the first-line preventative meds with low efficacy (3)?

Answer 7

Cyproheptadine
Gabapentin
Lamotrigine

Question 8

What are the 2 general types of treatment for migraines?

Answer 8

Abortive

Preventative

Question 9

T/F Early migraine treatment that includes a single, large dose is most effective.

Answer 9

True

Question 10

Are migraines more common in men or women?

Answer 10

Women. 20-25% of women and 8-10% of men.

Question 11

Name 2 combination drugs for migraines.

Answer 11

Sumatriptan + naproxen (Treximet)

Acetaminophen + butalbital (sedative) + caffeine (Fioricet)

Question 12

What are the second-line preventative meds with high efficacy (3)?

Answer 12

Methysergide
Flunarizine
MAOIs

Question 13

T/F With migraines, the focus should be on a cure.

Answer 13

False. Focus should be on adequate control, not a cure.

Question 14

T/F CCBs may relieve migraine auras but are not as effective as BBs.

Answer 14

True

Question 15

What are the first-line preventative meds with high efficacy (4)?

Answer 15

BB
Tricyclics
Valproate (anticonvulsant)
Topiramate (anticonvulsant)

Question 16

What are the first-line preventative meds with low efficacy (3)?

Answer 16

Verapamil
NSAIDs
SSRIs

Question 17

What are possible tolerance issues with propanolol?

Answer 17

Bradycardia

Low blood pressure

Question 18

What is a major concern when using valproic acid (VPA) or topiramate?

Answer 18

Black box warning of suicide risk for those with major depression disorders.

Question 19

T/F Preventative treatment provides relief in approximately 4 weeks.

Answer 19

False. May take up to 8-12 weeks to have noticeable effect.

Question 20

Severe migraine can lead to _____ and may necessitate IV. Nausea or vomiting may require an IV as well.

Answer 20

Severe migraine can lead to gastric stasis and may necessitate IV. Nausea or vomiting may require an IV as well.

Question 21

What percentage of migraine sufferers have an aura?

Answer 21

20%

Question 22

T/F Amitriptyline may cause insomnia.

Answer 22

True

Question 23

T/F Tension-type headache is more common, but migraine is more often presented in primary care for treatment.

Answer 23

True

Question 24

How do triptans work to abort migraines?

Answer 24

Promote vasoconstriction.

Block pain pathways to brain.

Question 25

What is the treatment for severe migraines that are incapacitating?

Answer 25

Go to ED for IV treatment.

Question 26

T/F Aura symptoms can be both negative and positive in the beginning.

Answer 26

False. Typically begin with positive symptoms (scintillation or parasthesia) and negative symptoms comes later (numbness, aphasia, scotoma).

Question 27

Name abortive treatments (4).

Answer 27

NSAIDs Acetaminophen Aspirin Triptans

Question 28

What is the most commonly used CCB and what is the dose?

Answer 28

Verapamil Start with 80 mg 3-4x daily. 720 mg daily max.

Question 29

What are indications for preventative treatment (4)?

Answer 29

Overuse of abortive treatment. Different types of migraines. Frequent migraines. Long-lasting pain, causing significant disability.

Question 30

What are 7 examples of foods that trigger migraines?

Answer 30

``` Chocolate Cheeses Fried foods Nitrites Red wine Oranges Hot dogs ```

Question 31

_____ treatment should be aggressive. _____ treatment should start low and go slow.

Answer 31

Abortive treatment should be aggressive. Preventative treatment should start low and go slow.

Question 32

What additional treatments would be considered for moderate migraines that inhibit daily activities but are not incapacitating?

Answer 32

Triptan combinations Consider regular, preventative treatment Antiemetics for n/v

Question 33

Name the triptans listed in asynch (3).

Answer 33

Sumatriptan (Imitrex) Naratriptan (Amerge) Zolmitriptan (Zomig)

Question 34

Name abortive treatments for mild symptoms with minimal alteration in daily routine.

Answer 34

OTCs (Tylenol, ASA, NSAIDs) Excedrin (with caffeine) Triptans

Question 35

What happens if a patient develops tolerance to CCBs?

Answer 35

Switch to another CCB.

Question 36

T/F Preventative treatment should not be discontinued without a taper.

Answer 36

True

Question 37

If response to preventative migraine treatment is too mild, what do you do?

Answer 37

Increase dose or add 2nd agent

Question 38

What is the starting dose for preventative treatment with propanolol?

Answer 38

Start with 10-20 mg 2-3x daily. Can increase to 240 mg daily. Available as extended release, too.

Question 39

Which NSAIDs work best with migraines?

Answer 39

There is no data comparing efficacy of different NSAIDs.

Question 40

T/F Auras are mostly visual.

Answer 40

True

Question 41

Do migraines begin at an earlier age in men or women?

Answer 41

Men

Question 42

T/F There is no data to support the use of SSRIs in preventing migraines.

Answer 42

True

Question 43

Name 14 common migraine triggers.

Answer 43

``` Change in weather Stress Alcohol Hunger Fatigue/lack of sleep Loud noises Flickering lights Noxious stimuli Foods Exertion Nitroglycerin Minor head trauma Menses Surgical menopause ```

Question 44

How can you figure out migraine triggers?

Answer 44

Headache diary