Migraine

Question 1

pathophysiology of migraines?

Answer 1

sensitized neurons in pts
trigger comes along
brain releases potent vasodilators and inflammation reactions
vasodilation = big pain; inflammation leads to more inflammation

Question 2

WHat % of pts have aura w/ migraine?

Answer 2

30%

Question 3

Types of aura?

Answer 3

Visual (90%): flickering bright lights, blind spots, lightning bolts
Sensory disturbances: tingling, numbness, pins and needles
Speech disturbances: difficulty word-finding

Question 4

Migraine triggers?

Answer 4

stress
meal-skipping
foods (chocolate, soft cheese)
alcohol (especially red wine)
caffeine withdrawal
dehydration
menstruation
lights/sunlight
erratic sleep/shift work
perfume/odour
obesity
change n barometric pressure

Question 5

POUND acronym?

Answer 5

Pulsatile quality of headache
One-day duration of headache(4-72hrs if left untreated)
Unilateral headache
Nausea or vomiting
Disabling intensity of headache

Question 6

POUND points system?

Answer 6

each worth 1 point
0-2: 17%
3: 64%
4-5: 92%

Question 6

Why avoid T3’s in migraine pts?

Answer 6

opioids have double the risk of medication overuse headache; caffeine and acetaminophen doses are subtherapeutic

Question 7

Triptan SEs?

Answer 7

Nausea
chest discomfort
palpitations
dizziness
facial flushing
Serotonin syndrome
poor taste w/ nasal sprays
injection site reactions w/ subQ

Question 8

CI’s of triptans?

Answer 8

CVD
Use within 24hrs of ergots
with MAOI use
cautioned wirh SSRI, SNRI (serotonin drugs)

Question 9

TRiptan MOAs?

Answer 9

potent vasoconstrictors
potent serotonin agonists

Question 10

Fast acting triptans?

Answer 10

Suma, Riza, Zolmi, Almo, Ele -triptan

Question 11

Long acting triptans?

Answer 11

Nara, Frova - triptan

Question 12

which triptans have dose adjustments?

Answer 12

Riza: dialysis 5mg
Almo: <30mL/min: 6.25mg
Nara: 15-50mL/min: 1mg, avoid under 15mL/min

Question 13

SubQ triptan?

Answer 13

Sumatriptan

Question 14

Nasal spray triptans?

Answer 14

Suma
Zolmi

Question 15

Best efficacy at 2hrs?

Answer 15

SubQ Sumatriptan

Question 16

Best tolerability triptans?

Answer 16

Nara and frova

Question 17

Cheapest cost triptan?

Answer 17

almo po
suma po
zolmi po
riza po

Question 18

Highest efficacy triptan?

Answer 18

SubQ sumatriptan
(works in up to 80% of pts)

Question 19

3x3 rule of triptans?

Answer 19

Try triptans for 3 migraines before giving up
try atleast 3 different triptans before giving up on the class

Question 20

Max days per month to use triptans?

Answer 20

9d

Question 21

Max days per month to use opioids?

Answer 21

9d

Question 22

Max days per month to use NSAIDs or Acet?

Answer 22

14d

Question 23

Max days per month using multiple classes?

Answer 23

9d

Question 24

Options for pre-treatment of menstrual migraines?

Answer 24

Naproxen 500mg BID x 6d
Naratriptan 1mg BID x 6d
Frovatriptan 2.5mg BID x 6d
Estradiol gel 1.5mg daily x 7d

Question 25

when are combined hormonal contraceptives CI?

Answer 25

migraine w/ aura

Question 26

Ubrogepant dose?

Answer 26

50-100mg stat

Question 27

Atogepant prevention dose?

Answer 27

10-60mg

Question 28

AEs of CGRPs?

Answer 28

Nausea and somnolence

Question 29

Benefits of CGRPs vs triptans?

Answer 29

not CI in CVD
very low risk of medication overuse headache

Question 30

Amitriptyline prophylaxis dose?

Answer 30

50-75mg/d hs

Question 31

Propranolol prohpylaxis dosing?

Answer 31

80-160mg/d

Question 32

Metoprolol prophylaxis dosing?

Answer 32

100-200mg/d

Question 33

Candesartan prohpylaxis dosing?

Answer 33

16mg/d

Question 33

Topiramate prophylaxis dosing?

Answer 33

100mg/d

Question 34

Who should be considered for migraine prophylaxis?

Answer 34

pts preference
>6 headache days/month
severe disabling attakcs especcialy if >3/month
acute treatment not working well or CI

Question 35

how many mg of rizatriptan do you use if pt is also on propanolol?

Answer 35

5mg not 10mg b/c propanolol increases rizatriptan levels by 70%

Question 36

AEs of CGRP monoclonal antibodies?

Answer 36

hypertension

Question 37

Onset of CGRP monoclonal antibodies?

Answer 37

days but, give 3-6 months

Question 38

Red flag symptoms for acute headache? (emergency call ambulance)

Answer 38

impairment of speech, sensation, strength, or consciousness
Fever
stiffness
thunderclap headache
eye SEs

Question 39

Red flag symptoms of acute headache (urgent)

Answer 39

first ever headache w/ exercise
comorbs and new headache over age 50

Question 40

Migraine common symptoms and acute treatment? prophylaxis?

Answer 40

usually unilateral
pulsating pain
can have aura
N or V
Acute: NSAIDs, triptan, acet, anti-emetic, DHE,etc.
Prophylaxis: TCA, beta-blocker, topiramate, candesartan, venlafaxine, anti-CGRP

Question 41

Tension-type headach common symptoms, acute treatment? Prophylaxis?

Answer 41

typically bilateral
pressing or tight pain
photophobia or phonophobia present
Acute reatment: NSAIDs, acet, ketoralac, metoclopramide, chlorpromazine
Prophylaxis: TCA, maybe; mirtazapine, venlafaxine, gabapentn, topiramate

Question 42

Cluster headache common symptoms, acute treatment? Prophylaxis?

Answer 42

Combination of unilateral, orbital, supraorbtial, temporal
Stabbing pain
cluster of headaches, multiple in a day
nasal congestion, rhinorrhea, eyelid edema
ACute: SubQ sumatriptan, intranasal sumatriptan, zolmitriptan, vagal nerve stim
Prophylaxis: Verapamil 240-960mg
lithium, galcanezumab, topiramate

Question 43

Anti-CGRP MOA?

Answer 43

prevent/reduce vasodilation