Ch 46: Migraines

Question 1

migraine definition

Answer 1

chronic headaches that can cause sig pain for hours or days, may cause NV and sens to light/sound

Question 2

auras

Answer 2

warnings s/s like flashes of light, blind spots or tingling in the arms/legs, most migraines do not have this

Question 3

women with migraine with aura

Answer 3

higher risk of stroke and should not use estrogen containing contraceptives

Question 4

Dx

Answer 4

5 migraine attacks lasting 4-72 h and recur sporadically, 1 of the following (N +/- V, photophobia, phonophobia), 2+ of following (unilateral location, pulsating, mod-severe pain and aggravated by - or causing avoidance of routine physical activity)

Question 5

non drug tx

Answer 5

headache diary to ID triggers, stress mgmt, massage, spinal manipulation, cold compress, acupuncture

Question 6

natural products

Answer 6

caffeine + apap or asa combo. butterbur, coenz q10, feverfew, mg, peppermint topically, riboflavin alone or in combo.

Question 7

Triptans

Answer 7

MOA: agonist for 5HT1 receptor to vasoconstrict the cranial blood vessels, inhibit neuropeptide release, and dec pain tranmission. 1st line for acute tx.

Question 8

OTC acute tx

Answer 8

apap, advil migraine (ibu), excedrin migrain (asa/apap/caffeine), aleve (naproxen)

Question 9

Rx acute tx

Answer 9

triptans (5HT agonists), ergotamine- and butalbital- containing meds, opioids alone or in combo, diclofenac (cambia) in package form indicated for migraine tx. opioids and butalbital not rec 1st line d/t abuse potential –> use only in select cases

Question 10

sumatriptan brands and forms

Answer 10

Imitrex, Onzetra Xsail, Zembrace, SymTouch, +naproxen is Treximet. tab, SC (autoinjector and needle-free) via lateral thigh or upper arm, nasal spray (no prime - x1 dose) or powder.

Question 11

rizatriptan brand and form

Answer 11

maxalt as tab and ODT

Question 12

triptan contraindications, warnings, ADRs,

Answer 12

CIs: cerebrovascular disease (stroke/TIA), uncontrolled HTN, IHD, use <24 h of another triptan or ergotamine type med.
Warning: risk of inc BP.
ADRs: triptan sensations (pressure in chest or heaviness or pressure in neck region) usually dissipates after admin

Question 13

if nausea

Answer 13

ODT, nasal sprays, or injection forms of triptans useful.

Question 14

for children

Answer 14

almotriptan tabs (axert) or zolmitriptan nasal spray (zomig) for 12+ YO rizatriptan (maxalt) for 6-17 YO.

Question 15

triptan half life

Answer 15

shorter t1/2 faster onset, LA t1/2 have slower onset (frovatriptan/frova has longest at 26 h, naratriptan/amerge also long) useful for recurrent migraines or MAM

Question 16

MAM definition and tx

Answer 16

menstrual assoc migraines. may ppx with extended cycle PO contraceptives or start NSAIDs/ triptan with long t1/2 prior to menses and continue for 5-7 d.

Question 17

ergotamine MOA, indication, warnings, contraindications, BBW

Answer 17

nonselective agonist of 5HT causing cerebral vasoconstriction. indicated in pts with contraindications to triptans or who do not find benefit with triptan. 2nd line. warnings: CV events and cerebrovascular events DDIS. CIs: uncontrolled HTN, preg, IHD. BBW: potent 3a4 inhibitors d/t life-threatening peripheral ischemia.

Question 18

dihydroergotamine

Answer 18

DHE 45, Migranal. IV/IM/SC and intranasal. nasal spray: prime by pumping 4x. avoid <24 h of 5HT agonists and <2 wks of MAOIs.

Question 19

ergotamine + caffeine brand and forms

Answer 19

calergot, migergot. tab and suppository

Question 20

butalbital containing products

Answer 20

barbiturate. apap + butalbital + caffeine (fioricet), asa + butalbital + caffeine (fiorinal). fioricet and fiorin have form with codeine. not rec for acute migraines d/t abuse/dependence and lower efficacy. if used long term, needs taper.

Question 21

ppx tx info

Answer 21

pick 1: if pt requests it, if use acute tx >2 d/wk or >3/mo, if dec qol, or if acute txs are ineffective or contraindicated. ppx will reduce migraines ~50%. find the agent that works well. adequate trial is 2-6 mo.

Question 22

ppx tx options

Answer 22

BBs like propranolol (most lipophillic)/timolol/metoprolol. AEDs like topiramate (approved) and valproic acid. TCAs like low-dose amitriptyline (most evid). venlafaxine. natural products.

Question 23

Botox indication

Answer 23

botulinum toxin type A used for chronic migraines only aka >15 HA/mo

Question 24

medication overuse

Answer 24

limit acute tx to 2-3x/wk otherwise will have rebound HA