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MJ- F2 E4- Neuro > Headaches (migraines)- MJ > Flashcards

Headaches (migraines)- MJ Flashcards

(62 cards)

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1
Q

90% of primary headaches are which 3 types?

A
  1. Migraine
  2. Tension-type
  3. Cluster headaches
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2
Q

90% of primary headaches are migraine, tension-type, or cluster headaches–> which one is most frequent? Which one is most common type of headache leading to a PCP visit?

A

Most frequent= Tension-type

Most common leading to PCP visit= Migraine

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3
Q

Are the following considered primary or secondary headaches?

  • Migraine
  • Tension-type
  • Trigeminal autonomic cephalalgias (includes cluster headaches)
  • Other (new daily persistent headache)
A

Primary headaches

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4
Q

The following is the definition of which type of headache?

• episodic attacks of severe headaches often associated with nausea, photophobia, and/or phonophobia

A

Migraine headache

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5
Q

What are the 4 phases of migraine headache?

A
  • Prodrome – hours to days prior to headache
  • Aura
  • Headache
  • Postdrome – following headache resolution (may last up to 48 hrs)

*Not everyone gets every phase*

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6
Q

The following are symptoms of which phase of migraine headache?

  • Fatigue
  • Difficulty concentrating
  • Neck stiffness
  • Photosensitivity
  • Phonophobia
  • Nausea
  • Blurred vision
  • Yawning
  • Pallor
A

Prodrome symptoms

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7
Q

The following are symptoms of which phase of migraine headache?

  • Feeling tired
  • Difficulty concentrating
  • Neck stiffness
A

Postdrome symptoms

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8
Q
  • Are migraines more common in men or women?
  • Whites or blacks?
  • Higher or lower SES?
A
  • Women
  • Whites
  • Lower SES
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9
Q

What is the most common age group for migraine headache?

A

30-39

(still common 18-29, 40-49)

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10
Q

T/F, family history of migraine increases your risk for migraine headaches?

A

True

1st degree relative w/ migraines gives you a 4-9x higher risk

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11
Q

What 2 comorbid conditions increase risk for migraine headache?

A

Obesity

Depression/anxiety

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12
Q

The following are potential triggers for which type of headache?

  • Alcohol
  • Smoke
  • Sleep disturbances
  • Heat
  • Food
  • Exercise
  • Sexual activity
A

Migraine triggers

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13
Q

The following is the pathophysiology behind which type of HA?

  • Neuron dysfunction in the trigeminal system
    • Trigger → brainstem neuronal hyper-excitability
    • ↑ nerve cell activity and ↑ blood flow
    • Alteration in neuropeptide levels (serotonin and norepinephrine)
    • ↑ blood vessel dilation and inflammation of adjacent dura matter
    • •Activation of trigeminal nerve pain receptors
A
  • Migraine headache
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14
Q

What does the concept of a “threshold” have to do with migraine progression?

A

It means that a person can handle a certain amount of triggers before they hit their threshold and get a migraine

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15
Q

Is it more common to have a migraine with or without an aura?

A

Without

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16
Q

If a patient presents with c/o headache with associated N/V, photophobia and phonophobia, what type of headache is this most likely?

A

Migraine headache

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17
Q

What is an aura?

A

transient focal neurologic symptoms preceding or accompanying the headache

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18
Q

The following is the pathophysiology of what?

  • cortical spreading depression, a wave of neuronal and glial depolarization that moves slowly across the cerebral cortex corresponding to the clinical symptoms (ie, occipital cortex and visual aura).
A

Aura

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19
Q

The following describes criteria for which type of headache?

A. Fulfils criteria for migraine with aura

B. ≥2 of the following fully reversible brainstem symptoms:

  1. Dysarthria
  2. Vertigo
  3. Tinnitus
  4. Hypacusis
  5. Diplopia
  6. Ataxia
  7. Decreased level of consciousness

C.No motor or retinal symptoms

A

Migraine with aura-

Brainstem aura (AKA “basilar migraine”)

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20
Q

Which type of migraine should have ≥2 of the following reversible symptoms?

  1. Dysarthria
  2. Vertigo
  3. Tinnitus
  4. Hypacusis
  5. Diplopia
  6. Ataxia
  7. Decreased level of consciousness
A

Migraine with aura-

Brainstem aura (AKA “basilar migraine”)

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21
Q

Other than fulfilling criteria for migraine with aura, a retinal migraine should also have an aura of fully reversible monocular positive/negative visual phenomena that is confirmed during an attack by what 2 tests?

A

Either or both of the following:

  1. Clinical visual field examination
  2. Patient’s drawing of a monocular field defect
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22
Q

The following describes criteria for what type of migraine?

A. Fulfils criteria for migraine with aura

B. Aura consists of both of the following:

  1. Fully reversible motor weakness (NOT paralysis)
  2. Fully reversible visual, sensory, and/or speech/language symptoms
A

Hemiplegic migraine

(this is just weakness, NOT paralysis)

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23
Q
  • Menstrual migraines are related to decline in which hormone?
  • This has a temporal relationship with which days of a womans menstrual cycle?
A
  • Estrogen
  • Days -2 to +3 of cycle
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24
Q

Is aura common or uncommon with menstrual migraines?

A

uncommon

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25
What is the treatment for menstrual migraines?
**•Abortive** = same as other migraine •**Preventive** * **NSAIDS** (naproxen from day -7 to +6) * Scheduled dosing of **triptans** (Frova from day -2 to +4) * **Magnesium** (throughout menses) * **Extended-cycle hormonal treatment**
26
**A _chronic migraine_ is a HA occurring:** * ≥ \_\_\_\_\_days/month for \> _____ months; * on at least ____ days/month, has the features of migraine headache (or believed by patient to be a migraine at onset, and relieved by a triptan or ergot) * Has had \> 5 attacks fulfilling criteria for migraine +/- aura
* ≥ **15** days/month for \> **3** months * **8** days/month
27
What is abortive therapy for migraines (in general)?
**•Rest, quiet, dark** •**Pharmacologic treatment** (give _early_ in course of HA, PO not always best)--\> "EATAN" * **NSAIDS** * **Acetaminophen** * **Triptans** * **anti-emetics** * **Ergotamines**
28
What is **_1st line_** **mild-moderate abortive therapy** for migraines?
**_NSAIDS_** (OTC- ibuprofen, naproxen) (Prescription- Indomethacin, diclofenac, ketorolac)
29
What is **_2nd line_ mild-moderate abortive therapy** for migraines? When should these be used?
**_Acetaminophen​_** * less effective than NSAIDS * Use in pts that can't take NSAIDS
30
What is **_3rd line_ mild-moderate abortive therapy** for migraines? What is this medication a common cause of?
**_ASA/Acetaminophen/Caffeine (Excedrin)_** * For intermittent use * Common cause of **medication overuse HA**
31
What is the **_1st line_ _moderate-severe_** abortive therapy for migraines?
Triptans
32
**The following is the MOA of which migraine abortive therapy medication?** * **Activates serotonin receptors** on trigeminal neurons causing **vasoconstriction**
**Triptans** (1st line abortive therapy for moderate-severe migraines)
33
You should take **caution** in prescribing **Triptans** as abortive therapy for moderate-severe migraines in which patients?
Patients with controlled HTN
34
When should you **avoid prescribing Triptans** as abortive therapy for moderate-severe migraines?
* **_Pregnancy_** * **Hemiplegic or basilar migraine** * Hx stroke or TIA, or uncontrolled HTN
35
Triptans are contraindicated in what 3 conditions?
* Coronary or peripheral vascular disease * Prinzmetal angina
36
What are the side effects of triptans?
* Nausea * Vomiting
37
**Triptan** can be **combined** with which medication for improved efficacy in the treatment of moderate-severe migraines?
Naproxen
38
What is **_2nd line moderate-severe_** abortive therapy for migraines?
**Ergots** (Ergotamine tartrate/caffeine, Dihydroergotamine)
39
What is the MOA of Ergots?
Non-selective serotonin agonists
40
Ergots are less effective and have more adverse effects than which medications?
Ergots
41
T/F: Ergots are contraindicated in pregnancy?
True
42
Avoid giving Ergots (migraine abortive therapy) in **what condition** and in combination **with what group of meds**?
* CVD * In combo w/ potent CYP 3A4 inhibitors (-azoles)
43
* Which abortive treatment is the **last resort** for migraines? * When should you prescribe this?
* **Opiods** * Use only if pt cant take/does not respond to other tx
44
Are opiods more or less beneficial than migraine specific drugs?
**less** beneficial (last resort as abortive therapy) * Should be used only as rescue medications
45
What can regular use of opiods as alternative abortive therapy for migraines lead to?
* Can lead to **tolerance**, opioid-induced **hyperalgesia,** and **medication overuse headaches** * Potential for **abuse** and **dependence**
46
Which adjuct therapy- abortive therapy would you use in a patient w/ migraines who also has nausea and vomiting?
**Antiemetics/dopamine receptor blockers** (ex: Metoclopramide, Prochloperazine, Promethazine)
47
What is the risk of **Butalbital containing combination oral analgesics** as adjunct therapy for abortive treatment of migraines?
High risk for overuse and dependence | (this is a Barbituate)
48
Why is **hydration** an important adjunct therpay as abortive treatment for migraines?
* Dehydration can trigger migraines * N/V can lead to dehydration
49
What are 4 **non-pharmacologic preventative therapy** options for migraines?
* **Acupuncture** * **Avoidance of triggers** * **Behavioral modification** (regular meals, exercise, sleep hygiene, relaxation techniques, CBT) * **Headache diary**
50
What are 3 indications for pharmacologic preventative treatment of migraines?
* **\> 2-3 x / month** (b/c will put at threshhold for medication overuse from abortive meds) * **Significant disability** with attacks * Last **\> 48 hours** * Acute treatments contraindicated, ineffective, or overused
51
**Which prophylactic migraine medication has the following side effects:** * **Somnolence** * **Concentration difficulties** * **Visual disturbances** (nystagmus, diplopia) * **renal calculi** * **weight loss**
* Topiramate
52
**Which prophylactic migraine medication has the following side effects (popcorn):** * **GI sxs (N/V/D)** * **weight gain** * alopecia * hepatotoxicity * pancreatitis * drowsiness * thrombocytopenia * tremor (she only talked about the bolded ones in class)
Valproic Acid
53
Which 2 cardiovascular meds are most commonly used as prophylactic medications to prevent migraines?
Propanolol Verapamil
54
**Which prophylactic migraine medication has the following side effects :** * Fatigue * dizziness * **hypotension** * **brandycardia** * depression * insomnia * N/V * constipation
**Propanolol** | (so don't give to a cardio patient)
55
**Which prophylactic migraine medication has the following side effects (popcorn):** * **HA** * **Hypotension** * Edema * Flushing * **May aggravate AV block/heart failure** * constipation
**Verapamil** | (so don't give to a cardio patient)
56
**Which prophylactic migraine medication has the following side effects:** * **Sedation** (so _helps w/ insomnia_) * urinary retention * dry mouth * constipation * **weight gain** * blurred vision * edema * hypotension
**Amitriptyline** (this is good for a patient who also has insomnia)
57
**Which prophylactic migraine medication has the following side effects:** * **Somnolence** * **sexual dysfunction** * **nausea** * dry mouth * dizziness * diaphoresis * anxiety * weight loss
**Venlafaxine** (this is good for a patient that also has depression)
58
T**he following MOA is for which prophylactic treatment of migraines?** * Blocks release of Substance P and CGRP * Inhibits peripheral signals to CNS and blocks central sensitization
Botulinum toxin
59
What are 3 investigational treatment options for migraines that would most likely be managed by neuro?
•Neurostimulation techniques 1. Transcranial direct current stimulation 2. Vagal (and other cranial nerve) stimulators 3. Implantable occipital nerve stimulation
60
What is the main complication of pharmacologic treatment of migraines?
•Medication overuse headache (aka analgesic rebound headache) * All abortive meds may cause (least likely with NSAIDS) * Limit acute meds to **\< 10 days per month** * Introduce use of prophylactic treatment
61
How many days per month should you **limit taking medications** as treatment for migraines in order to **avoid medication overuse headache**?
\<10 days
62
The following are considered what type of symptoms? * Visual (ex:blind spot, scintillating scotoma) * Sensory * Speech/language * Motor * brainstem * retinal
Aura

MJ- F2 E4- Neuro (19 decks)

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