What are classic prodrome symptoms of migraine?
mood change, fatigue, muscle tension, yawning, cognitive dysfunction
What is mech of neurogenic inflammation
trigeminal nerve activation –> release of CGRP/substance P/neurokinin A causes vasodilation, mast cell degranulation –> neurogenic inflammation within meninges –> pain
What is use of NSAIDs in migraine treatment?
non-specific acute treatment efficacy comparable to oral triptans dosing limited due to concern for renal toxicity non-sedating no increase in nausea safe in presence of vascular disease
What is use of neuroleptics in migraine treatment?
D2 antagonist to treat headache pain and migraine-associated nausea
Why shouldnt you treat migraine with opioids?
poor efficacy/paradoxical increased pain sensitivity b/c:
- pro inflammatory [degranulate mast cell], vasodilator, activate opioid receptors
- drug seeking behavior
- increase N/V
- poor efficacy
What is role of dopamine in migraine?
- prodomal symptoms are due to DA activation
What is effect of DA antagonists in migraine? side effects?
- antiemetic
- sedative
side effects = sedation and orthostatic hypotension
ex. metoclopramide
What are some names of D2 antagonists that are used to treat migraines?
given IV usually
- cholopromazine
- prochlorperazine
- droperidol
- metoclopramide
What are advantages/disadvantages of neuroleptics as migraine treatment?
- effective IV, reduce N/V
side effects:
- sedation, prolonged QT, orthostatic HTN,
extrapyramidal effects [dyskinesia]
dihydroergotamine: use, mech, effects, other
use: specific acute treatment to stop migraine
mech: agonist to 5HT-1D receptor
effects: vasoconstriction, nausea
contraindications: vascular disease, HTN, renal/hepatic failure, pregnancy
other: less specific for 5HT receptor compared with triptans
How does giving 5HT effect migraine?
IV 5HT relieves migraine but intolerable side effects
triptans use, mech, effects, other
use:
mech: 5HT1B/D (and some 1G) receptor agonist
effects:
other
What are the 3 mechs of action triptans in improving migraine symptoms?
- intracranial vessel vasoconstriction [5HT1B]
- peripheral neuronal inhibition [5HT1D]
- presynaptic dorsal horn stimulation [5HT1D] causes 2nd order brainstem neuronal inhibition
What are effects of triptan?
- reduce all aspects of migraine disability
- minimal or no sedation
- intrinsic antiemetic properties
What is use of opioids in migraine treatment?
emergency/rescue treatment
What is clinical triad of serotonin syndrome?
- mental status change
- autonomic hyperactivity [HTN, fever, shivering, diarrhea]
- neuromuscular abnormality [myoclonus, ataxia, hyperreflexia]
When should you consider preventative migraine treatment?
- headache freq > 6 per month
- headahce disability too often
- acute meds inneffective or contraindicated
- prolonged migraine aura or profound disability
What is mech of migraine prevention?
- raise threshold for migraine activation [inhibit CSD, sensitization, neurogenic inflammation]
- stabilize more reactive nervous system
What is use of antiepileptic drugs as migraine prophylaxis? which drugs?
valproate and topiramate
valproate: use, mech, effects, other
use: migraine prophylaxis or epilepsy
mech: block Na channels
effects: nausea, weight gain, tremor, alopecia, encephalopathy, hepatitis, pancreatitis
other: contraindicated in pregnancy
topiramate: use, mech, effects, other
Use: migraine prophylaxis or epilepsy
mech: block Na/Ca, increase GABA-A
effects:
other:
What should you use to treat pt with bipolar disorder and migraine?
valproate
What is effect of propanolol in migraine?
beta blocker = prophylaxis for migraine
How is efficacy of antidepressants as migraine treatment affected by presence/absence of depression?
not affected!
What is role of ca-channel antagonists in migraine?
exact mech uncertain
verapmil = L-type Ca channel blocker = most commonly used
may be good for migraine with prolonged aura or vestibular migraine
Onabotulinum toxin A: use, mech
Use: chronic migraine prophylaxis
mech: Inhibits release Ach at NMJ, blocks peripheral sensitization