Lecture 2 - migraines, triptans

Question 1

migraines –
Pattern
symptoms
(what are the autonomic symptoms)

Answer 1

Acute and recurrent

Ha, Autonomic sensitivity (N, V, photophobia, phonophobia)

Question 2

three types of true migraines

general treatment for migraines
what is the exception

Answer 2

Migraine with aura (10%) – aura precedes the HA
Tx - triptans

Migraine without aura (85%) – no aura, but may have another prodrome (eg yawn)
Tx -Triptans

Complicated migraines
Cannot treat with triptans

Question 3

4 types of complicated migraines

Answer 3

Hemiplegic migraine
Ophthalmoplegic Migraine
Basilar Artery Migraine
Alice in Wonderland Syndrome

Question 4

Tension type HA

• pattern and symptoms
• considerations for treatment

Answer 4

Acute and recurrent HA, but without Autonomic Sx

Can be “mixed” with true migraine

Treatment with triptans only if mixed

Question 5

goal of for treating migraines

Answer 5

Treating migraine is a race against the clock to prevent cutaneous allodynia

Question 6

Pathophysiology of migraines

Answer 6

genetic susceptibility

Triggers – internal or external

Decreases in Serotonin from the Median Dorsal Raphe Nucleus and Trigeminal Vascular System

which leads to opening of the 5HT1D receptor – release of inflammatory mediators (PGE, histamines, bradykinin)

leads to meningeal inflammation

Question 7

3 drugs which can be used to treat migraines in the acute setting

Answer 7

• prostaglandin inhibitors
  
  • antihistamines

5ht Agonists – Triptans

Question 8

Mechanism of Triptans;

name a few

Answer 8

• Mimic Serotonin; Close the gate of inflammatory release upon Serotonin Drop and and stop the headache if you catch it early enough

Sumatriptan 
Zolmitriptan 
Rizatriptan 
Naratriptan 
Dihydroergoatamine

Question 9

Prevention of migraines

adjunct therapies

Answer 9

Avoid triggers
SSRIs, TCAs, Calcium Channel Blockers, Anticonsulvants

Anti-Emetics: 
Anxiolytics:

Question 10

assessment of migraine pt:

what is SNOOP?

Answer 10

SNOOP – red flag symptoms that would indicate dx other than migraine. Requires MRI

• Systemic sx: weight loss
• neurologic sx :
• Onset abrupt
• older pt at onset
• Previous HA history is different

Question 11

Secondary HA causes:

what is the most common reason for HA

Answer 11

Tumor, HTN, Infection, Hemorrhage

Infection = most common reason for HA

Question 12

of the secondary causes: which have a chronic progressive pattern vs acute onset pattern

Answer 12

Chronic progressive:
Tumor (worse in the AM, worse with valsalva)

HTN (malignant HTN)

Acute:
Hemorrhage (thunderclap)

Infection – meningitis, encephalitis

Question 13

what is the most common dx of patients in a HA clinic population

Answer 13

30-80% have chronic daily HA

Question 14

criteria for Chronic daily HA

Answer 14

> 15 HA/month
4 hours/day
Normal MRI

Question 15

three types of chronic daily HA

• patterns for each
  which is the hardest to treat

Answer 15

Transformed Migraine – CHD which develops acute and recurrent pattern

Chronic Tension Type HA -patients with tension type HA that is now chronic
No migraine spikes

• new persistent daily HA- a new HA that doesn’t go away
  hardest to treat