Lecture 50 - Pharmacotherapy of Migraines Flashcards
Migraine types
migraine without aura (common)
migraine with aura (classic)
Migraine without aura (common) - diagnostic criteria
◦ At least five attacks
◦ Headache lasting 4 – 72 hours
◦ Unilateral location, pulsating quality, moderate/severe pain, aggravation
by routine activity
◦ Nausea and/or vomiting,
photophobia, phonophobia
Migraine with aura (classic)
◦ At least two attacks
◦ At least one fully reversible aura
◦ No aura lasting more than 60 minutes
◦ Headache follows aura within 60 min
◦ Aura symptoms: visual, sensory, speech/language, motor, brainstem, retinal
Migraine headache phases
1: prodrome
2: aura
3: migraine headache
4: postdromal
Prodrome
- Hours or days
before onset of
headache - May experience
euphoria, depression,
irritability, food
craving, constipation, neck
stiffness, yawning
Aura
15-30% of patients
* Commonly visual, may be sensory, verbal, or motor
* Before or during migraine, lasts less than 60 minutes
* Photopsia (flash of
light or floater in
eye), scotoma (blind spot), zigzag lines, numbness/tingling
in arms, legs, face
Migraine headache
- Dull ache that intensifies
- Unilateral and throbbing
- Phonophobia, photophobia
Postdromal
- May last several days after headache has ended
- Tiredness, head pain, GI distress, mood changes, weakness, cognitive difficulties
Migraine triggers
Medication Overuse Headache
* Associated with analgesics, ergots, triptans – rebound headaches from medication overuse more than two times per headache or two times per week chronically
* Can be managed by gradual reduction of medication use limited to no more than 2 doses per headache or two times per week and avoidance of butalbital/opioids – use meds with less withdrawal potential (low-dose NSAID)
Medications: oral contraceptives, hydralazine, nitroglycerin, nifedipine, cocaine
Diet: chocolate, oranges, tomatoes, onions, aged cheese, processed meats, cultured dairy, alcohol (specifically red wine and champagne), caffeine
Additives/preservatives: aspartame and monosodium glutamate
Environment: altitude/weather changes, perfume, tobacco smoke, loud noises, flickering lights Too little or too much sleep, skipping meals, stress, hormone changes
Avoid _____ in treatment
analgesic overuse
Abortive treatment
◦ Education to avoid medication overuse
◦ Mild-moderate: NSAIDs, acetaminophen
◦ Moderate-severe: triptans/ergots
Preventive treatment
◦ Four or more attacks/month with disability at least 3 days/month
Abortive treatment guidelines
first line: triptans, NSAIDs
second line: NSAIDs
Prevention treatment guidelines
first line: monotherapy: valproate, topiramate, metoprolol, propranolol, frovatriptan
second line: monotherapy: amitriptyline
Non-pharmacolgical therapy
biofeedback and relaxation therapy
cognitive behavioral therapy
diet
sleep
transcutaneous electrical nerve stimulatiion device
exercise, massage, acupuncture, thermal biofeedback, heat/cold applications, headache diary
Overview of triptans for abortive treatment: contraindications
Contraindications: recent use (within 24 hours) of an ergot or other triptan, MAO-A inhibitor use in the last 2 weeks (frovatriptan, rizatriptan), ischemic heart disease, angina, history of stroke or TIA or hemiplegic/basilar migraine, arrhythmias, peripheral vascular disease, uncontrolled hypertension, ischemic bowel disease, severe hepatic impairment
Overview of triptans for abortive treatment: warnings/precautions
Warnings/precautions: MI, pain/pressure/tightness in chest/throat/neck/jaw, CVA, HTN, GI ischemic reactions or peripheral vasospasm, medication overuse headache, serotonin syndrome, sulfa allergy (almotriptan), corneal opacities (almotriptan), seizures (use with caution)
