Migraine Flashcards
What is a migraine?
- chronic headaches lasting for hours or days.
- accompanied by other symptoms including:
Nausea
Vomiting
Photophobia (sensitivity to light)
Phonophobia (sensitivity to sound) - most migraines cause nausea, vomiting, and sensitivity to light and sound
- some migraines are accompanied by auras
Migraines are often divided into two categories:
1)
2)
1) may occur with aura
2) may occur without aura
Aura: sensory warning symptoms or signs (auras)
- examples:
-such as flashes of light
- blind spots
- tingling in the arms or legs “pins and needles “ sensation
- the aura symptoms are reversible and will resolve overtime on their own
“Most migraines do not have aura”
While it is important to know that a migraine is a headache, NOT ALL headaches are migraines!
a patient should seek medical attention when a headache is accompanied with:
- fever -rash
- stiff neck
- confusion
(all above are classic symptoms of meningitis) - confusion
- seizures
-double vision
-weakness - numbness
- aphasia
(all of the above symptoms are classic for TMJ or stroke)
a headache accompanied by:
-fever, stiff neck, rash, confusion, seizures, double vision, weakness, numbness, chest pain, shortness of breath, or aphasia (trouble speaking) could indicate __________
serious cardiovascular, cerebrovascular, or infectious event. Patient should seek medical attention.
Causes of Migraines: Not Well Understood
from a pathophysiology standpoint, we believe one of the first things that occurs is ___________
Cortical spreading depression: meaning there is an increased neuronal activity happening across the cerebral cortex.
This is believed to activate the trigeminal nerve and resulting in the release of (CGRP) Calcitonin gene-related peptide and other neurotransmitters.
The neurotransmitters and neuropeptides that are released contribute to the process of neurogenic inflammation. Also called aseptic or sterile inflammation.t bacterial or viral cause.
Serotonin is a neurotransmitter involved in the neurogenic inflammation process. Its release is believed to be partly responsible for the release of CGRP.
Serotonin, CGRP, and other neurotransmitters and neuropeptides involved in migraine pathogenesis are sometimes referred to as vasoactive neuropeptides. Because one of the results of neurogenic inflammation is vasodilation. In other words, the release of these substances has an effect on the cranial blood vessels.
CGRP is a potent __________
vasodilator
serotonin can act as a ________
vasoconstrictor or vasodilator
Vasodilation of the intracranial blood vessels is believed to be:
at least partially responsible for migraine headache pain
Causes of Migraines: Not Well Understood
Another result of this cascade of events, is the ______.
This is also called the _________
sensitization of the trigeminal nerve, which also contributes to migraine pain.
sensitization of the trigeminal nerve is called “Central sensitization”, is believed to be responsible for the long duration of migraine attacks.
By definition a migraine lasts ________
4-72 hours when untreated.
allodynia:
pain due to a stimulus that does not normally provoke pain
We need to understand a little of this pathophysiology because ________ and _________ are drug targets for treating and in some cases preventing migraines.
serotonin
(CGRP) Calcitonin gene-related peptide
Triggers are stimuli that patients should identify and avoid to
reduce migraine incidence.
-
-
-
-
-
Hormonal Changes in Women
- one common trigger in women is hormone fluctuations specifically with estrogen (these can sometimes be prevented using hormonal contraception)
Foods
- beer, red wine, aged cheeses, chocolate, aspartame, (MSG) monosodium glutamate, salty foods, processed foods
Stress
- stress is a major cause of migraines
Sensory Stimuli
-bright lights, sun glare, loud sounds and certain scents (pleasant or unpleasant odors)
Changes in Wake-Sleep pattern
- either missing sleep or getting too much sleep (including jet lag)
Changes in the environment
- a change of weather or barometric pressure
Migraines associated with hormone fluctuations are called ___
(MAM) Menstrual-Associated Migraine
Women who experience (MAM) Menstrual associated migraines with aura should use ____________
Progestin-only pills, because these women are at an increased risk of stroke. Should NOT USE estrogen contraceptives since further increases risk!!!
Diagnosis Criteria of a Migraine:
To be diagnosed with migraine, an adult must have:
At least 5 attacks fulfilling the following criteria:
1) Each attack of headache must:
- last 4-72 hours
- and headache attacks recur
2) The attacks must be accompanied by at least 2 characteristics:
- unilateral location (pain is only on one side of the head)
- pulsating pain “throbbing pain”
- moderate to severe pain
- worse with physical activity
3) the headache attack must also have one other symptom
- Nausea with or without vomiting
- Photophobia (sensitivity to light, which makes pain worse)
- Phonophobia (sensitivity to sound, which makes pain worse)
osmophobia
sensitivity to smells
Non-Drug treatments available for Migraine:
Some of these are preventative measures instead of taking a treatment.
- Keeping a headache diary can be helpful at identifying triggers
- Stress Management techniques
- Cold compresses
- massage (used for prevention NOT particularly useful in stopping an attack that is in progress)
- spinal manipulation (performed by a chiropractor, used as a preventative treatment)
- acupuncture (more likely used for prophylaxis)
- Transcutaneous electrical nerve stimulation units (TENS units)
TENS units approved for the prevention and/or treatment of migraines include:
Cephaly
Relivion
- these are worn by the patient and provide small electrical pulses that ultimately block pain signals
gammaCore Sapphire device is approved for both migraines and cluster headaches.
Natural products that can be used for Migraines alone or in combination include:
Vitamins:
- Riboflavin (vitamin B2), can be used prophylaxis
Minerals:
- Magnesium for migraine prophylaxis, diarrhea possible side effect
Herbals:
- Butterbur for migraine prophylaxis, avoid in patients allergic to ragweed
- Feverfew for migraine prophylaxis, avoid in patients allergic to ragweed
- Peppermint, the oil can be used topically for acute migraine attacks or for migraine prevention
Others:
- Coenzyme Q10 (Ubiquinone), used for migraine prevention
- caffeine with Tylenol or with aspirin to treat migraine headaches
Acute Treatment of Migraine is also called ____
Abortive Treatment
- treats a migraine attack
- taken only as needed
Prophylactic Treatment of Migraine is also called ________
Preventive Treatment
- reduces attack frequency, severity
- taken regularly
Acute Drug Treatment: For MILD attacks
Options for treating a migraine that is in progress include:
For MILD attacks
OTC analgesics:
-Tylenol- acetaminophen
-Bayer/Bufferin/Ecotrin - aspirin
-Advil/Motrin/Advil Migraine - ibuprofen
-Aleve - naproxen
Combination OTC products:
- Excedrin Migraine (aspirin/acetaminophen/caffeine)
Why do some of these combination products for migraines contain caffeine?
Caffeine acts as a cerebral vasoconstrictor
- so, it is going to help shrink down some of those over inflamed blood vessels in the head. Which will help to reduce migraine pain.
- it also improves absorption of other drugs
The recommendation for caffeine consumption is no more than 400mg caffeine per day for healthy adults.
Acute Drug Treatment: For Moderate-Severe Migraine attacks
Options for treating a migraine that is in progress include:
For Moderate-Severe Migraine attacks
- prescription NSAIDs
-Triptans - CGRP antagonists
- Ergotamine derivatives & butalbital containing medications
- Lasmiditan (Reyvow)
What classes of medications are NOT recommended for the acute treatment of migraine?
- Butalbital containing combinations (Fioral & Fiorset), NOT very good at treating & (high risk for abuse and dependance)
- Opioids (high risk for abuse and dependance)
- Tramadol & Tapentadol, (high risk for abuse and dependance)
These ARE ALL LAST LINE OPTIONS!!!!!
Medication Overuse/ Rebound Headaches
What is Medication Overuse Headache?
- patient has headaches that occur more than 10-15 days per month
- due to the overuse of a medication
- let patient know to limit use of acute treatment to no more than 2-3 times per week
Triptans
Indications:
MOA:
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class:
Indications: 1st line for acute treatment of moderate to severe migraines
MOA:
Selective agonists for the serotonin receptor (1B/1D subtypes). These drugs bind to these serotonin receptors, this causes vasoconstriction of cranial blood vessels and inhibits neuropeptide release (so also inhibit release of CGRP) which is stopping this neurogenic inflammation and ultimately decreasing pain transmission.
” Selective 1B&1D serotonin receptor agonists”
Dosing:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes: Should be taken at the 1st sign of a migraine for best efficacy.
Drug-Drug/Food interactions:
serotonin type 3 antagonists are antiemetics used for chemotherapy induced N/V
ondansetron
Acute (abortive) treatment of Migraine is when ______
we are treating a migraine that is already present.
Preventative (prophylactic) treatment of migraine is when ___
we are taking treatment regularly to prevent a migraine from occurring.
Which triptan medication is contraindication with Strong CYP3A4 inhibitors?
eletriptan (Relpax)
Which triptan medications are contraindicated with MAO inhibitors? or within two weeks of stopping a MAO inhibitor?
Sumatriptan/Rizatriptan/Zolmitriptan
Which triptans are available as ODT?
rizatriptan/zolmitriptan
which triptans are available as nasal sprays?
Should these nasal devices be primed?
sumatriptan/zolmitriptan
No, they contain 1 dose, DO NOT prime.
Which triptan medication is available as a nasal powder?
sumatriptan (Onzetra Xsail)
Which triptan medications should not be given to a patient who has phenylketonuria?
Maxalt-MLT & Zomig ZMT
Which triptan medication has the longest duration?
frovatriptan (longest half-life of 26 hours)
Which triptan medications car considered to be long- acting but have a slower onset?
frovatriptan & naratriptan
Which triptan medications have a short half-life but a fast onset of action?
almotriptan/eletriptan/rizatriptan/sumatriptan/zolmitriptan
Which triptan medication should be dispensed in its original container/manufacturer bottle to protect from moisture?
Treximet (sumatriptan +naproxen)
Which triptan medications are approved for children and adolescents greater than or equal to 12 years old?
almotriptan tablets, zolmitriptan nasal spray & Treximet
