Propranolol Valproate Topiramate Onabotulinum toxin Ergotamine + Dihydroergotamine Sumatriptan Metaclopromide Caffeine NSAIDs

vascular headache = vasodilation 2 versions : classic = aura common = w/o aura

20% visual/sensory aura aphasia, vertigo, pallor, chills, tremor, unilateral weakness

women genetic start in adolescence

mental endogenous exogenous - food, ETOH, allergens, MSG, etc. other - lights, smells, temp, altitude

Repeated headache attacks, lasting 4 hours - 3 days 2 of these: unilateral pain throbbing pain aggravation w/ movement moderate/severe intensity +1 of these: N/V Photophobia/phonophobia

Serotonin Periphery GI

Motility Malignant carcinoid tumors secrete emesis, nausea

frequent occurence (>3-5/month) mild-moderate therapy classic> over 1/2 success rate >6 weeks tx to work may need tolerance break after 6 months UP CSD threshold (supress)

Onabotulinum toxin SE

Neck pain Muscular weakness (Ach) eyelid/eyebrow ptosis (improper technique)

Migraine Flashcards by O lawformonde

Migraine

Rx list

Propranolol
Valproate
Topiramate
Onabotulinum toxin
Ergotamine + Dihydroergotamine
Sumatriptan
Metaclopromide
Caffeine
NSAIDs

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Migraine

Mech

*vascular headache = vasodilation

2 versions :

classic = aura
common = w/o aura

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Classic migraine

20%
visual/sensory aura
aphasia, vertigo, pallor, chills, tremor, unilateral weakness

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Migraine

Who?

women
genetic
start in adolescence

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Migraine

s/s

*Onset w/ waking
*4 hour - 3 days
*from trigger
*n/v
*photophobia
*scalp tenderness
*lightheadedness
*vertigo
MORE THAN PAIN

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Migraine triggers

mental
endogenous
exogenous - food, ETOH, allergens, MSG, etc.
other - lights, smells, temp, altitude

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Repeated headache attacks, lasting 4 hours - 3 days

2 of these:

unilateral pain
throbbing pain
aggravation w/ movement
moderate/severe intensity

+1 of these:
N/V
Photophobia/phonophobia

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CGRP calcitonin g related peptide

From trigeminal ganglian neuron

*Sterile inflammation / sensitization of blood vessels AND affect brain

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Serotonin

role in migraine

5HT + metabolites change (increase) during migraine
triggers pain afferents
5HT constricts cerebral vessels
Migraine - other serotonin behaviors = sleep, appetite,depression
DON’T REALLY KNOW
best Rxs address serotonin

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Serotonin

Periphery - hemostasis

*hemostasis. = platelet aggregation, vasoconstriction (spasm = too much)

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Serotonin
Periphery

Motility
Malignant carcinoid tumors secrete
emesis, nausea

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Prophylactic Tx

frequent occurence (>3-5/month)
mild-moderate therapy
classic>
over 1/2 success rate
> 6 weeks tx to work
may need tolerance break after 6 months
UP CSD threshold (supress)

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Prophylactic Tx

Rx 1st line

1st line =
*B-blocker
Propranolol
Timolol

*Anticonvulsants
Valproate
Topiramate

+others REVIEW SLIDE

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Beta blockers

Migraine prophylaxis

*mech unknown
*many S.E
Fatigue, GI disturbance
Depression, insomnia,nightmare
*NO IN ASTHMA, DEPRESSION, HF
*NO w/ CCB
*withdrawal = CV distress

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Anticonvulsants

Topiramate

block sodium + calcium channel
block glutamate receptors
UP gaba
stop TNC
SE - paresthesia, fatigue, cognitive impairment, weight loss

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Onabotulinum Toxin (BoTox)

Chronic 15< per month
Every 12 weeks
Cleaves snares in release of CGRP
1) lowers peripheral sensitization
2) lowers central sensitization

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Onabotulinum toxin

Neck pain
Muscular weakness (Ach)
eyelid/eyebrow ptosis (improper technique)

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Acute Tx

Mild ot moderate

Naproxen
Caffeine
vasoconstriction
aids in absorption of analgesics
adjuvant
Metoclopramide REGLAN
5ht3 + D2 receptors
anti-emetic, up gastric emptying
adjuvant

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Severe Migraine Tx

Study These Flashcards

Ergots

Triptans

Ergots

Mech

Study These Flashcards

oldest
Dx and Treatment
Vasoconstrictor CNS
non- selective 5ht ags

Ergots

Routes

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Dihydroergotamine (DHE) - parenteral/nasal
eratic w/ oral response
PR - nausea

*combos = caffeine, sedatives

Ergot

Therapy

Study These Flashcards

Must take Early - not rescue drugs
S.E. w/ ergotamine may be limiting
dependence

Ergots

S.E.

Study These Flashcards

Dihydroergotamine = parenteral admin faster
Less S.E.

Drug interactions = triptans, b blocker, nicotines

Triptans

Study These Flashcards

Sumatriptan IMITREX

Triptans

1st line * selective 5HT1 ags (b/d/f) * multiple routes * rapid * good response

Triptans S.E.

* Minimal effects - receptor selectivity * Re-emergent migraine * Coronary disease (watch) - vasoconstriction

Triptans Rx interaction

MAOIs (break down??)

Triptans "Stratified care"

- mix = oral/nasal/injectable as needed * injectible (5 mins)- rescue * nasal (15mins) - fast * NSAID (naproxen)= adjuvant

New migraine therapies

*-Ditans = 5-H1F receptor ag, only TG path,no vessels, good with CV dz * CGRP antags (gepants) * CGRP antibodies

Triptans

* onset | * duration

Sumatriptan Mech

* serotonin derivative | * Selective ags = 5HT 1b/1d

Other mild/moderate migraine Tx

* opiods * phenothiazines (don't use - S.E.) * Combos - vasoconstrict + analgesic + sedative. (Acetaminophen+Aspirin+caffeine)

CSD = cortical spreading depression

* Spread from back to front * Decrease (depole) in Blood flow, Then Increase (hyperpole) in blood flow * aura * dilation = pain

TG system activatoin

Input from meningial vessels Trigem afferents --> Trigem ganglion --> trigem nucleus caudalis --> thalamus --> cortex Input from Locus ceruleus + Periaqueductal gray + raphe nucleus (serotonin) =. (bstem) =CSD activates this

CSD = TG system =

CSD = aura TG system = pain

Serotonin targets for Migraine

5HT1 = B/D/F

Migraine Prophylaxis Anti-convulsants Valproate

* up GABA-mediated transmission (down inflammation) | * S.E. = N/V, weight, NO PREGGER

Migraine prophylaxis Anti-convulsants Topiramate

* Block Na+/Ca2+ channel * Down Glutamate, UP Gaba, STOP TNC *S.E. = topiramate = paresthesias

Migraine prophylaxis Anti depressants

TCAs * amitriptyline * nortriptyline

Migraine prophylaxis CCB

Verapamil *block 5-HT *S.E. - hypoTN

Migraine prophylaxis NSAIDs

Naproxen | *frequent use - withdrawal, s/s worse

Triptans vs. ergots Later in migraine

Triptans effective!

Which give rebound headache

Triptans Don't take too close together

Migraine = main tx ideas Directly constrict blood vessels Rx

Caffeine | Triptans

Migraine = main tx ideas Inhibit vasodilation

Shut off inflammatory mediators = CGRP Inhibit leakage with vasodilation

Migraine = main tx ideas Work centrally

TNC

Migraine Flashcards

(46 cards)