Migraines Flashcards
(44 cards)
What are the progression/steps of a migraine attack?
1) Vulnerability (external factors)
2) Start of attack
3) Prodrome
4) Aura (does not always happen)
5) Headache
6) Post-Headache state
Cause of migraines:
Not fully understood. Likely due to vasodilation in cranial blood vessels and/or neurotransmitter imbalances. May be genetic factors.
Patients should identify and avoid “triggers” if possible such as:
1) Hormonal changes in women (ex. menstrual-associated migraines). Can be treated with oral contraceptives, the estradiol patch, or creams.
2) Foods
3) Stress
4) Sensory stimuli (ex. bright lights, smells)
5) Changes in sleep-wake pattern
6) Changes in the environment
Migraines can be diagnosed when an adult has at least 5 attacks fulfilling the following criteria:
1) Headaches last 4-72 hours and recur sporadically
2) Have ≥ 2 of the following characteristics: unilateral location, pulsating, moderate-severe pain and aggravated by (or causing avoidance of) routine physical activity
3) One of the following occurs during the headache: nausea and/or vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound)
Non-drug treatments include:
1) Headache diary
2) Massage, applying cold compresses to head
3) Natural products: caffeine, butterbur, feverfew, magnesium, riboflavin, coenzyme Q10, topical peppermint
Acute treatments to treat existing headaches include:
1) OTC or Rx NSAIDs
2) acetaminophen
3) Excedrin Migraine (aspirin, acetaminophen, caffeine)
4) Triptans
5) Ergotamine
6) may benefit from antiemetic for N/V
Triptans are selective serotonin…
agonists for the 5-HT1 receptor (1B/1D) and cause vasoconstriction of cranial blood vessels, inhibit neuropeptide release, and decrease pain transmission
Triptans should be taken…
at the first sign of a migraine; can repeat dose if it does not help
Which two triptans are available as orally disintegrating tablets (ODTs)? (no water needed)
1) rizatriptan (Maxalt-MLT)
2) zolmitriptan (Zomig)
Which two triptans are available as nasal sprays?
1) sumatriptan (Imitrex)
2) zolmitriptan (Zomig)
Which triptan can be given by SQ injection (preferred site is lateral thigh or upper arm)?
Sumatriptan is available as:
1) a prefilled syringe (contains latex derivative)
2) autoinjector (Imitrex STATdose System, Zembrace SymTouch)
What are contraindications for use of triptans?
Cerebrovascular disease (stroke/TIA), uncontrolled hypertension, ischemic heart disease, peripheral vascular disease, history of hemiplegic or basilar migraine, use within 24 hours of another triptan or ergotamine-type medication
What are warnings associated with triptans?
Risk of increased BP, serotonin syndrome, cardiac and cerebrovascular events, arrhythmias, medication overuse headache (MOH), seizures (sumatriptan only);
What are side effects for triptans?
Paresthesia (tingling/numbness), dizziness, hot/cold sensations, chest pain/tightness, dry mouth, somnolence, nausea. May feel pressure or heaviness in the chest and/or neck (should improve)
sumatriptan + naproxen
Treximet (dispense in the original container and protect from moisture)
Which triptans contain phenylalanine and should not be used in patients with phenylketonuria?
1) rizatriptan (Maxalt-MLT)
2) zolmitriptan (Zomig ZMT ODT)
Which triptans are considered long-acting and have slow onset?
1) frovatriptan (Frova); half-life is 26 hours
2) naratriptan (Amerge)
* Note: can be a good option if headache recurs after dosing, lasts a long time, or can be anticipated in advance (e.g.MAM)
Triptan Drug interactions
1) risk of serotonin syndrome with SSRIs and SNRIs
2) Sumatriptan, rizatriptan and zolmitriptan are contraindicated with MAO inhibitors (or within 2 weeks of stopping)
3) Eletriptan is C/I with strong CYP3A4 inhibitors (reduce dose of almotriptan)
Ergotamine drugs may be used in patients with C/I to triptans or for those who do not find benefit with them.
they are nonselective agonists of sertonin receptors
dihydroergotamine
1) D.H.E. 45 Injection (IM/SC/IV)
2) Migranal (nasal spray)
Note: Prime nasal spray by pumping 4 times. Do not inhale deeply. 1 spray (0.5 mg) into each nostril, can repeat after 15 minutes, up to a total of 4 sprays.
ergotamine + caffeine
1) Cafergot (tablet)
2) Migergol (suppository)
What are contraindications associated with ergotamines?
1) Use with strong CYP3A4 inhibitors due to serious and life-threatening peripheral ischemia
2) Uncontrolled HTN
3) Pregnancy (category X)
4) ischemic heart disease
5) angina/MI
6) Peripheral vascular disease
7) Hemiplegic or basilar migraine
8) Sepsis
9) Use with pressors/vasoconstrictive drugs
Butalbital-containing products are not recommended for treating acute migraines due to…
dependence issues and lower efficacy. Must be tapered off if used regularly and long-term.
Consider prophylactic treatment if the patient:
1) requests it
2) uses acute treatments ≥2 days/week or ≥3 times per month
3) or if the migraines decrease their quality of life or if acute treatments are ineffective or contraindicated
