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neurology/psychiatry > migraines > Flashcards

migraines Flashcards

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1
Q

primary versus secondary headache

A

primary: tension headache, cluster headache, migraine with or without aura

secondary: head/neck trauma, vascular disorders, seizures, tumor, substance withdrawal (MEDICATION OVERUSE HEADACHE), infection, psych disorder

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2
Q

migraine: location?

A

unilateral

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3
Q

migraine: type of pain?

A

throbbing, pulsating

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4
Q

migraine: onset and duration?

A

onset gradual, duration 4-72 hours

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5
Q

other symptoms with migraines

A

nausea, vomiting, photosensitivity, phonosensitivity

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6
Q

risk factors for migraines

A

female (more common than men)
age
genetics (50% chance if 1 parent has migraines, 75% chance if both parents have migraines)

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7
Q

depolarization theory for the pathophysiology of migraines

A

vasoactive peptides like CGRP and neurokinin A and substance P are released. then interact with dural blood vessels to cause vasodilation, neurogenic inflammation, activation of sensory neurons in trigeminal nerve, pain

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8
Q

what are the phases of a migraine?

A

premonitory, aura, headache, postdromal

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9
Q

what are some food triggers of migraines

A

alcohol, caffeine or caffeine withdrawal, chocolate, MSG, nitrate or tyramine containing foods, yeast productsw

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10
Q

what are some environmental triggers of migraines

A

glare/flickering lights, high altitude, loud noises, strong smells/fumes, tobacco smoke, weather changes

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11
Q

what are some behavioral/physiologic triggers of migraines

A

excess or not enough sleep, fatigue, menstruation, menopause, skipped meals, strenuous physical activity, stress or post stress

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12
Q

what is the premonitory phase?

A

a prodrome/warning signs experienced by ~80% of patients hours-days before migraine onset. can consist of neurologic, psychologic, autonomic, and constitutional symptoms. ex: photophobia, anxiety, diarrhea/constipation, stiff neck, etc…

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13
Q

what is an aura

A

+ and - neurologic symptoms that precede or accompany a migraine attack including visual, sensory, and motor symptoms

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14
Q

migraines with aura increase ________

A

risk of ischemic stroke 2.4x higher than migraine without aura

(2nd highest risk factor for stroke, after hypertension)

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15
Q

what are some symptoms of aura

A

visual: scintillating scotomas, fortification spectrum
sensory: paresthesias
motor: dysphasia, weakness

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16
Q

what is the postdrome phase

A

resolution phase, can consist of fatigue, irritability, impaired concentration and mood
some patients report mild euphoria/feeling refreshed

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17
Q

what is the acronym that describes migraines?

A

SULTANS
Severe
Unilateral
Location (unilateral)
Throbbing
Activity provokes pain
Nausea
Sensitivity to light/sound

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18
Q

what is the acronym that describes concerning symptoms/red flags?

A

SNOOPS
Systemic s/sx (fever, myalgia, wt loss)
Neurologic s/sx (confusion, AMS)
Onset (sudden, abrupt, split second)
Older patient with new onset (40, 50 yo)
Pattern change
Secondary risk factors (HIV, cancer)

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19
Q

diagnostic criteria for migraine without aura

A

at least 5 attacks
headache 4-72 hrs
not better accounted for by another diagnosis
at least 2 of the following: unilateral, pulsating, moderate-severe, aggravation by activity
and at least 1: n/v, photophobia, phonophobia

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20
Q

diagnostic criteria for migraine with aura

A

at least 2 attacks
not better accounted for by another diagnosis
at least 1 fully reversible aura symptoms
at least 3 characteristics: aura spreads gradually over 5 minutes, 2 aura symptoms occur in succession, at least one is unilateral, at least one is positive, aura is accompanied by headache within 60 minutes

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21
Q

what drug classes can be used for acute treatment of migraines?

A

analgesics like NSAIDs and APAP
triptans
ergot alkaloids
CGRP receptor antagonists (gepants)
5-HT1F receptor agonists (ditans)

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22
Q

general treatment algorithm for MILD migraine symptoms

A

1st line: oral NSAIDs, APAP
2nd line: combo: acetaminophen/aspirin/caffeine
3rd line: triptans, ergots, gepants, ditans

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23
Q

general treatment for SEVERE migraine symptoms

A

triptans
ergots
gepants
ditans

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24
Q

limit for analgesics such as NSAIDs and APAP?

A

3 days/week or 15 days/month to avoid MOH

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25
which combination analgesics should be AVOIDED
products containing butalbital: abuse potential
26
mechanism of triptans
selective agonists at 5HT1B and 5HT1D
27
limit for triptans
3 days/week or 10 days/month to avoid MOH
28
which triptans have the best outcomes
sumatriptan SQ rizatriptan ODT zolmitriptan ODT eletriptan tablets
29
considerations for failed triptans
try a different triptan if unsuccessful for 3 attacks. consider different class after failed TWO triptans.
30
timing of administering triptans
give within 1 hour of onset, effective if within 4 hours
31
side effects from triptans
dizziness, fatigue, flushing, paresthesias, n/v local injection site inflammation taste perversion, nasal discomfort angina/coronary ischemia
32
drug interactions with triptans
SSRIs/SNRIs, ergots, other triptans, MAOI (2 weeks), CYP4A4 inhibitors, propranolol, cimetidine
33
contraindications to triptans
cerebrovascular disease like stroke, TIA CV: uncontrolled HTN or ischemic heart disease hemiplegic or basilar migraine
34
which drugs are ergot alkaloids
ergotamine dihydroergotamine
35
place in therapy for ergot alkaloids
moderate to severe migraines in patients failing triptans
36
mechanism of ergots
nonselective 5HT1 agonists that activate other types of serotonin receptors, alpha adrenergic, and DA
37
preferred routes of administration for ergots
IV>IM>Inhaled>SQ>PO (GI absorption erratic)
38
administer ______ with parenteral dihydroergotamine
antiemetic (mitigate nausea)
39
common side effects from ergots
n/v, muscle cramps & abd pain, numb/tingling figers/toes
40
serious side effects from ergots
sustained generalized vasoconstriction, HTN, MI, CVA, gangrene, bowel ischemia, coronary ischemia
41
drug interactions with ergots
triptans, CYP3A4 inhibitors
42
contraindications with ergots
PREGNANCY or breastfeeding, CV Disease (HTN, etc), impaired renal/hepatic function, hemiplegic or basilar migraine
43
which drugs are CGRP receptor antagonists
ubrogepant rimegepant zavegepant
44
place in therapy for CGRP receptor antagonists
for patients with insufficient response to triptans
45
MOA of CGRP receptor antagonists/gepants
decrease activity of CGRP lacks direct vasoconstrictive activity
46
side effects from CGRP receptor antagonists/gepants
nausea, somnolence, dry mouth
47
contraindications for CGRP receptor antagonists/gepants
concomitant use of strong CYP3A4 inhibitors not rec in pregnancy
48
which drug is a selective serotonin 5-HT1F receptor agonist
lasmiditan
49
lasmiditan place in therapy
in lack of response or contraindication to triptans
50
lasmiditan MOA
selective 5-HT1F agonist that lacks vasoconstrictor (5HT1B/D) activity
51
side effects of lasmiditan
dizziness, somnolence, paresthesia, fatigue, nausea CV do NOT drive within 8 hours of administration!!
52
place in therapy for antiemetics in migraines
monotherapy for migraine treatment, adjunct to simple analgesics/triptans when nausea/vomiting limit the absorption of oral medications
53
preferred antiemetics in migraine treatment
parenteral dopamine antagonists metoclopramide, prochlorperazine, chlorpromazine administer with IV diphenhydramine to prevent akathisia and acute dystonic reactions
54
candidates for migraine prophylaxis
recurrent attacks producing significant disability, frequent attacks, ineffective or contraindicated to acute treatment, uncommon migraine variants with risk for severe neuro injury, patient preference
55
what is an adequate therapeutic trial for migraine prophylaxis
2-3 months for oral agents 3-6 months for monoclonal antibodies maximum effects take 6 months
56
which agents are level A for migraine prophylaxis (established efficacy)
Oral: antiepileptics- divalproex, valproate, topiramate; beta blockers- metoprolol, propranolol, timolol; ARB- candesartan Parenteral- CGRP mAbs, onabotulinumtoxin A
57
which agents are level B for migraine prophylaxis (probably effective)
oral: antidepressants- amitriptyline, venlafaxine; beta blockers- atenolol, nadolol; ACEi lisinopril parenteral: onabotulinumtoxin A + CGRP
58
migraine prophylaxis for patients whose headaches recur in a predictable pattern (ex menstrual migraines)
NSAID or triptan at time of vulnerability
59
migraine prophylaxis for healthy patients or comorbid hypertension, angina
B-adrenergic antagonist (verapamil if contraindicated)
60
migraine prophylaxis for patients with comorbid depression or insomnia
TCA
61
migraine prophylaxis for patients with comorbid seizure disorder or bipolar illness
anticonvulsant
62
contraindications for divalproex, valproate
pregnancy, liver disease precaution: pancreatitis, thrombocytopenia
63
precautions for topiramate
history of kidney stones, cognitive impairment, pregnancy
64
contraindications for beta blockers
asthma, diabetes, CHF, depression
65
contraindications for candesartan
pregnancy
66
precautions for amitriptyline
BPH, glaucoma, elderly (Beer's)
67
precautions for venlafaxine
abrupt withdrawal, concomitant triptan use
68
contraindications for lisinopril
pregnancy
69
CGRP is a _____ that does _____
a neuropeptide that is expressed in the trigeminal ganglia nerve that leads to vasodilation
70
MOA of CGRP mAbs
antagonize CGRP receptor preventing vasodilation during migraine attacks
71
FDA approved CGRP mAbs for migraine prevention
Erenumab (Aimovig) Fremanezumab (Ajovy) Calcanezumab (Emgality) Eptinezumab (Vyepti)
72
place in therapy for CGRP mAbs
benefits patients who did not respond to other prophylaxis classes decreases migraine frequency in 3-6 months
73
reauthorization for CGRP mAbs depends on what criteria
reduction in monthly headaches of at least moderate severity of >50% or a clinically meaningful improvement in validated scale
74
botox MOA
inhibits acetylcholine release at motor nerve terminals
75
indication/ADEs/contraindications to botox for migraine prophylaxis
FDA approved for chronic migraines ADEs: neck pain and muscle weakness contraindications: infection at injection site
76
supplements that may be beneficial for migraines?
magnesium oxide-- ADEs diarrhea riboflavin (B2)-- ADEs yellow/orange urine
77
general features of tension headaches
bilateral mild to moderate pain dull, aching, non-pulsating, headband-like other symptoms are STRESS can last 30 min-7 days
78
treatment for tension headaches
1st: analgesics, NSAIDs 2nd: combination analgesics containing caffeine
79
general features of cluster headaches
unilateral, supraorbital, SEVERE pain sharp, stabbing commonly occurs at night 15-180 minutes, up to 8 attacks/day can also cause unilateral autonomic symptoms, restlessness
80
treatment for cluster headaches
oxygen, triptans for ACUTE treatment prevention with verapamil (1st line), lithium, corticosteroids
81
causes of medication overuse headaches
withdrawal due to regular overuse of headache medications. more than 15 days/month for 3 months of simple analgesics. more than 10 days/month for 3 months of combination, triptans, ergots.
82
treatment of medication overuse headaches?
avoid stopping treatment altogether- start prophylactic regimen to decrease reliance on acute therapy
83
risk factors for medication overuse headaches
age <50 years female smoking physical inactivity high daily caffeine intake >540 mg
84
medication overuse headache prevention
no more than 3 days per month of butalbital no more than 9 days per month of combination analgesics no more than 15 days per month of NSAIDs
85
features of menstrual related migraines
occurs immediately before monthly cycles (~3 days), oral contraceptives and hormone replacement therapy may change frequency or severity of migraine
86
what is the root cause of menstrual related migraines
decline in estrogen immediately prior to menstruation
87
treatment of menstrual related migraines
triptans 1-2 days before menses NSAIDs 1 week before

neurology/psychiatry (22 decks)

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