Flashcards in Migraines/HA Deck (105):
What causes an aura phase?
Reduction in cerebral blood flow that beings in the occipital region and moves across the cerebral cortex
What causes migraines?
From fibers in the intracranial extra cerebral blood vessels, dura mater, and large venous sinuses
Could be related to dysregulation of serotonin release
Are there any nociceptors in the brain?
What causes the release of neuropeptides in migraines?
Activation of the trigeminal sensory nerve
What neuropeptides are released during a migraine?
Calcitonin gene related peptide (CGRP)
What do neuropeptides cause?
Dura plasma extravasation
What parts of genetics can cause migraines?
Cause imbalances of the CNS which have a lower threshold for pain
Abnormalities in Ca and Na channels responsible for neurotransmitter
Low levels of serotonin, dopamine, and increased levels of glutamate
What is premonitory sx?
Occurs in the hours or days before the onset of the HA
Can vary greatly between individuals, but is consistent w/in the individual
Generalized throughout the body
Bothersome but not debilitating
Could be caused from something other than a migraine
What is an aura?
A complex of positive and negative focal neurologic sx that precedes or accompanies an attack
Evolves over 5-20 minutes
Lasts less than 60 minutes
Most often visual and affects half of visual field
Most often debilitating
What are positive sx of an aura?
Photopsia (flashes of light)
Teichopsia (shimmering colors)
Fortification spectrum (arc of light)
What are negative sx of an aura?
Scotoma (area of partial alteration in the field of vision)
Hemianopsia (decreased vision in half the field)
What are the sensory/motor sx of an aura?
Numbness in face and arms
What are the presentations of migraines?
Gradual onset, peaking in minutes, lasting 4-72 hours
Pain in face and head, most common in frontotemporal region
Unilateral initially, can become bilateral throughout the attack
Throbbing and pulsating
Common: nausea, GI SEs
What are common food triggers of migraines?
What environmental factors are triggers of migraines?
What are behavioral factors that are triggers of migraines?
excess or insufficient sleep
What is a mild HA?
Aware of HA
Able to continue daily routine w/minimal alterations
What is a moderate HA?
HA inhibits daily activities
What is a severe HA?
What patients should receive migraine tx?
Greater than 2 attacks/week
Attacks lasting longer than 48 hours
What is the maximum amount of days that HA medications should be taken?
What is the most common cause of daily HA?
What is the HA medication cycle?
HA returns as soon as medication wears off
What are non-pharm migraine tx options?
Track HA/activities/triggers/sx to avoid/decrease potential
What are the most effective OTC analgesics for migraine?
NSAID or ASA/APAP/Caffeine
Which medications have higher risks of rebound HA?
When is APAP recommended?
Which NSAIDs have the most demonstrated benefit for migraines?
How do NSAIDs work in migraines?
Inhibits inflammation and pain by inhibiting PGs
What is the MOA of barbiturates in migraines?
Depresses the sensory cortex
Decreased motor activity
Altered cerebellar function
Drowsiness and sedation
What are the concerns of butalbital use in migraines?
What is midrin?
What is the MOA of isometheptene?
Sympathomimetic that reduces stimuli leading to vascular HA via constriction of dilated cranial and cerebral arterioles
What is the MOA of dichloraphenazone?
Sedative and antipyrine that reduces the emotional response to painful stimuli
What is midrin useful for?
Mild to moderate HA
What is the MOA of butorphanol?
Mixed opioid agonist
How is butorphanol supplied?
What are the ergot alkaloids?
What is the MOA of ergot alkaloids?
Partial agonist and/or antagonist activity on a variety of receptors to cause constriction of peripheral and cranial blood vessels and inhibit inflammation
What are DDIs of ergot alkaloids?
Strong 3A4 inhibitors
Azoles, PI, macrolides
What are the AEs of ergot alkaloids?
Cardiac valvular fibrosis (avoid in patients w/AFib or valve disease)
Most common: N/V/D, ab pain, weakness, fatigue, sweating, chest tightness
Which medication is not commonly recommended in the elderly for migraines?
What can enhance the absorption and potency of ergot analgesia?
What are ergot alkaloids used for?
Moderate to severe HA
What should not be used within 24 hours of ergot alkaloids?
What are contraindications for ergot alkaloids?
Coronary cerebral or peripheral vascular disease
What is the MOA of triptans?
Selective agonists of the 5-HT1b and 5-HT1d receptors
Normalization of dilated intracranial arteries by vasoconstriction, neuronal inhibition, and inhibition of transmission through trigeminocervical complex
Which medication is an appropriate first line choice for mild to severe migraines?
What are AEs of triptans?
What are contraindications for triptans?
How does botulinum toxin work in migraines?
Significant decrease in number of days
What is petasites derived from?
What is the use of petasites in migraines?
What is the use of histamines in migraines?
Decreased attack frequency
Decreased rescue medication use
What is the use of Co-Q10 in migraines?
Reduced attack frequency
When are opioids used in migraines?
Reserved for patients with mod-severe sx whom have failed above treatments or contraindications to treatment
What are drawbacks to using opioids for migraines?
Dependency and rebound HAs
What is the most common anti-emetic for migraines?
Metoclopramide - can increase absorption of migraine medication
When are corticosteroids used for migraines?
Continuous migraine for up to 1 week
Which medications are used for migraine prophylaxis?
How long can a prophylactic dose change take to reach maximal effectiveness?
How long should monitor max doses to make sure the dose has had time to work before adding on additional medications?
When do we give prophylactic migraine medications?
Substantial impact on daily life
Do not respond well to acute care
Frequency is great enough that acute care may lead to rebound HAs
How do BB work in migraines?
When are BB not effective for migraine prophylaxis?
With intrinsic sympathomimetic activity
What is the most common antidepressant used for migraine prophylaxis?
Which antidepressants should not be used for migraine prophylaxis?
Which anticonvulsants have demonstrated efficacy in migraine prophylaxis?
What is the MOA of anticonvulsants in migraine prophylaxis?
Enhancement of GABA inhibition
Modulation of glutamate
Inhibition of sodium and calcium ion channels
When are anticonvulsants useful in migraine prophylaxis?
How do we monitor VPA?
Monitor liver function
How do we monitor Divalproex?
What are AEs with divalproex/VPA?
When are CCBs used in migraine prophylaxis?
2nd or 3rd line
Verapamil is the most common
How long until verapamil is effective?
When should women start prophylaxis of migraines?
2-3 days prior to menses or usual start of HA
How dow contraceptives work in migraines?
Decrease duration and severity
When should contraceptives be avoided for migraine prophylaxis?
2-4 times more likely to have a stroke
What is a cause of a tension HA?
Thought to originate from myofascial factors and sensitization of nociceptors
What are stimuli of tension HA?
Non-physiologic motor stress
Local myofascial release of irritants
What is the presentation of tension HAs?
No premonitory sx/aura
Dull, non-pulsatile tightness or pressure
Bilateral pain is most common
Frontal or temporal pain most common regions
Mild photophobia or phonophobia may be reported
How can tension HA be classified?
Episodic or chronic
What are types of tx for tension HA?
Most are treated OTC by the patient, relatively poorly studied
What are behavioral therapies for tension HA?
Can reduce sx
What are non-pharm tx for tension HA?
Heat or cold packs
Trigger point injections
How long can non-opioid therapy be used for tension HAs?
No more than 9 days per month to stop overuse/rebound HAs
What is the most severe of the primary HA disorders?
What are the characteristics of cluster HAs?
Severe, unilateral head pain in series lasting for weeks or months separated by remission periods lasting months or years
Are men or women more likely to have cluster HAs?
What is the pathophysiology of cluster HAs?
Cyclic nature implicates a pathogenesis of hypothalamic dysfunction with resulting alterations in circadian rhythms
What hormones are out of sync in cluster HAs?
How long can cluster HAs occur?
2 weeks to 3 months followed by pain free intervals (2 years)
When is the most common time for cluster HA?
At night during season change
What is the onset and duration of cluster HA?
Suddenly and last 15-180 minutes
Which HA do not present with auras?
What is the pain like in cluster HAs?
Boring in intensity
What are the locations of pain in cluster HAs?
Temporal unilateral locations
What are cluster HAs accompanied by?
How often may cluster HA occur during an attack?
Once every other day to 8 times a day
What positions might a patient with a cluster HA be in?
Sitting and rocking or pacing clutching their head
Patients with cluster HA may use what?
What are the treatments of cluster HAs?
What forms of triptans are most effective for cluster HAs?
What medications are used for cluster HA prophylaxis?
Lithium (can be added to verapamil)
Ergotamine (prophylactis or abortive)
Corticosteroids (relief after 1-2 days)