What are the 4 phases of a migraine headache?
1) prodrome (drowsy, irritable, photophobic)
2) aura (5-60 mins: focal neuro symptoms - visual or parasthesia)
3) headache (unilateral, throbbing, aggravated by physical activity)
4) resolution (hopefully)
Familial hemiplegic migraine is due to mutations of what and on which chromosome?
- chromosome 19, mutations of calcium channel
What kind of blood flow is happening during the aura and headache phases of migraines (usually)?
- aura: reduction of CBF, wave of depolarization
- headache: increase of CBF, activation of trigeminovascular system with release of vasodilatory and permeability promoting peptides
What are some nonpharmacologic ways to treat headaches?
- healthy habits (sleep, balanced meals, regular exercise, stop smoking)
- address psychological factors
- stress management, relaxation
- identify and avoid triggers
What are nonspecific meds to acutely treat migraines?
- NSAIDs
- COX-2 inhibitors
- neuroleptics/antiemetics
- corticosteroids
- opioids
A patient with a long history of migraines comes into your office sad and frustrated because he keeps having headaches. One of his previous doctors (because you would never make this mistake) gave him a barbituate for acute headache attacks. While taking a thorough history, you realize that he’s taking the barbs almost every day, and he’s drinking coffee like a mad man. What phenomenon is occuring?
- rebound headaches!
How do ergotamines work?
- act as a nonselective 5HT agonist in trigeminovascular pathway
- may also be a vasoconstrictor
What drug acts similarly to the ergotamines but has fewer side effects and can be used IV or for cluster headaches?
dihydroergotamine (DHE)
A patient comes to the ED in the thick of a severe migraine. What is the premier abortive treatment and how does it work? What conditions should you be sure they don’t have before you administer?
- triptans! (sumatriptan)
- works as a selective 5HT1b-d agonist
- Contraindicated in vascular disease, uncontrolled hypertension, and complicated migraines
What are indications that you should give a patient prophylactic migraine meds instead of acute abortive ones?
varies for each patient, but generally:
- greater than 3 severe migraines per month or greater than 2 moderate migraines per week
- inability to use effective symptomatic tx
Which tricyclic antidepressants are indicated for migraine and tension headache prevention and how does their prescription differ from their antidepressant action?
- amitriptyline, protriptyline, and nortriptyline
- given in very low doses
Which SSRIs are used to prevent migraine and tension headache and what are some side effects?
- fluoxetine, paroxetine, and sertraline
- SE: weight gain, sexual dysfunction
What antihypertensives can be used for prevention of migraine?
- beta blockers (propranolol, timolol, etc)
- calcium channel blockers (verapamil)
What AEDs can be used for prevention of migraine?
- valproic acid
- topiramate
You come to me complaining of frequent migraines. I tell you I want to inject something into 31 sites in your head and neck. What am I (probably) talking about?
- onabotulinum toxin
How do you differentiate tension type headaches from migraines?
- tension type: bilateral, can last up to 7 days, and no aggravation upon routine physical activity
What is an acute treatment for a cluster headache that is very well tolerated but not long lasting or realistic?
- 100% oxygen for 15-20 mins
What drug can be used to prevent cluster headaches that doesn’t overlap with other headache types?
- lithium
You have a patient with cluster headaches. What is the appropriate treatment for A) short term prevention B) long term prevention C) acute rescue
A) DHE, steroids
B) verapamil (Ca channel blocker), topiramate (glutamate receptor blocker), valproate, or lithium
C) triptans, oxygen, DHE, lidocaine
