Migraine Headache

Question 1

What is the prevalence of migraines?

Answer 1

8% women, 6% men (More common in boys than girls, reverses after puberty)

Question 2

What are the symptoms of migraines?

Answer 2

Unilateral or bilateral

Often preceded by an aura - usually visual

Variable duration - from hours to days

Variable incidence - from a few per year to a few per month

Question 3

What are triggers of migraines?

Answer 3

85% of migraineurs could report something that triggers the migraine.
These include WEATHER, missing a meal, stress, alcohol & various types of food

About 50% of women report menses as a trigger. A recent study showed that over 50% considered crying to be a
trigger

Question 4

What is the migraine attack?

Answer 4

1. Prodrome (know they’re gonna get a headache)
2. Aura
3. Headache
4. Postdrome

Question 5

What is the management of Acute Headache?

Answer 5

• Often nonopioid analgesics (NSAIDs) will be effective for this purpose & should be tried 1st
• Combo of acetamiophen, acetylsalicylic acid & caffeine may be effective
• Occasionally opioid drugs may be used to treat refractory migraine headache, but should be used as a last resort

Question 6

Drugs for Acute Migraine

Answer 6

• Ergot Alkaloids
• Ergotamine, Dihydroergotamine
• Postulated mechanism of action - nonspecific serotonin agonists
• Side effects most often related to arteriolar constriction
• Coanalgesic with caffeine

Question 7

Why is there caution with Ergot Alkaloids?

Answer 7

• Liver disease
• Rebound headache with frequent use
• CV disease - arteriolar vasocon
• POOR PERIPHERAL CIRCULATION (Raynaud’s, St. Anthony’s Fire)

Question 8

Management of Acute Headache

Answer 8

The “Triptans”
- Sumatriptan Naratriptan Risatriptan Zolmitriptan

• Postulated mech of action - agonist at 5HT1 receptor
• SE similar to ergot alkaloids

Question 9

What are the Triptans?

Answer 9

These are 5HT 1B and 1D (serotonin) receptor agonists

available as a pill, a nasal spray and sublingual preparation. Sublingual - fast & effective action

v. effective for migraine but also v. expensive

usually relieve nausea as well as headache

Question 10

What is the caution with Triptans?

Answer 10

Concurrent MAOI or SSRI antidepressants
- serotonin syndrome - (akathisia-like restlessness, muscle twitches, myoclonus, hyperreflexia, sweating, shivering & tremor - possibly leading to seizures & coma)

Not concurrently with ergot alkaloids (24 hr washout)

Question 11

What is the Migraine Prophylaxis?

Answer 11

Propanalol (& other B-blocker)
– b/c migraines might be related to BP

Amitryptiline (& other TCAs)

Gabapentin
- anticonvulsant-possibly modulates Ca2+ receptors

Candesartan
- ANG II receptor antagonist - reduces BP

Dietary supplements:
- Riboflavin, Coenzyme Q10, Magnesium Citrate