Migraine Diagnosis
2 Features must occur
- Unilateral head pain
- Throbbing pain
- Worsens with activity
- Moderate/severe pain
And 1 of these
- N/V
- Photophobia
- Phonophobia
Migraine classifications
- Aura present
- Aura Not present (most common)
- Chronic migraine
- 15 day/month for 3 months
Migraine Risk factors
- Family Hx
- Estrogen and progesterone
- Genetic and environmental factors
Migraine Triggers
Fatigue Oversleeping Missed meals Overexertion Weather change Stress Hormonal changes Bright lights or strong smells
Pathophysiology
- Changes in neurotransmitter levels in CNS
2. Blood vessel tone (blood flow)
Clinical Phases
Premonitory phase
- 1/3 have:
- fatigue
- irritability
- loss of concentration
- stiff neck
- food cravings
Migraine Aura
-up to 1/3 have aura symptoms lasting up to [1 hr]
(Bright spots or flashed, usually visual)
Headache phase
- Throbbing pain
- Fatigue, N/V/D, hypersensitivity to touch on head
- Lasts [4-72 hrs]
Recovery Phase
-Irritability, fatigue, depression
Abortive (symptomatic) Therapy
- Aspirin-like drugs
(ASA, acetaminophen, NSAIDS) - Serotonin 1B/1D Receptor Agonists (triptans)
- sumatriptan (Imitrex) - (CGRP) Calcitonin Gene-related Peptide Antagonist
Serotonin 1B/1D Receptor Agonists
sumatriptan (Imitrex)
MOA:
- constricts intracranial blood vessels
- suppresses release of inflammatory neuropeptides
- Block brain pathways for pain
Route:
-Sub-Q, PO, Intranasal
SE:
-Injection site reaction (SQ), chest pressure, flushing, weakness, headache, bad taste (nasal)
Considerations
-Avoid with ischemic stroke or heart disease and angina
Calcitonin Gene-related Peptide (CGRP) Antagonist
rimegepant (Nurtec)
MOA: mediates pain transmission
Route: PO
SE: GI upset
Considerations: CYP substrate
Preventive Therapy
**>4 per month or last >12 hrs
- Beta-Blockers
- Propranolol (Inderal) - Tricyclic antidepressants
- Antiepileptic drugs
- divalproex (Depakote)
- topiramate (Topamax) - Estrogens
- Mensural migraine
Preventative Therapy Goals
- Reduce attack frequency, severity, and duration
- Improve responsiveness to treatment of acute attacks
- Improve function and reduce disability
- Prevent progression or transformation of episodic migraine to chronic migraine
