migraines

Question 1

tension type

Answer 1

-most prevalent form of HA; bilateral, 30 minutes – 7 days

Question 2

vascular

Answer 2

migraines with and w/o aura, mixed HA syndrome

Question 3

migraine symptoms

Answer 3

severe, recurrent, unilateral; sleep is required to terminate most attacks

Question 4

migraine w aura

Answer 4

minimum of 2 attacks (ever) and 3 of the following:

• Gradual onset, mild to severe intensity
• Reversible, aura lasts 5-60 minutes
• HA follows aura within 60 minutes
• May or may not have N/V, photophobia, phonophobia
• Normal neurologic exam

Question 5

migraine w/o aura

Answer 5

Common migraine, minimum 5 attacks lasting 4-72 hours

• Any 2: unilateral, pulsing, aggravated by routine physical activity, moderate to severe intensity
• And 1 of: N/V, Photophobia and Phonophobia

Question 6

attacks

Answer 6

Prodrome (fatigue/dizziness), aura (visual, sensory), Headache (2/3 unilateral), Postdromal (washed out feeling)

Question 7

goals of migraine therapy

Answer 7

reduce frequency, severity, and disability to improve patients QOL

Question 8

step care of migraines

Answer 8

drug in sequential manner (i.e. everyone starts with Tylenol with no regards to severity)

Question 9

stratified care of migraines

Answer 9

migraine specific agents based on symptom severity

Question 10

non specific abortive agents

Answer 10

• Aspirin: at first sign of attack, do not use enteric coated, effective with metoclopramide
• Acetaminophen: at first sign of attack, APAP and metoclopramide as effective as triptan
• NSAIDs: at first sign of attack, Ibuprofen, Ketoprofen, Naproxen, Ketorolac (quick onset); usually very safe if used short term, but max doses are under care of a physician
• Combinations: Excedrin (APAP, ASA, Caffeine): difficult for patients who can’t tolerate caffeine to sleep, Fiorinal (Butalbital, ASA, Caffeine, w or w/o Codeine), Fioricent (Butalbital, APA, Caffeine w/ or w/o Codeine)
• Opiate Analgesics: Butorphanol Nasal Spray, PO Hydromorphone, Oxycoodone (avoid these 2 if possible)

Question 11

triptans

Answer 11

specific abortive agents

• Moderate to severe migraine treatment or if mild not responsive to NSAIDs
• Naratriptan: long half-life
• Almotriptan: good efficacy and high tolerability, but short duration
• Frovatriptan: long DOA, patients who need low recurrence
• Sumatriptan: multiple dosage forms (PO, IN, SQ) with quick onset, but limited by adverse effects
• Rizatriptan: rapid and consistent relief, but short duration
• Eletriptan: high efficacy and low recurrence, but ADRs are common
• Zolmitriptan: PO and intranasal, high ADRs

Question 12

triptan AE

Answer 12

somnolence, nausea, dizziness, asthenia

Question 13

triptan CI

Answer 13

CV disease, cerebrovascular disease, PVD, uncontrolled HTN, hemiplegic or basilar migraines

Question 14

triptan interactions

Answer 14

• MAOIs: increase blood triptan levels
• SSRIs and SNRIs: risk of serotonin syndrome = theoretically contraindicated
• propranolol and Rizatriptan: increase in triptan AUC
• CYP3A4 may increase triptan levels

Question 15

ergotamine products

Answer 15

specific abortive agents

• Very effective at first sign of attack
• Potent vasoconstrictor
• Increased N/V = treatment with antiemetic
• Pregnancy Category X
• Less Expensive
• All oral products formulated with caffeine = sleep disruption
• Avoid using more than 2x per week

Question 16

DHE

Answer 16

specific abortive agent

-very effective, lower SE than ergotamine; nasal spray and injection

Question 17

isometheptene

Answer 17

specific abortive agent

• Midrin (IMH, APAP, and a sedative)
• May be used in pregnant or breast-feeding women

Question 18

migraine treatment

Answer 18

• PO therapy with Sumatriptan 50-100mg, Rizatriptan 10mg, Almotriptan 12.5mg, Eletriptan 40mg, or Zolmitriptan 2.5mg
• Slower Effect or Better Tolerability: Naratriptan 2.5mg, Frovatriptan 2.5mg
• Infrequent HA: Ergotamine, DHE
• Early Nausea/Vomiting: Sumatriptan nasal spray or injection, Zomitriptan nasal spray or dispersible, Rizatriptan wafer
• HA Recurrence: Ergotamine, Naratriptan, Eletriptan, Frovatriptan, Almotriptan, DHE
• Menstrual-Related: Ergot at night, estrogen, patches, short-term NSAIDs; Acute= triptans, DHE, nasal spray
• Rapid Symptoms: Sumatriptan SC, DHE IM, Zolmitriptan nasal spray

Question 19

migraine prophylaxis nonpharm

Answer 19

lifestyle, ice packs, avoiding triggers, HA journal

Question 20

criteria for pharm migraine tx

Answer 20

2 or more attacks per month, or if vasoconstriction is contraindicated

Question 21

1st line migraine prophylaxis

Answer 21

-Beta-blockers (propranolol, timolol), topiramate, TCAs, Valproic Acid

Question 22

beta blockers in migraine prophylaxis

Answer 22

• Propranolol LA is drug of choice; 80mg PO daily -> 80mg PO BID -> 80mg PO TID
• Timolol also approved
• Caution in asthma d/t non-selective nature
• Others: Atenolol, Metoprolol, Bisoprolol (if needing selective block)

Question 23

topiramate in migraine prophylaxis

Answer 23

• Mood stabilizer

- Slow titration: 25mg PO daily -> increase 25mg/week -> 100mg PO daily

Question 24

TCAs in migraine prophylaxis

Answer 24

• Useful in no response to BB, or cannot tolerate BB side effects
• affective agents: Amitriptyline, Doxepin, Imipramine, Nortriptyline, Protriptyline, Desipramine, Trazodone
• Amitriptyline 25mg-300mg/day or Doxepin 10-150mg/day (Usually a lower dose than for depression)
• Given at bedtime to minimize daytime drowsiness
• DOC for Mixed Headache Syndrome (2-8 migraines/ month, daily low-grade tension HA)

Question 25

SSRIs in migraine prophylaxis

Answer 25

fluoxetine, sertraline, paroxetine see a reduction in migraine attacks

Question 26

2nd line migraine prophylaxis

Answer 26

-CCBs, ACE-Inhibitors, ARBs, Antiepileptics, ASA, Alpha-blockers, Trazodone, Botox, Quetiapine, Memantine, NSAIDs (use if 1st line were ineffective or contraindicated)