Pharmacotherapy - Migraines
Terms
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- Who has more headaches - men or women?
- Women (3:1)over men
- What is the age of peak prevalence?
- 25 to 55 years old. Absolute peak at age 40
- What are associated medical disorders
- Epilepsy, Stroke (women <45yo), Raynaud's, Asthma, depression, anxiety, panic, bipolar
- What are barriers to proper migraine treatment?
-
1. Comes up as after thought at MD appt.
2. Clinicians focus on R/O 2ndary causes
3. Step care = patients lose interest. - Describe the 6 steps of migraine induction.
-
1. Neural dysfunction
2. Cascade
3. Vasodilation
4. Trigeminal nerve activation
5. Vasoactive neuropeptide release
6. Exacerbation of vasodilation - What are the 2 mechanisms of action for triptans?
-
1. Bind blood vessels to decrease vessel inflammation (5HT-1b)
2. Bind never terminals to prevent release of neuropeptides (5HT-1d) - Migraine is a loss of (a)_______ and inability to (b) ______.
-
(a) central inhibition
(b) accommodate various stressors - What are the four phases of migraine?
-
1. premonition/prodrome
2. Aura (optional)
3. Headache
4. Postdrome -
Prodrome:
- prevalence
- general symptoms(9) -
- 60% experience it
- elation, irritability, depression, neck stiffness, food craving, fluid retention, thirsty, drowsy -
Aura:
- prevalence
- cause
- symptoms
- duration -
- 15% experience it
- cortical/brainstem dysfunction
- visual hallucinations or tingling. Also, speech or motor problems
- lasts 20-60 min. Usually ends before HA, but may persist -
Migraine Headache:
- describe pain
- associated symptoms -
Pain:
Generally unilateral, throbbing (can be bilateral)
Associate Symptoms:
N&V, photophobia, phonophobia, osmophobia
Resolution with sleep -
Postdrome:
Symptoms -
Mood changes
muscle weakness
physical tiredness
down appetite -
A
U
S
T
I
N -
A - Aggrevated by activity
U - unilateral
S - Sensitivity to light/sound/smell
T - Throbbing
I - Intensity is mod to severe
N - Nausea and vomiting - What are the red flags in HA Hx?
-
Age of onset >45 yo
Time from onset to peak pain
Pain >5
Aggravating factors
Associated symptoms - Name 2 Migraine Disability Assesments
-
Headache Impact Test (HIT-6)
Migraine Disability Assessment Scale (MIDAS) - Is Step Care or Stratefied Care preferred?
- Stratefied.
- Describe the stratefied care approach
- Uses assessments to determine disability/severity. Initial treatment is based off of need.
- What are some non-pharmacologic strategies to treating migraine?
-
Biofeedback
relaxation therapy
cold compress
sleep
rest
HA diary
Accupuncture
Alternative Meds:
Feverfew
Mg
Riboflavin
CoQ-10
valerian root
Omega-3's - Goals of acute treatment
-
rapid relief
consistent relief
no recurrence
minimize use of rescue meds
cost-effective
avoid SE's - Specific migraine meds
-
triptans
ergotamine - Non-specific migraine meds
-
Acetaminophen/aspirin/caffeine
aspirin
ibuprofen
naproxen - Rescue meds (common opiates)
-
butorphanol
acetaminophen with codeine - Common antiemtics
-
metoclopramide - favorite (up GI motility too!)
chlorpromazine
prochlorperazine -
5HT receptors involved in:
-Treatment
-Prevention
-N&V -
Treatment = 5HT-1b, 1d
Prevention = 5HT-2
N&V = 5HT-3 -
Ergot derivatives
- Agents (2)
- interact with receptors
- ADEs
-Available forms -
Agents:
ergotamine, dihydroergotamine (DHE)
Receptors:
5HT-1, alpha & beta adrenergic, DA, 5HT-3
ADEs:
N&V, diarrhea, excessive vasoconstriction
Available forms:
spray, injection - Are melt-tabs faster or slower onset?
- Slower!
- Contraindications for TRIPTANS
-
-Heart disease
- Uncontrolled hypertension
- pregnancy (cost/benefit)
- hepatic impairment - Triptan Drug interactions
-
- W/in 24h of ergot use
- W/in 2 wks of MAOI use
- SSRI's (including St. John's wort) -->serotonin syndrome
- Oral contraceptive = potential triptan increase
Specific:
propanolol and rizatriptan --> increase rizatriptan conc by 70%