Professional Documents
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Recognizing Migraine
Pounding unilateral headache Preceded by visual or other aura Nausea, vomiting Light and sound sensitivity
What is migraine?
Migraine with aura (MA)
At least two attacks fulfilling these criteria: At least three of the following:
one or more fully reversible aura symptoms gradually developing or sequential aura symptoms no one aura symptom lasts longer than 1 h headache shortly follows or accompanies aura
Japan 8%
Chile 7%
1-year prevalence rates Population-based studies Population IHS criteria (or modified)
Rasmussen and Olesen (1994); Rasmussen (1995); Lipton et al (1994); Lavados and Tenhamm (1997); (1994); Sakai and Igarashi (1997)
Diagnosis of migraine
Diagnosis depends on patient history No specific tests or clinical markers Positive diagnosis if attack history fulfils IHS criteria for migraine Other pointers include:
family history of migraine age of onset <45 presence of aura menstrual association
Cady (1999); Warshaw et al (1998)
Onset: sudden, abrupt, or split-second Older: new onset and progressive headache, especially
in middle-age >50 (giant cell arteritis)
Physiology
Vasospasm Lance Spreading Wave of Depression Leao Trigeminocentric Allodynia
Vasospasm
I. Aura: Arteries Spasm
Visual and focal neurological symtoms Pial and Occipital small artery branches
Phases of Migraine
Vague Prodrome: psychic change and cravings e.g. chocolate Aura: Focal symptoms and vision Headache: Throbbing unilateral pain Inflammation: Prolonged phase and TTH Postdrome Migraine related stroke
Spreading Wave
Brainstem controls Cortical Activity Epileptic like phenomenon that spreads over Cortex Visual Phenomenon that spreads over surface of brain like shimmering C Cheiro-oral Jacksonian phenomena Concurrence of migraine and epilepsy Why epilepsy drugs work for migraine
Trigeminal Theory
Serotonin again Trigeminal Afferents: sensory function of face and meninges Trigeminal efferents to vessels Cause vessel spasm and sensitivity This theory primarily explains action of Triptans: 5-HT 1b,d agonists
Migraine Pathophysiology
Allodynia Theory
Migraine is a state of hypersensitivity Light, sounds, smells, touch (head in headache) Need for dark room Best preventives decrease sensitivity. Anticonvulsants, tricyclics, beta and calcium channel blockers
Cutaneous allodynia
Phenomenon later in migraine attack Once it develops pts less likely to respond to triptans In small sample 15% of pts with and 93% of pts without CA responded to triptan (Burstein et al)
Migraine Phenomena
Focal and paroxysmal onset of symptoms Specific visual phenomena Spreading numbness and moving visual phenomena and sensory distortions. Nausea, vomiting sick headache Pounding unilateral or bilateral pain Psychic changes Light and sound sensitivity even between attacks Effectiveness of triptans Effect of anticonvulants Role of serotonin
Some Dicta
Any paroxysmal headache is likely to be migraine unless proven otherwise Sinus headaches and tension headaches are almost always migraine headaches First ever severe headache or sudden thunderclap headaches may be SAH
Treatment
Effective treatment of attack Prevention Address comorbidities
CGRP triptan NK SP
CGRP NK SP
5-HT1B
Acute Attack
Triptans:
sumatriptan, zolmitriptan, almotriptan, naratriptan, frovatriptan, elitriptriptan, riaztriptan
NSAIDs Fioricet Midrin (isometheptane, chlorphenoxazone, apap OTC: Caffeine, apap, phenacitin, asa Ergots: Caffergot, DHE nasal, injected Narcotics Depacon
TRIPTANS
Selective 5-HT1B/1D/1F agonists As a class, relative to nonspecific therapies, triptans provide
Rapid
Triptans
Learn to use one or two Effective medicines
Almotriptan
Tablet
Tablet (25, 50, 100 mg) Injection (6 mg) Nasal spray (5, 20 mg*)
Frovatriptan
Tablet
(2.5 mg)
Zolmitriptan
Eletriptan
Tablet
(20, 40 mg)
Naratriptan
Are there differences between the triptans? If one triptan fails, will another triptan work?
Rizatriptan
Relpax Cautions
Available only in oral form CYP 3A4
Do not give within 72 hours of: Ketoconazole, Nefazadone, clarithromycin, rotonavir, nelfinavir, others. caution with verapamil, erythromycin.
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Autoscopy
Relpax Dosing
40 mg. May repeat X1 in 2 hours Max dose in 24 hours is 80 mg Repeating dose most efficacious if headache returns
Parenteral triptans
Imitrex injections: Very good fast reliable onset but peaks quickly with short half life Imitrex and Zomig nasal: absorption not reliable, taste not so good but may be tried if a lot of nausea Zomig ZMT and Maxalt MLT on tongue: not strictly parenteral absorbed thru gut
Triptan worries
Not released under age 18 If you even suspect CAD dont use or get proper exclusionary tests.
Man or woman of a certain age Smoker or other risk factors
Cerebrovascular disease or complicated migraine - contraindicated Watch for overuse. These are rescue medicines
Consider Combinations
Triptan + NSAID Triptan + anti-nausea Unconventional agents Phenergan, Compazine alone or in combination. Zyprexa or atypicals We dont have enough alternatives
Prophylaxis
Anticonvulsants: topiramate, valproate, Keppra, gabapentin Tricyclics
Amitriptylene, nortriptylene, trazodone
Beta Blockers
Timolol, propranolol, nadolol
Plea
Listen to patients Migraine is mixed up with a lot of things
Emotional factors: ennui, husbands, bosses, general dissatisfaction with life Sleep disturbances Hormonal changes
If you do not address these you will not be treating your patients Dont just throw drugs at your patients Be attentive and empathetic