Term
| migraine prevalence and impact |
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Definition
migraine accounts for 20% of outpatient visits to neurologists
affects 13% of the US population (18% of women and 6% of men)
prevalence highest from 25-55 years of age
112 million bedridden days per year
cost US employers: ~$13 billion per year due to missed work days and impaired work function |
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Term
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Definition
premonitory symptoms precede a migraine attack by several hours to one or two days
typical symptoms include fatigue, concentration difficulty, neck stiffness, sensitivity to light or sound, nausea, blurred vision, yawning, or pallor
these may occur alone or in combination
prmonitory symptoms typically occur several hours to days prior to the headache
aura usually immediately precedes the migraine and typically lasts no longer than 1 hour |
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Term
| features of migraine aura and migranious accompaniments |
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Definition
the most common type of aura is visual, otherwise called a scintillating scotoma
visual scotoma:
moving "blind spot"
diplopia:
double vision
aphasia:
dysruption in speech
mydriasis:
increase pupil size
dysarthria:
difficulty in speech articulation
cyclical vomiting:
repetitive vomiting
paraesthesias:
tingling usually in the extremities, like the fingertips for example |
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Term
| cause of hemiplegic migraines and basilar migraines |
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Definition
thought to be due to direct vasoSPASM
TRIPTANS AND ERGOTAMINE DERIVATIVES ARE CONTRAINDIATED!! increased risk of stoke due to increased constriction |
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Term
| IHS criteria for migraine without aura |
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Definition
no single feature required or sufficient to make diagnosis
greater than or equal to 5 attacks lasting 4-72 hours
greater than or equal to 2 of the following:
unilateral (40% bilateral or generalized)
pulsating (50% nonpulsating)
moderate to severe intensity (~20% mild)
pain worsened by exertion (>95%)
at least one of the following:
nausea (>90%) or vomiting (>50%)
photophobia (>85%) and phonophobia (>60%)
no organic disease that might cause headaches |
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Term
| IHS criteria for migraine with aura |
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Definition
one or more full reversible aura symptoms indicating focal cerebral cortical and/or brain stem dysfunction
at least one aura symptom develops gradually over more than 4 minutes or 2 or more symptoms occur in succession
no aura symptom lasts for more than 60 minutes
if more than one aura symptom is present, accepted duration is proportionally increased
headache follows aura with a free interval of less than 60 minutes (it may also begin before or simultaneously with the aura)
no history or exam evidence of disease that might cause headaches
20% HAVE AN AURA |
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Term
| episodic vs. chronic migraine |
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Definition
patients typically present with episodic
migraines may "transform" into chronic migraines (> or equal to 15 migraines/month)
chronic migraine represents a continuum of either central sensitization or analgesic overuse |
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Term
| IHS criteria for infrequent episodic tension HA |
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Definition
at least 10 episodes occurring on <1 day per month on average (<12 per year)
headache lasting from 30 minutes to 7 days
headache has at least 2 of the following characteristics:
bilateral location pressing/tightening (non-pulsating) quality
mild or moderate intensity no aggravated by routine physical activity such as walking or climbing stairs
both of the following:
no nausea or vomiting (anorexia may occur)
no more than one of photophobia or phonophobia
not attributed to another disorder |
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Term
| IHS criteria for sinus headache |
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Definition
frontal headache accompanied by pain in one or more regions of the face, ears, or teeth
clinical, nasal endoscopic, CT and/or MRI imaging and/or laboratory evidence of acute and acute-on-chronic rhinosinusitis
headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis
headache and/or facial pain resolve within 7 days after remission or successful treatment of acute or acute-on-chronic rhinosinusitis
more thought of as a spectrum of migraine depending on symptoms |
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Term
| IHS criteria for medication overuse headache |
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Definition
headache present on GREATER THAN OR EQUAL TO 15 DAYS/MONTH
regular overuse for greater than or equal to 3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
headache has developed or markedly worsened during medication overuse
headache resolves or reverts to its previous pattern within 2 months after discontinuation of overused medication |
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Term
| IHS criteria for cluster headache |
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Definition
at least 5 attacks
severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 minutes if untreated
headache is accompanied by at least one of the following:
ipsilateral conjunctival injection (the forcing of a fluid into the conjunctiva, the mucous membrane that lines the eyelids) and/or lacrimation
ipsilateral nasal congestion and/or rhinorrhea
ipsilateral eyelid oedema
ipsilateral forehead and facial sweating
ipsilateral miosis and/or ptosis (drooping eyelid)
a sense of restlessness or agitation
attacks have a frequency from one every other day to 8 per day
not attributed to another disorder |
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Term
| IHS criteria for SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) headaches |
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Definition
at least 20 attacks
attacks of unilateral orbital, supraorbital, or temporal stabbing or pulsating pain lasting 5-240 seconds
pain is accompanied by ipsilateral conjunctival injection and lacrimation
attacks occur with a frequency from 3-200 per day
not attributed to another disorder |
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Term
| criteria for menstrual migraine |
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Definition
attacks, in a menestruating woman, fulfilling criteria for MIGRAINE WITHOUT AURA
attacks occur exclusively on day 1 +/- 2 of menstruation in at least 2 out of 3 menstrual cycles and at no other times of the cycle |
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Term
| when do we need neuroimaging? |
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Definition
cluster-type headache
abnormal findings on neurologic examination
undefined headache
headache with aura
headache aggravated by exertion or valsalva-like maneuver
headache with vomiting |
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Term
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Definition
emotional stress (80%)
hormones in women (65%)
not eating (57%)
weather (53%)
sleep disturbances (50%)
odors (44%)
neck pain (38%)
lights (38%)
alcohol (38%)
smoke (36%)
sleeping late (32%)
heat (30%)
food (27%)
exercise (22%)
sexual activity (5%) |
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Term
| acute (abortive) migraine therapy |
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Definition
first line:
NSAIDs
APAP/caffeine/aspirin
metoclopramide or prochlorperazine (ER)
would not use NSAIDs in an ER situation b/c headache could be due to stroke
second line:
triptans
ergotamine derivatives
opioids? NEVER FOR MIGRAINES
evidence shows those treated with opioids more likely to "transform" into chronic migraines (and more likely to happen more quickly) |
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Term
medications that can cause medication overuse headache
shortest, medium, and longest amount of time to cause MOH |
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Definition
SHORTEST time to rebound symptoms:
opioids (33%)
butalbital (48%)
aspirin (32%)
acetaminophen (46%)
caffeine
MEDIUM time to rebound symptoms:
ergotamine derivatives (12%)
triptans (18%)
no actual evidence that dihydroergotamine results in analgesic overuse headache
LONGEST time to rebound symptoms:
NSAIDs (10%) |
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Term
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Definition
eletriptan
NO reported ADRs
sumatriptan
most potent; highest incidence of ADRs (chest tightness)
zolmitriptan
high incidence of ADRs
rizatriptan
high incidence of ADRs
naratriptan
NO reported ADRs
almotriptan
low incidence of ADRs
frovatriptan
has the longest t1/2; not correlated with actual clinical outcomes |
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Term
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Definition
CHEST SYMPTOMS
chest tightness
chest pressure
chest pain
probably not cardiac in origin
probably due to vasoconstriction or esophageal spasm
OTHER
fatigue
paresthesias
nausea
dizziness
drawsiness |
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Term
| contraindications and warnings of triptans |
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Definition
cardiovascular:
contraindicated in CAD
contraindicated in those at risk for CAD
serotonin syndrome with SSRI |
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Term
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Definition
ergotamine tartrate
rarely used
dihydroergotamine
extreme N/V (dihydro < ergot)
paresthesias
chest tightness
diarrhea
"ergotism"
peripheral ischemia: cold, numb, painful extremities; paresthesias; diminished peripheral pulses and claudication |
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Term
| timing of administration of abortive migraine therapy |
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Definition
| take the medication as soon as headache apparent |
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Term
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Definition
represents a re-organization of the CNS neuronal circuitry
presence of cutaneous allodynia predicts triptan failure and refractory headache
presence of cutaneous allodynia predicts risk of transformation
sign of central sensitization from a migraine |
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Term
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Definition
all patients should be evaluated for use of preventive therapy
accepted indications:
2 or more attacks/month that produce disability lasting 3 or more days/month
contraindications to triptan or abortive therapy, or failure of these options
use of abortives > 2x/week
presence of uncommon migraine conditions |
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Term
| preventive migraine medication classes |
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Definition
anticonvulsants:
valproate
gabapentin
topiramate
antideprssants:
TCAs
SSRIs
beta-blockers:
propranolol - has peripheral serotonin activity; non-cardioselective; highest lipophilicity (more CNS penetration)
nadolol
atenolol
timolol
calcium channel blockers:
verapamil
nimodipine - highest lipophilicity
serotonin antagonists:
methysergide
others:
NSAIDs (not the best choice b/c there is a risk of transformation)
neuroleptics
dietary supplements:
butterbur
feverfew |
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Term
| recommendations for migraine prevention in patients with headaches that recur in a predictable pattern (e.g. menstrual migraine) |
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Definition
NSAID at the time of vulnerability
daily triptan at the time of vulnerability |
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Term
| recommendations for prevention of migraine in patients with comorbid hypertension, angina, or anxiety |
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Definition
beta blockers
verapamil if beta blockers contraindicated or ineffective
SSRI for anxiety + migraine |
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Term
| recommendations for migraine prevention in patients with comorbid depression or insomnia |
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Definition
TCAs
secondary amine better tolerated
for depression + migraine: SSRI or SNRI |
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Term
| recommendations for migraine prevention in a patient with comorbid seizure disorder or manic-depressive illness |
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Definition
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Term
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Definition
reserved for patients with severe/intractable life-threatening headaches who have failed other treatments
fetal age, maternal age, premorbid conditions will determine agent used
avoid Rx first trimester and 2 weeks prior to delivery
breast feeding - lipid solubility of drug, molecular weight, protein binding, +/- active secretion in breast milk
triptans are category C, may become category B |
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Term
| management opportunities for migrain and coexistent disease |
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Definition
opportunity: treat both conditions with single drug
hypertension and ischemic heart disease - beta blocker or CCB
epilepsy or mania - divalproex, topiramate
depression - TCA or SSRI
raynaud's phenomenon - CCB
overweight - topiramate
limitations: avoid treatments
epilepsy - antidepressants, neuroleptics, or sumatriptan
depression, asthma, beta blockers
obesity - TCAs and divalproex |
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Term
| migrain trigger avoidance |
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Definition
FOOD:
alcohol, caffeine/caffeine withdrawal, chocolate, citrus fruits, bananas, figs, raisins, dairy products, fermented and pickled foods, monosodium glutamate, nitrate containing foods (processed meats), saccharin/aspartame, sulfites in shrimp, tyramine containing foods, yeast products
ENVIRONMENTAL TRIGGERS:
glare of flickering lights, high altitude, loud noises, strong smells and fumes, tobacco smoke, weather changes
BEHAVIORAL:
excess or insufficient sleep, fatigue, menstruation, menopause, skipped meals, stenuous physical activity, stress or post-stress |
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Term
| elements of a headache diary |
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Definition
urge patients to keep a headache diary
exposure to triggers
grade, describe, and rank headaches
indicate use of abortive:
did it work?
did the headache recur within 24 hours? |
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