Term
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Definition
| recurring episodes of throbbing head pain, frequently unilateral, that when untreated can last 4-72 hrs; can be severe & associated with N/V, & sensitivity to light, sound, and/or movement |
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Term
| Clinical Presentation of Migraine HAs |
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Definition
| Premonitory symptoms: neurologic, aura evolves over 5-20 min & lasts less than 60 min, can be visual or sensory; HA: occurs within 60 min of end of aura, generally occurs in early AM hrs on awakening, unilateral & throbbing or pulsating; Pain: gradual onset that lasts 4-72 hrs, occur anywhere in face or head; Resolution: feeling tired, exhausted, irritable, or listless |
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Term
| Screening & Diagnosis of Migraine HAs |
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Definition
| comprehensive HA hx (age, attack freq, timing, duration, precipitating/aggravating factors, description of symptoms, S&S's) --> encourage HA diaries; Medical & neurologic physical exam; Neuroimaging studies if needed; Headache Impact Test (HIT), Migraine Disability Assessment Scale (MIDAS) |
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Term
| Points to Consider with Acute Management |
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Definition
| 1) Do NOT use more than 2-3 days per wk; 2) Medication Over-use; 3) Medication Over-use HA |
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Term
| NSAIDs - aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Anaprox, Naprosyn), diclofenac (Cambia, Cataflam) |
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Definition
| MoA: prevents neurogenically-mediated inflammation in trigeminovascular system by inhibiting PG synthesis; 1st line therapy for tx of mild-moderate migraine attacks, also used prophylactically to prevent HAs that occur in predictable pattern; SEs: GI - dyspepsia, N/V, diarrhea; CNS: somnolence, dizziness; Drugs w/ long half-life are preferred; modestly effective for reducing frequency, severity & duration of attacks; GI & renal toxicity limit daily or prolonged use |
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Term
| NSAIDs preferred to treat Migraine HAs |
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Definition
| aspirin, ibuprofen, naproxen, acetaminophen + ASA + caffeine have most consistent evidence for efficacy |
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Term
| analgesics - acetaminophen (Tylenol), acetaminophen + aspirin + caffeine/aspirin + butalbital + caffeine (Fiorinal), acetaminophen + butalbital + caffeine (Fioricet), isometheptene + dicholoralphenazone + APAP (Midrin) |
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Definition
| first line agents for tx of mild-moderate migraine attacks, also used as rescue therapy; |
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Term
| Points to Consider when Prescribing Narcotics |
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Definition
| 1) pt reports identical previous migraine attacks AND 2) pt has moderate/severe attack distress AND 3) no history of substance abuse AND 4) At least one of following: consistent lack of relief from migraine specific drugs, consistent lack of relief from non-narcotic drugs, max. dose of current abortive drugs, C/I to other abortive drugs |
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Term
| opiate analgesics - meperidine (Demerol), butorphanol (Stadol), oxycodone (Oxycontin), hydromorphone (Dilaudid) |
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Definition
| reserved for pts w/ moderate-severe infrequent HAs in which conventional therapies are C/I or as a rescue medication after pts have failed conventional therapies; frequent use leads to rebound HAs & dependence |
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Term
| ergot alkaloids & derivatives - ergotamine tartrate (Ergomar [oral], Cafergot [SL], Migergot [rectal]), dihydroergotamine (DHE 45, Migranal, Dihydroergotamine mesylate) |
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Definition
| MoA: non-selective 5-HT1 receptor agonist that constricts intracranial BVs & inhibits development of neurogenic inflammation in trigeminovascular system; 1st line tx for moderate-severe migraine attacks; SEs: GI - N/V, Other: abdominal pain, weakness, paresthesias, muscle pain, diarrhea, chest tightness; C/I: renal or hepatic failure, coronary cerebral or peripheral vascular dx, uncontrolled HPN, pregnancy/nursing; Do NOT use ergot derivatives & triptans within 24 hrs of each other |
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Term
| serotonin receptor antagonists - triptans - sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), eletriptan (Relpax) |
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Definition
MoA: selective 5-HT1B & 5-HT1D receptors --> normalization of dilated intracranial arteries via vasoconstriction, peripheral neuronal inhibition, inhibition of transmission thru trigeminocervical complex; Place: 1st line tx of moderate-severe migraine, also used for rescue therapy;
SEs - Oral only: paresthesias, fatigue, dizziness, flushing, warm sensations, somnolence, chest tightness; C/Is: ischemic heart dx, uncontrolled HTN, cerebrovascular dx; Do not use with ergot derivatives; Do not administer within 2 wks of MAOIs; Risk of serotonin syndrome when taking with SSRIs; |
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Term
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Definition
| first generation triptan; oral (30 min onset), nasal (15 min onset), and injectable (SC, 10 min onset) forms; 1st line for moderate-severe migraine & for rescue dose; 30-40% of pts who respond to this drug experience HA recurrence w/in 24 hrs due to short half-life; SEs: Oral - paresthesias, fatigue, dizziness, flushing, warm sensations, somnolence, chest tightness; SC - minor injection-site rxn; Intranasal - taste perversion, nasal discomfort |
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Term
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Definition
| goal is to relieve pain, NOT reverse attack; Give pts at least 2 abortive drugs, ideally more than one formulation |
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Term
| antiemetics - metoclopramide (Reglan), chlorpromazine, prochlorperazine (Compro) |
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Definition
| adjunctive tx to combat N/V that accompany migraines; Administer single-dose before ingestion of oral abortive migraine med; suppository, IM/IV routes may be use if N/V is prominents |
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Term
| corticosteroids - dexamethasone, prednisone |
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Definition
| rescue therapy for status migrainous (severe, continuous migraine that can last up to 1 wk), also induces remission in cluster HAs; no high quality studies support effectiveness |
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Term
| Prophylaxis of Migraines - Points to Consider |
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Definition
| 1) these meds should be taken daily; 2) takes 4-6 wks before meds reach full effect. once effective, consider tapering in 6-12 months |
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Term
| beta-adrenergic antagonists - propanolol, nadolol, timolol, atenolol, metoprolol |
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Definition
| MoA: unknown but may raise migraine threshold by modulating adrenergic or serotonergic NT in cortical or subcortical pathways; Place: most widely used drugs for migraine prophylaxis; SEs: drowsiness, fatigue, sleep disturbance, vivid dreams, memory disturbances, depression, impotence, bradycardia, hypotension; Precautions: pts w/ asthma, depression, diabetes, AV conduction disturbances, peripheral vascular dx, CHF; Select based on selectivity, convenience of formulation, & tolerability; Particularly useful in pts w/ comorbid ANXIETY, HTN, or ANGINA |
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Term
| Non-Pharm Therapy for Migraines |
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Definition
| Apply ice to head; Rest or sleep in dark, quiet environment; ID & avoid factors that provoke attacks (keep HA diary); Wellness programs (reg. sleep, exercise, eating habits, smoking cessation, limit caffeine); Behavioral Interventions (relaxation therapy, biofeedback, cognitive therapy) |
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Term
| Acute Management of Migraines |
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Definition
| first line agents for infrequent mild to moderate attacks: Analgesics & NSAIDs; First line agents for moderate to severe attacks: triptans or ergots |
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Term
| Prophylactic Management of Migraines |
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Definition
| consider these agents (Beta-blockers, antidepressants, anticonvulsants, Ca Channel Blockers, NSAIDs): recurring migraines that produce significant disability, frequent attacks requiring symptomatic meds > 2x wk, or if symptomatic therapie are ineffective , C/I, or produce serious adverse effects |
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Term
| antidepressants - TCAs (amitriptyline, nortriptyline, doxepin, protriptyline, imipramine), SSRIs (fluoxetine), MAOIs (phenelzine) |
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Definition
| MoA: not fully understood but may downregulate central 5-HT2 & adrenergic receptors; 2nd & 3rd line prophylaxis of migraines |
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Term
| TCAs - amitriptyline, doxepine, nortriptyline, protriptyline, imipramine |
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Definition
| most widely studied w/ demonstrated efficacy in prophylaxis of migraines; SEs: anticholinergic effects, increased appetite, weight gain, sedation; Pearls: evening doses preferred due to sedative effects, N & P have more favorable SE profile than A |
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Term
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Definition
| 3rd line prophylaxis of migraine treatment; definitive benefit has not been demonstrated; useful in pts w/ comorbid depression; less effective than TCAs but have gained favor due to better adverse-effect profile |
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Term
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Definition
| used in refractory HA but complex adverse effect profile limits use; strict adherence to tyramine-free diet (no alcohol, cheese, pickles, aged foods) is necessary to avoid potentially life-threatening HTN crisis |
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Term
| anticonvulsants - divalproex sodium (Depakote), valproic acid (Depakene), topiramate (Topamax), gabapentin (Neurontin) |
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Definition
| MoA: multiple effects but mostly due to enhancement of GABA mediated inhibition, modulation of excitatory NT glutamate, & inhibition of Na & Ca ion channels; Place: additional option for migraine prophylaxis |
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Term
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Definition
| N/V, HEPATOTOXICITY, ALOPECIA, asthenia, somnolence, WEIGHT GAIN; C/I: pregnancy, hx of pancreatitis or chronic liver dx; useful in migraineurs w/ comorbid seizures, anxiety disorder, or bipolar disorder; Obtain baseline LFTs w/ therapy |
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Term
| SEs of topiramate (Topamax) therapy |
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Definition
| fatigue, diarrhea, nausea, PARESTHESIA, anorexia, WEIGHT LOSS, difficulty with memory; useful in migraineurs w/ comorbid seizures, anxiety disorder, or bipolar disorder |
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Term
| SEs of gabapentin (Neurontin) therapy |
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Definition
| somnolence, DIZZINESS, ASTHENIA |
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Term
| calcium channel blockers - verapamil |
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Definition
| MoA: may decrease frequency of migraine attacks; Place: 2nd or 3rd line prophylactic option; SEs: constipaton, hypotension, bradycardia, AV block; Pearls: therapeutic effect not noted for up to 8 wks after initiating therapy |
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Term
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Definition
| most common HA; more common in women in adulthood; least studied; pain originates from myofascial factors & peripheral sensitization of nociceptors; self-limiting; Presentation: NO premonitory symptoms or aura present, mild-moderate pain that is dull, nonpulsatile tightness or pressure, minor disability |
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Term
| Treatment of Tension-type HAs |
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Definition
| Pharm: effective for acute tx of mild to moderate tension-type HAs --> analgesics (APAP, ASA), NSAIDs (ibuprofen, naproxen, ketoprofen, indomethacin, ketorolac) - do not use more than 2-3 days/wk; Non-pharma: psychophysiologic therapy, physical therapy |
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Term
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Definition
| most severe type of HA; attacks of severe, unilateral head pain that occur in series (lasts for wks or months, separated by remission periods of months or yrs); relatively uncommon; men are more likely to experience |
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Term
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Definition
| Abortive therapy: oxygen, ergotamine derivatives, triptans; Prophylactic: verapamil, lithium, ergotamine, corticosteroids |
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Term
| Abortive Therapy in Tx of Cluster HAs |
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Definition
| oxygen: standard, acute tx, no ADRs, caution in smokers, COPD; ergotamine derivatives: IV is quickest; Triptans: safe & effective, SC or intranasal are preferred, SC is most effective |
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Term
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Definition
| preferred CCB for prevention of cluster HAs; benefits appear 1 yr after therapy starts |
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Term
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Definition
| effective for episodic & chronic cluster HAs, can use in combo w/ verapamil; SEs: tremor, lethargy, nausea, diarrhea, abdominal discomfort; Monitor: Thyroid fcn, Renal fcn, & blood serum drug levels; |
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Term
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Definition
| effective for prophylaxis & abortive therapy of cluster HAs; usual dose: 1-2 mg daily |
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