Migraine Headache

Migraine Headache

  • Most common in women by the age of 35
  • Believed to be a neurovascular HA
  • We use prophylactic agents (vasodilators like BBs) to prevent constriction but for acute attacks we use vasoconstrictors (like triptans) to dilate other arteries in the scalp & neck
  • Migraine Symptoms:
    • Prodrome:  indicates a migraine is imminent.  May be psychological, neurological, physiological symptoms (diarrhea, etc) or autonomic (yawning, thirst, etc)
    • Aura:  spreading vasoconstriction causing visual, smell, body distortion symptoms
    • Pain:  unilateral, concentrated in the temple, dull at the beginning followed by pounding, throbbing or pulsating;  peaks in an hour & then lasts for 4-72 hours
    • Other s/s:  N/V, phonophobia, photohobia, post-HA syndrome
  • Precipitating factors:  hormonal fluctuations, inconsistency of daily routine, head trauma, meds (vasodilators), weather, other external stimuli (flickering lights)
    • Need to rule out other potential causes before diagnosing it as a migraine
      • If a patient says they have thunderclap pain (it came on extremely suddenly) or a fever or stiff neck immediately call 911
  • MIDAS score is used to evaluate the migraine severity & measure its impact on QOL  (it also helps in determining the treatment regimen)
  • Acute Migraine Treatment:
    • Look for concurrent meds that could be a problem (CCBs, nitrates, etc) & d/c
    • If the patient gets more than 2 migraines a week, they need prophylaxis
    • Need to treat at least 3 attacks in order to assess the efficacy of the med  (switch if an acute agents fails to control pain in 2 attacks)
    • NSAIDs:  used for MIDAS grade 1 or 2
      • ASA, IBU, Naproxen     (no evidence of APAP as monotherapy)
      • Work by decreasing inflammation & PG synthesis
      • SE:  GI bleeding, med overuse HA,  watch out in kidney dysfunction
    • 5HT receptors agonists (triptans):  used for MIDAS > 3   (or grade 2 if NSAIDs are CI)
      • Work by causing vasoconstriction & inhibiting mediator release
      • SE:  tingling, sensation of warmth, dizziness, angina-like pain, med overuse HA, parasthesias
      • CI:  uncontrolled HTN, peripheral vascular disease, heart disease/TIAs, use of MAOIs within the last 2 weeks, prego
        • Patients should get an ECG prior to admin
    • Erogtamines:  used for MIDAS > 3
      • Affects 5HT receptors (more so than triptans), anti-inflammatory
      • SE:  mod overuse HA, N/V, vasoconstriction/vasospasm (can cause severe HTN & peripheral ischemia), ergotism (MI, hepatic necrosis, bowel/brain ischemia possible)
      • CI:  PVD, kidney or renal disease, uncontrolled HTN, ischemic heart/brain disease, prego, prolonged aura
      • Available in oral, intranasal, I, IV, SQ formulations
    • Opiates:  used for MIDAS grade > 3
      • used when other drugs have failed or are CI (generally only used as rescue therapy)
      • SE:  med overuse HA, sedation, dizziness, confusion, n/v, dependence
      • Butorphanol has been shown to have benefit
    • Antiemetics/antipsychotics (phenothiazines)
      • Chlorpromazine, prochlorperazine are both good also for the nausea & pain associated with migraines
    • Pro-motility agents:  metoclopramide
    • Combo agents:  Isometheptine + dichloralphenazone + APAP
    • Corticosteroids:  dexamethasone & HCT  (insufficient evidence of benefit)
    • Anesthetics:  lidocaine  (insufficient evidence of benefit)
  • Prophylactic Migraine Treatment:
    • Need to have an adequate trial prior to declaring a treatment a failure  (must give it a couple of months)
    • Goal is to reduce frequency, severity & duration
    • Try to taper after ~6 months of success
    • Beta-Blockers  (but not those with ISA):  use propranolol or timolol
      • SE:  fatigue, altered memory, hypotension, depression, bradycardi
      • CI:  asthma, heart block, PVD, bradycardia
    • Amitriptyline  (TCA)
      • SE:  drowsiness, anticholinergic effects, postural hypotension, weight gain
      • CI:  MAOI, seizures, urinary retention, constipation, arrhythmias, narrow angle glaucoma
    • Valproic Acid  (Depakote ER)
      • SE:  n/v, somnolence, weight gain, hair loss, tremor, hepatotoxicity, thrombocytopenia, lots of DDIs
      • CI:  pancreatitis, hepatic disease
    • Topiramate (Topamax)
      • SE:  CNS, memory issues, cognitive slowing, weight loss, kidney stones
      • Caution in renal dysfunction
    • Methysegide (semisynthetic ergot)
      • Reserved for refractory HA  (not used in the US anymore)
      • SE:  peripheral ischemia, fibrosis (d/c for 1 month every 6 months)
      • CI:  PVD, uncontrolled HTN, collagen diseases, ischemic heart/brain disease, prego
    • CCBs  (mainly verapamil)
      • Longest time to onset
      • Mainly affects HA frequency not severity nor duration
      • SE:  constipation, H/V, hypotension, peripheral edema
      • CI:  CHF, hypotension, heart block
    • Botulism toxin (Botox–31 injections at 12 week intervals)
      • Chronic migraine prophylaxis only (HA occur at least half of the days of the months for greater than 4 hours each time)
      • Block sensory nerves the relay pain messages to the brain
      • SE:  bruising/swelling at injection sites, spread of toxin effects, hypersensitivity
    • Recognize if the patient has uncontrolled HTN, that it affects your treatment choice for migraine headaches

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