Neuro: Schriefer Migraine And Cluster Headaches

Front 1

A 27-y-o woman presents with a 5 month history of left-sided pulsatile head pain, occurring 1 – 2 x per week. The headaches are frequently preceded by flashes of light. The ensuing pain is associated with N & V and photophobia. The headache is not alleviated by aspirin or ibuprofen.

Back 1

Know the buzzwords:

1. Pusatile head pain
2. occurin 1-2x per week: severe
3. flashes of light
4. Nausea and Vomiting
5. Photophobia

Front 2

What are the 3 types of Headaches?

Back 2

1. Vascular (e.g., migraine) - this is old NOT CORRECT

2. Muscle contraction (tension)

3. Headache caused by underlying disease

Front 3

What are characteristics for Migraine Headaches

Back 3

Characterized by recurrent attacks of steady or throbbing pain frequently occurring at night


Are frequently unilateral and associated with anorexia. May or may not have prodromal aura

Front 4

What is the Pathogenesis of Migraines?

Back 4

arise due to an underlying disturbance in brain function (i.e., neurologic cause).*****

NOT vascular!

A neurovascular hypothesis proposes that a disturbance in central pain processing pathways leads to release of neuropeptides (CGRP, substance P, neurokinin A) and serotonin, which cause vasodilation in the cranial circulation. Dilation of these vessels causes pain.

Front 5

Does the brain have pain fibers?

Back 5

NOPE

But.....MENINGES do

Front 6

Migraine are they similar to epilepsy?

Back 6

Yes both caused by short change in brain area

Change in electrical activity and Bloodflow*****

Front 7

What is a Cluster Headache?

Back 7

Related to migraine but is characterized by brief, excruciating, non-throbbing pain occurring in a series or cluster of attacks

Front 8

How long do cluster headaches last for?

Back 8

hours only

you get these......ummmmm excedrin......

Front 9

What are effective NON-pharm treatment options for Migraines?

Back 9

biofeedback, avoid triggers, OMT, acupuncture

Front 10

What are some things that can trigger a migraine?

Back 10

Alcohol (e.g., red wine)Foods (e.g., chocolates, certain cheesesIrregular sleep patternsacute changes in stress levels

Front 11

What are environmental causes of headache?

Back 11

Time-zone shifts
High altitude
Barometric pressure changes

Front 12

Why can women have migraines?

Back 12

Menstrual cycle

Front 13

What are a specific Treatment for Migraines?

Back 13

Triptans*****

EXAM

Front 14

What are Triptans?

Back 14

5HT1 Receptor Agonists (Triptans)

-Sumatriptan (Imitrex); plus naproxen (Treximet)
-Zolmatriptan (Zomig)
-Naratriptan (Amerge)
-Rizatriptan (Maxalt)
-Frovatriptan (Frova)
-Almotriptan (Axert)
-Eletriptan (Relpax)


ALL HAVE TRIPTAN IN THEM

Front 15

What is the MOA of Triptans?

Back 15

Mechanism and pharmacological effects – 5HT1D/5HT1B receptor agonists which constrict large cranial blood vessels, decrease inflammation around sensory nerves, and inhibit trigeminal neuronal discharge. These actions relieve pain and other symptoms of migraine

Front 16

What Triptans have long halflives?

Back 16

Naratriptan
&
Flovatriptan

**flovatriptan has the longest half life

***ON EXAM!!!!!

Front 17

What is a common side effect of Triptans?

Back 17

Nausea and vomiting most common after oral administration.


Bad

Front 18

WHAT are CONTRAINDICATIONS for Triptans?

EXAM*****

Back 18

. Contraindicated in patients with coronary artery disease and angina

causes vasoconstrction****

Front 19

What overuse of triptans cause?

Back 19

Overuse may increase headaches (>2x/wk)

Front 20

What is Serotonin syndrome?

Back 20

drug interaction bet drugs which increase seragenergic activity

MOST DANGEOUS****

coma, HTN crisis, convulsions, can be fatal

Front 21

What is Ergotamine and Dihydroergotamine

Back 21

Alternative to Triptans

Used to tx Migraine

Front 22

What is the MOA of Ergotamine and Dihydroergotamine?

Back 22

Ergotamine binds to all subtypes of 5HT1, and 5HT2 receptors as well as adrenergic and dopaminergic receptors. Agonist activity at 5HT1B and/or 5HT1D receptors on cerebral blood vessels probably responsible for anti-migraine activity.

more like a shotgun approach --> higher sideeffects

Front 23

Pharmacological effects Ergotamine and Dihydroergotamine

Back 23

Pharmacological effects – receptor interaction leads to constriction of dilated arteries and a decrease in pain.

Front 24

How is Ergotamine and Dihydroergotamine absorbed?

Back 24

Slowly absorbed following oral administration

Front 25

How can we speed up the abs of Ergotamine and Dihydroergotamine

Back 25

Caffeine increases rate and extent of absorption, so combination prep available (Cafergot)****

EXAM

Front 26

How are Ergotamine and Dihydroergotamine metabolized?

Back 26

Rapidly metabolized by liver but may be stored in tissues


Majority of metabolites excreted in bile

Front 27

What is the nasal form of Dihydroergotamine?

Back 27

Migranal

Front 28

Ergotamine and Dihydroergotamine Adverse reactions

Back 28

- Nausea and vomiting
- Muscle weakness and pain
- Chest pain, tachycardia, bradycardia
- Allergic reactions
- Ergotamine dependence
- Cafergot plus CYP3A4 inhibitor (macrolides, protease inhibitors) may cause fatal ischemia*****EXAM

Front 29

What are the drugs that be used prophylaxis for migraine treatment?

Back 29

1. Beta Blocker
2. Valproate
3. Amitriptyline
4. Calcium Channel Antagonist
5. Montelukast
6. Coenzyme 10
7. Pestasites hybridis (butterbur) root

Front 30

What do β-blockers such as propranolol or timolol do in the TreatmentProphylaxis of Migraine

Back 30

Reduces frequency and severity of attacks

Front 31

What does Valproate (Depakote ER) do?

Back 31

effectiveness similar to propranolol. Other antiepileptics, such as topiramate, also effective.

Anti-epileptic drug

Front 32

What does Amitriptyline do?

Back 32

mechanism unknown; MAO inhibitors also effective, SSRI for menstrual migraine

Front 33

How do Calcium channel antagonists work?

Back 33

verapamil, nimodipine;

prevent vasospasm – some recent studies question their effectiveness

Front 34

How do Montelukast (Singulair) work?

Back 34

thought to decrease frequency by decreasing inflammation

Front 35

What does Coenzyme Q10 do?

Back 35

mitochondiral defect increases mitochondiral energy

Front 36

EXAM****

Features and Treatments of Mild Migrane:

Back 36

Features:
Occasional throbbing headachesNo major impairment of functioning

Treatments:
Mild analgesics (NSAID)Combination analgesicsAntiemetics, depending on severity

Front 37

EXAM****

Features and Treatments of Moderate Migrane:

Back 37

Features:

Moderate or severe headachesSome impairment of functioningNausea common

Treatments:
Combination analgesicsTriptan or Ergot alkaloidAntiemetics

Front 38

EXAM****

Features and Treatments of Severe Migrane:

Back 38

Features:

More than 3 severe headaches a monthSignificant functional impairmentMarked nausea and/or vomiting

Treatments:
Triptan or Ergot alkaloid (+/- NSAIDS) Prophylactic medicationsAntiemetics

Front 39

How would you treat ACUTE cluster headache?

Back 39

Fast acting triptan (nasal or SC) or oxygen are the first choices;

cyproheptadine used occasionally.

Front 40

How would you PREVENT a cluster headache?

Back 40

Verapamil is drug of choice;

melatonin may be effective