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12 Cards in this Set
- Front
- Back
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What's the biological basis for migraines and auras?
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prodrome: hypothalamus
aura: cortical spreading depolarization in a hypersensitive cortex headache: referred pain from meningeal nociceptros due to neurogenic inflammation and peripheral sensitization persistance: central sensitization |
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What's the acute treatment of headaches?
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meds to use after the attack has started to stop progression.
treat early, use < 2-3 days/week, good for infrequent attacks or low compliance non-specific meds: acetaminophen, NSAIDs, isometheptene mucate, metaclopramide specific meds: ergotamine, triptans, serotonin-agonists |
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What's preventive treatment of headaches?
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key goal is to prevent the cortical spreading depression
indications: attacks interfere with daily life in spite of acute treatment, frequent attacks (>4/month), acute meds overuse (>2x/wk), CI/failure/intolerance of acute meds, prolonged disabling aura, hemiplegic migraine, migrainous infarction, patient preference anticonvulsants (valproic acid, topiramate), beta-blockers, amitryptiline (tricyclic), verapimil (CCB) |
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What are rescue meds?
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Meds to take during a headache if the acute meds aren't working, eg status migrainous.
neuroleptics (prochlorperazine, chlorpromazine, droperidol) opioids (for infrequent, mod/severe nonresponsive headaches. corticosteroids |
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What are the nonspecific meds used acutely for migraines?
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NSAIDs (naproxen, aspirin, ibuprofen, ketoprofen, flurbiprofen, tolfenamic acid, meclofenamate), acetaminophen, isometheptene mucate (vasoconstrictor), metaclopramide (to increase gastric absorption)
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triptans
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sumitriptan, zolmatriptan, rizatriptan, naratriptan, amotriptan, frovatriptan, eletriptan (newer agents are more centrally-active).
MOA: 5HT1B agonist --> cranial blood vessel constriction use: migraines with and w/o aura, early or late in the attack (best before allodynia) may be synergistic with NSAIDs AE: angina, MI, stroke, increased BP, chest tightness, asthenia, dizziness, somnolence, paresthesias CI: ischemic heart disease, hx of MI, silent ischemia, Prinzmetal's angina, uncontrolled HTN, suspected CAD, basilar or hemiplegic migraines. don't combine with MAOI or ergots. |
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ergots
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dihydroergotamine (DHE), ergotamine
MOA: non-selective 5HT1 agonist --> acts on blood vessels and neurons use: acute care of migraiens AE: less N/V, cramps, rebound headahces and headache recurrence with DHE than with ergotamine. don't give in pregnancy or in liver disease. ergotamine (old form): ergotism, gangrene CI: ischemic heart disease, hx of MI, silent ischemia, Prinzmetal's angina, uncontrolled HTN, suspected CAD, basilar or hemiplegic membrances. don't combine with triptans. |
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valproic acid
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MOA: GABA-agonist anticonvulsant
use: migraine prevention (quite effective), all seizure types, bipolar (esp with rapid cycling or mixed episodes) relative indication: mania, epilepsy, anxiety relative CI: liver disease, bleeding disorder AE: tremor, hair loss, weight gain, nausea, sedation, hepatotox, pancreatitis |
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topiramate
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MOA: GABAa and AMPA-R agonists, CA antagonist anticonvulsant
use: migraine prevention (quite effective), all seizures except absent seizures, pain, essential tremor relative indication: epilepsy, mania, obesity relative CI: kidney stones |
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beta-blockers
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propanolol and timolol
migraine prevention relative indication: HTN, angina relative CI: asthma, depression, CHF, Raynaud's, DM AE: drowsiness, nightmares, insomenia, depression, decreased exercise tolerance CI: CHF, asthma, diabetes quite effective if you don't underdose, be sure to taper off |
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antidepressants
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amitryptyline (tricyclic) is consistently quite effective in preventing migraines, independent of the antidepressant effect
relative indication: other pain disorder, depression, anxiety, insomnia AE: drowsiness, urinary retention, dry mouth, weight gain, constipation, tremor, confusion CI: glaucoma, urinary retention, heart block, mania fluoxetine (SSRI) can be moderately effective. relative indication: depression, OCD. relative CI: HTN |
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verapimil
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calcium channel blocker moderately effective in preventing migraines
relative indication: migraine with aura, HTN, angina, asthma AE: constipation, AV block, CHF CI: CHF, heart block, hoTN, sick sinus syndrome. use caution in hepatic/renal patients. |
