Migraine 1
What is the diagnostic criteria for migraine?
A B C D E
Status Migraine is defined as migraine headache lasting greater than 72 hours. It is common for these patient to come to the ED for treatment (since meds at home not working).
What is a common medication combination we use for these patients?
IV DHE (although not actually used anymore due to side effects but still taught in classic teaching)
Antiemetics (Ondansetron, Metoclopramide)
Ketorolac, Promethazine
Fluids, Magnesium, steroids, Valproic acid and
List all level A medications used for migraine prophylaxis
Topiramate, Valproic acid
Propranolol, Metoprolol, Timolol
Frovatriptan for MRM
What is the MOA of Ubrogepant, Rimegepant, Atogepant, erenumab.
CGRP antagonist (receptor)
What is the most common primary headache disorder in the population?
Tension type headache
What is the pathophysiology of a migraine headache? What are the steps?
Generator--> CSD--> meningeal vessel dilation+ trigeminovascular system activated--> release of neuropeptides--> inflammation+ worsening dilation--> Trigeminal nerve processes pain
What is the definition of a chronic migraine?
Migraine happening more than 15 days per month for 3 months at least
List all level B medications for migraine prophylaxis
Amitriptyline, Venlafaxine
Atenolol, Nadolol (meh)
Zolmitriptan and Naratriptan for MRM (meh)
When are CGRP antagonists initiated?
Failure of 2 or more prophylactic meds (side effects or effectiveness)
but according to AHS, they consider it first line
What is a complex or atypical migraine?
How can you tell the difference between retinal migraine and migraine with visual aura?
Literally same as migraine with aura (complex/atypical is outdated)
Retinal migraine only affects one eyeball while migraine with visual aura will affect both eyes
What is more common, migraine with aura or without aura?
What is the most common aura?
Who has migraines more, men or women?
Migraine without aura is more common (80%)
Visual aura
Women (3:1) (hormonal maybe)
When does a patient qualify for Botox treatment for migraines?
Chronic migraine
Or failed multiple prophylactic treatments (usually 2-3)
Some exceptions as we don't always stick to this
This medication used to be commonly used for migraine prophylaxis but years later it fell off as evidence wasn't good and fell to level U
Verapamil (CCB)
Say if the following is abortive or prophylactic or both:
Ubrogepant
Rimegepant
Atogepant
Ubrogepant--> pure abortive
Rimegepant--> abortive and prophylactic (PRN vs every other day)
Atogepant--> pure prophylactic
A woman with migraine with aura reads online about the risk of stroke in migraine patients.
Is the risk of stroke increased in migraine? what migraine type? if so, what are two common risks that they should avoid?
Migraine with aura x2
Smoking x6 and estrogen containing OCP x9
Decision for estrogen OCP is individualized based on patient vascular risk factors
NSAIDs, Acetaminophen and Triptans are considered abortive treatment for migraine.
What is the MOA of triptans and how does it lead to decreased headache severity?
Serotonin agonist at 5HT1 D and B
It causes vasoconstriction--> no more meningeal blood vessel dilation--> no more neuropeptides released (nip it from the bud)
Take the triptan early and not late when the cycle has been going on for a while
Believe it or not, people with migraine actually have rhinorrhea, lacrimation, conjunctival injection and sinus pressure (which can be confused as a sinus headache).
Why is this?
CN 5 and CN7 cross communicate (CN5 activates the parasympathetic SSN of CN7)
This is why when you get hit in the face with a ball, you tear up and have a runny nose! same thing in migraine
This prophylactic medication commonly causes weight gain, tremor, and increases the half life of Lamotrigine
Valproic acid
What is the MOA of Galcanezumab and Fremanezumab?
CGRP antagonist (molecule)
Two birds, one stone is common when using prophylactic medications for migraine.
Give 3 examples where we treat the migraine but also the medication chosen helps with some other medical problem the patient has.
Valproic acid--> seizure, weight gain
Topiramate--> weight loss
Beta blocker--> HTN (careful for asthma)
Amitriptyline--> sleep, weight gain
Migraine treatment is aimed at using both an abortive and prophylactic medication. What are the indications to be on a prophylactic medication?
4 migraines per month
Disabling, affect QOL or work
Severe
(The above is all variable and patient dependent)
What is the MOA of Topiramate and list common side effects we discuss with the patient before starting them on it.
Na channel blocker, enhances GABA A, inhibits carbonic anhydrase and glutamate
Teratogenic (cleft lip/palate), dysgeusia, paresthesia of finger tips, kidney stones, acute angle glaucoma, brain fog and word finding trouble (dopamax), small weight loss
What is the MOA of Botox and how long does the effect usually last?
Cleaves SNAP 25 protein--> prevents release of Ach in the NMJ--> decreased muscle contraction affected by nerve transmission from migraine headache
3 months
A patient comes in with migraine and right sided weakness and says this is typical for her migraines, says her mom has the exact same thing. You suspect she has FHM. What are three common genes affected in this condition?
FHM1 (+cerebellar ataxia)--> CACNA1--> P/Q calcium channel defect
FHM2--> ATP1A2--> Na/K ATPase defect
FHM3--> SCN1A--> voltage gated Na channels defect