Migraine Issues
Migraines typically last between how many hours?
What is 4-72 hours
Migraines last between 4-72 hours, and must have associated phonophobia AND photophobia or nausea and vomiting.
There is most often unilaterality, pounding or throbbing quality, severity rated from moderate to severe, and worsening with activity or symptoms that cause avoidance of activity.
Name a risk factor that will increase migraine chronicity:
What are: Tobacco use, obesity, depression, difficulty sleeping or apnea, stress, and low socioeconomic status
Preventive management & risk mitigation can impact transformation back to a migraine-free lifestyle.
How long should we be sleeping on average?
What is ≥ 7 hours of sleep per night in adults
What is 10+ hours for children and adolescents
Children and adolescents need much more sleep time+ hours for children and a
Avoidance of ( ) medication class as they can impair cognitive function in the elderly.
What are anticholinergic medications (e.g. benadryl)
Although they do not cause dementia, they can impair cognitive function (even in normal brains), thus avoid in the elderly.
Screening for autism should occur for ALL patients at:
What are 18 and 24 mos. Patients with a positive screen should be referred to specialists in developmental or behavioral pediatrics for a much more comprehensive interdisciplinary evaluation.
Screening: General developmental screening at 9, 18, and 30 mo. Autism-specific screening at ages 18 and 24 mo. The most common tool in the U.S. is the modified checklist for autism in toddlers- MCHAT-R.
Sensitivity and specificity are 85%/99% (when used properly).
https://mchatscreen.com/ (you can download the screening test here).
DSM-5 Diagnostic Criteria:
https://iacc.hhs.gov/about-iacc/subcommittees/resources/dsm5-diagnostic-criteria.shtml
Migraine and depression/anxiety seem to have a bidirectional relationship. True or False?
What is True
Rebound headaches can be treated with:
What are steroids
Rebound headaches can be treated with steroid taper or occipital nerve blocks.
What is sleep Hygiene?
What are basic sleep-promoting behaviors.
Tosini, G., Ferguson, I., & Tsubota, K. (2015). Effects of blue light on the circadian system and eye physiology. Molecular Vision, 22, 61-72. https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734149/
A classic progression of AD includes:
What are short-term memory loss and word-finding difficulty
Short-term memory loss, and word-finding difficulty, precede loss of executive function (e.g. poor judgment, and inappropriate social behaviors).
Name three pharmacotherapeutic options in the adolescent patient with depression in addition to shared-decision making + CBT:
What are prescribing SSRIs: start with fluoxetine because FDA approved for adolescents and has a long half-life to avoid discontinuation symptoms in the setting of poor adherence
Monitor closely for the unmasking of bipolar disorder- mania) w SSRIs may reveal an increase in energy and/or decreased need for sleep.
Escitalopram or sertraline are also reasonable options
Fluoxetine dosing: start at 10mg, titrate to 20-40mg (therapeutic range) weekly by increments of 10mg
May need a higher dose of SSRI to treat co-morbid anxiety with depression, but want to titrate slowly to avoid adverse effects given anxiety is a potential early side effect of SSRI initiation
**Refer to psychiatry if the patient fails 2 SSRIs. Will augment therapy with mood stabilizers, anti-psychotics, or transition to SNRI. EARLY referral is ideal. Resource dependent.
The USPSTF recommends initiating screening at age 12
The Treatment for Adolescents With Depression Study (TADS): Long-term Effectiveness and Safety Outcomes. Arch Gen Psychiatry. 2007;64(10):1132–1143. doi:10.1001/archpsyc.64.10.1132
Clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression (GLAD-PC):https://publications.aap.org/pediatrics/article/141/3/e20174081/37626/Guidelines-for-Adolescent-Depression-in-Primary?autologincheck=redirected
A patient with Bipolar disorder and a migraine disorder will have positive outcomes on Lithium therapy: True or False?
What is False
According to Sekula et al., (2022), 30% of people with bipolar disorder (BD) suffer from migraines as opposed to 17% in the general population. A longitudinal study demonstrated that lithium use in patients with migraines, increases mania symptoms, leading to poor clinical outcomes. Concluding that the use of lithium is contraindicated in BD comorbid with migraine.
Triptans can be safely used with SSRIs and SNRI medications. True or False?
What is True
Triptans appear to be safely used with SSRI and SNRI medications, as there is no documented evidence of serotonin toxicity in patients who have been co-prescribed.
Venlafaxine (Effexor) has level B evidence for migraine prophylaxis.
OnabotolinumtoxinA is FDA approved for chronic migraine only. Specify what parameters deem a chronic migraine indication for this treatment:
What are equal to or > 15 headaches/month, 8/15 are migraines.
Counsel patients on the importance of consistent, quality sleep and stress management with things like yoga or meditation.
AD requires at least two areas of cognition:
What are judgment and language
AD requires at least two areas of cognition (e.g. judgment and language).
First line treatment of anxiety and OCD in youth is:
What is a form of CBT called exposure therapy
If the child has moderate to severe anxiety or OCD, then the combination of exposure-based CBT and medication (SSRI) is more effective than either alone.
In order to treat an anxiety disorder, we need to understand what the child’s core fear is.
In exposure therapy, the therapist exposes the child to anxiety/fear-provoking stimuli in a gradual manner. This process can be distressing and it is important to have conversations with the child’s caregivers about how to tolerate their child’s distress while supporting their child.
Compton SN, Walkup JT, Albano AM, Piacentini JC, Birmaher B, Sherrill JT, Ginsburg GS, Rynn MA, McCracken JT, Waslick BD, Iyengar S, Kendall PC, March JS. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health. 2010 Jan 5;4:1. doi: 10.1186/1753-2000-4-1. PMID: 20051130; PMCID: PMC2818613.
Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA. 2004 Oct 27;292(16):1969-76. doi: 10.1001/jama.292.16.1969. PMID: 15507582.
A Hemiplegic migraine must have exam-confirmed motor weakness + aura, including dysphagia.
Name the drug class that should be avoided for abortive treatment in hemiplegic migraines:
What is Triptans
Triptans are avoided in the management of hemiplegic migraine.
Think: vasoconstriction MOA risks and ischemic factors
Name a daily supplement that can be taken to prevent and is also useful in the treatment of migraine(s) with aura:
What is Mg
Magnesium 400-500 mg/day seems to be useful to prevent or for acute treatment of migraine with aura.
Name a medication that has a higher risk of precipitating medication overuse in headaches:
What are butalbital +/- caffeine
acetaminophen and NSAIDs seem to have a lower risk of precipitating medication overuse headaches.
butalbital and caffeine have a high risk of medication overuse headaches.
Note that there is the risk of seizure with abrupt withdrawal of butalbital.
Once criteria are met for an AD diagnosis, initiate:
What is a cholinesterase inhibitors
Cholinesterase inhibitors also have the following names: acetylcholinesterase (AChE) inhibitors or anticholinesterases.
They are a group of drugs that block the normal breakdown of acetylcholine (ACh) into acetate and choline and increase both the levels and duration of actions of acetylcholine found in the central and peripheral nervous system.
The acetylcholinesterase inhibitors have a variety of indications. Most commonly, their use is in treating neurogenerative diseases such as Alzheimer disease, Parkinson disease, and Lewy body dementia.
A careful diagnosis and history of adult ADHD should reveal symptoms dating back to:
What is childhood
They may have found ways to cope, 'scrape' by, or function in childhood.
Cooper M, Hammerton G, Collishaw S, Langley K, Thapar A, Dalsgaard S, Stergiakouli E, Tilling K, Davey Smith G, Maughan B, O'Donovan M, Thapar A, Riglin L. Investigating late-onset ADHD: a population cohort investigation. J Child Psychol Psychiatry. 2018 Oct;59(10):1105-1113. doi: 10.1111/jcpp.12911. Epub 2018 Apr 23. PMID: 29683192; PMCID: PMC6175329.
Health Inequities: Children of color are underdiagnosed with ADHD. Expert opinion- they're more likely to be (erroneously) diagnosed with oppositional defiant and conduct disorder instead of ADHD. The risk of not treating a Black boy with ADHD means that down the road, they may act in a way that society deems dangerous; society already has less room for error for Black boys:
Moody, M. From Under-Diagnoses to Over-Representation: Black Children, ADHD, and the School-To-Prison Pipeline. J Afr Am St 20, 152–163 (2016). https://doi.org/10.1007/s12111-016-9325-5
Abdominal migraines are typically seen in what age group?
What are children/adolescents
Abdominal migraines are characterized by abdominal pain or vomiting as part of the headache syndrome. These symptoms usually predominate over the headache. This is seen primarily in children and adolescents, although can manifest as cyclic abdominal pain and vomiting in adults.
Name a CGRP antagonist approved for either episodic or preventative treatment for chronic migraines:
*blocks calcitonin gene-related peptide activity (CGRP)
The CGRP are:
Quilipta (atogepant, preventative)
Ubrelvy (ubrogepant, acute-episodic)
Zavzpret (acute- zavegepant, nasal spray)
Nurtec (rimegepant, ODT acute & episodic qod prohylaxis)
vAimovig (erenumab, sc q month)
vAjovy (fremanezumab, sc q month)
Emgality(galcanezumab, sc q month)
Vyepti (eptinezumab, IV Q3mos)
Approved for episodic and chronic migraines, although insurance coverage will be a limiting factor.
Define medication overuse headache:
Medication overuse headache is defined as intake of greater than 15 days a month of naproxen or acetaminophen.
Highest Risk: Use of butalbital, triptans, ergots, or opiates for more than 10 days a month for headache also constitutes overuse headache.
Hence why preventative treatment is an important therapeutic measure.
Name two AD prevention efforts:
What are engagement with a wide circle of friends, intellectual exercises (cross-word, sudoku, etc.), active lifestyle, BP control, WT control
Poor evidence for Vitamin E, Gingko biloba, axonal (fractionated coconut oil).
After a mild traumatic brain injury (mTBI) -new and preferred term rather than 'concussion'- children may have:
Name three symptoms
What are headache(s), nausea, emesis, dizziness, difficulty with concentrating or sleeping, and/or anxiety or mood disruption
Symptoms depend on many factors, including premorbid factors (PMHx, psychiatric history, propensity for mTBI) and the injury itself
mTBI is an acute brain injury resulting from mechanical injury to the head or from external forces resulting in confusion/disorientation, loss of consciousness <30 min, post-traumatic amnesia <1 day, and/or transient neurologic abnormalities (focal signs or seizures) with a GCS of 13-15.
mTBI is a clinical definition and does not require neuroimaging to diagnose
Complicated mTBI: mTBI plus swelling, intracranial bleeding, microhemorrhage, or contusion on neuroimaging
Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed for diagnosing and managing pediatric mTBI in the United States.
Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. 2018 Nov 1;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853. Epub 2018 Nov 5. Erratum in: JAMA Pediatr. 2018 Nov 1;172(11):1104. PMID: 30193284; PMCID: PMC7006878.