Headaches

Quickly and effectively resolving acute headache symptoms (abortive or preventative?)

Abortive therapy

Decreasing frequency and severity of future headaches (abortive or preventative?)

Preventative therapy

Unilateral

Throbbing

Nausea, vomiting

Sensitivity to light, sound, movement

With or without aura

Symptoms of migraine headache

Do migraines have common triggers?

Yes

Mild/moderate acute migraine treatment

NSAIDs

Acetaminophen

+/- aspirin and caffeine

Moderate/severe acute migraine treatment

"Triptans"

+/- NSAIDs

Alt: Dihydroergotamine

Emergent/hospitalization acute migraine treatment

-IV fluids

-NSAIDs

-Anti-emetics

Persistent symptoms: Sumatriptan injection then Valproic acid

Alternative Dihydroergotamine

During treatment for an emergent, acute migraine with persistent symptoms (after IV fluids, NSAIDs, anti-emetics) what can you administer?

Sumatriptan injection then Valproic acid

Alternative treatment for migraine treatment

Dihydroergotamine

NOT recommended acute migraine treatment

Opioids

Ibuprofen, naproxen, ketorolac

NSAIDs

Metoclopramide, Prochlorperazine

Anti-emetics

Are triptans used as abortive or preventative therapy for migraines?

Abortive therapy (resolve acute headache symptoms)

Serotonin 1b/1d agonists —> promotes vasoconstriction and blocks pain pathways in brain

Triptans

Triptans are available as PO, Nasal, and IV. Order from fastest onset to slowest?

IV > nasal spray > oral

When should you take a triptan so that it is MOST effective?

Taken at onset of early/mild symptoms, do not "wait" until symptoms are severe

Chest pressure

Flushing

Serotonin syndrome (rare)

Adverse effects of triptans

Occurs when you take medications that cause high levels of the chemical serotonin to accumulate in your body. Symptoms usually occur within several hours of taking a new drug or increasing the dose of a drug you're already taking.

Serotonin syndrome

Cannot give Triptans within 24 hours of...

Dihydroergotamine (DHE)

When should you avoid triptans?

Avoid when vasoconstriction would be hazardous (e.g. MI, stroke, uncontrolled HTN, vascular disease)

Agonist at serotonin, NE, and DA receptors —> vasoconstriction

DHE (Dihydroergotamine)

When administering DHE, pre-medicate with...

Anti-emetic (e.g metoclopramide)

Contraindications of DHE include the same as triptans (avoid where vasoconstriction would be hazardous) plus...

Pregnancy

When should you add a preventative migraine therapy?

> or = 4 headache days per month

Debilitating headaches

Acute therapy adverse effects, contraindication, failure, or overuse

What are the goals of preventative migraine therapy?

50% decrease in headache days

Decrease attack severity, duration, disability

Improved response to acute therapy

With preventative migraine therapy, are max effects quick or slow?

Delayed/slow

Divalproex, valproate, topiramate

Anti-epileptic

Preventative migraine therapies include...

Anti-epileptic meds (Divalproex, valproate, topiramate)

Beta blockers (Propranolol)

TCAs (Amitryptaline)

Botulism toxin injections

Test 2: A 32 year-old female with a history of migraines had been successfully managed with the occasional abortive agent, but now reports 4-6 migraines per month over the last few months. Assuming no contraindications, which of the following would be a potential migraine prophylaxis agent?

Propranolol

Which anti-epileptic drugs can you NOT use in pregnancy?

Divalproex

Valproate

Topiramate

Divalproex, Valproate (neural tube defects)

Fatigue, sexual dysfunction, negative effects on reactive airway diseases

Beta blockers

Emerging preventative migraine meds

CGRP (calcitonin gene related peptide) agents

Expensive and reserved for those who have failed or are intolerant to other migraine therapies

CGRP

Ubrogepant and monoclonal antibodies - "mab" drugs

CGRP agents

Tension type HA treatment

NSAIDs

APAP (acetaminophen)

+/- aspirin/caffeine

(Note - same as mild migraine treatment)

Cluster HA acute treatment

SQ or nasal triptans and/or oxygen

Unilateral but with presentation of lacrimation/rhinorrhea

Cluster HA

Generally defines the overuse of any med for HA

> or = 10-15 days per month

If overuse HA, when should you try discontinuing the offending agent?

As able and abruptly as possible

How would you counsel a patient regarding the timing of triptan administration?

Take immediately upon onset of symptoms

Which triptan formulation has the fastest onset of action?

Injectable sumatriptan

Oral naratriptan

Nasal zolmitriptan

Oral rizatriptan

Injectable sumatriptan (speed of onset from fastest to slowest is injection, nasal, oral)