NEURO 22: Therapeutics of Migraines / Headaches

ACUTE MIGRAINE: Mild-Moderate

1) 1st line

2) Of the 1st line, which specific drug has the fastest onset of action

3) What to give for nausea/vomiting thats intolerable

1) NSAID or acetaminophen

2) Diclofenac POTASSIUM

3) Metoclopramide or Domperidone

• Metoclopramide 5-10 mg PO PRN

• Metoclopramide 10mg IV over 3 min q6-8h

ACUTE MIGRAINE: Moderate-Severe / NSAID Failure

1) 1st line

2) 2nd line

3) a) ___ should not be used with b) ___ due to c) ____

4) What should opioids be limited to

1) Triptan + NSAID

2) UbroGEPANT or DihydroERGOtamine

3)

a) Dihydroergotamine (DHE)

b) Triptans

c) they’re both vasoconstrictors

4) Limited to less than 7 days a month

When should you consider migraine prophylaxis

1. Migraines are frequent (≥4/ month), long lasting (≥12 hours) or debilitating

2. Acute treatments ineffective, CI, intolerable

3. Using abortive medications ≥2/week / risk of MOH

4. Menstrual migraines

MIGRAINE PROPHYLAXIS: First Time Strategy

1) Which drug classes should be considered

1) Beta Blockers (Propranolol, Metoprolol)

2) TCAs (Amitriptyline, Nortriptyline)

MIGRAINE PROPHYLAXIS: + Depression/Anxiety (3)

Amitriptyline

Nortriptyline

Venlafaxine

MIGRAINE PROPHYLAXIS: Hypertension (4)

Propranolol

Metoprolol

Timolol

Candesartan

MIGRAINE PROPHYLAXIS: Epilepsy (2)

Valproate

Topiramate (for fatties)

MIGRAINE PROPHYLAXIS: OTCs

Magnesium Citrate

Riboflavin

Coenzyme Q10

Butterbur

** Low evidence

MIGRAINE PROPHYLAXIS: Pregnancy

1) Should you use medications

2) What are safe (2)

3) What to NOT use aka teratogenic (1)

AVOID MEDICATIONS

• Safe = Magnesium, Propranolol

AVOID Valproate

1) What do we use to assess for migraine severity

2) What is a class 4 in this context

MIDAS

Severe disability (Score 21+)

Behavioral interventions (5)

S Sleep

E Eat/Drink

E Exercise

D Diary

S Stress Management (CBT, relaxation training, biofeedback)

Non-Pharm for Acute Migraine (4)

1. Application of cold or pressure

2. Topical peppermint oil

3. Rest/stimulus deprivation

4. Neurostimulator

Non-Pharm for Chronic Migraines (5)

1. Identify + AVOID triggers

2. Lifestyle consistency

3. Eliminate caffeine

4. Relaxation training

5. Biofeedback, physiotherapy, CBT, neurostimulation

GOALS

Acute = Return to normal activity within ____

Prevention = ___% reduction in HA days / month

1) 2 hours

2) 50% reduction

MIGRAINE PROPHYLAXIS: Lactation Pharmacology

1) Acute

2) Prevention

1)

1st line = Acetaminophen

2nd line = NSAID

Antiemetic = safe

2)

1st line = Propranolol, Magnesium

2nd line = Divalproex / Valproic Acid

What should children AVOID

Metoclopramide (risk of dystonbia)

Tension-Type Headache

1) Acute Treatment

2) Prevention

1) Acetaminophen / NSAID

2) Amitriptyline, Mirtazapine, Venlafaxine

Cluster Headaches

1) Acute treatment

2) Prevention

1) Sumatriptin SC or 100% oxygen therapy

2) Verapamil, steroids, lithium