Migraine. Winter retreat
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1 Migraine Winter retreat
2 Migraine without aura: Attacks last 4 to 72 hrs. At least2of the following : unilateral ; pulsating ; mod. or severe intensity; aggravation by activity At least1of the following : N/V ; photophobia and phonophobia At least5attacks fulfilling the above criteria.
3 Migraine Status migrainosus: Attack lasting more than 72 hours. Features of migraine and tension headache overlap. EPIDEMIOLOGY: Migraine affects up to 12% of population.
4 Migraine Variants: Basilar migraine Retinal migraine Migraine aura without headache(acephalic), Migrainous vertigo Ophthalmoplegic Hemiplegic Menstural
5 PATHOPHYSIOLOGY Primary neuronal dysfunction called "Cortical spreading depression" causing a wave of neuronal depolarization. Activates trigeminal nerve. Alter BBB permeability Causes inflammatory changes in the pain-sensitive meninges that generate headache.
6 Role of serotonin: Serotonin receptor agonists (Triptans) : Inhibit release of vasoactive peptides, causing vasoconstriction, and block pain pathways in the brainstem. Brainstem serotonergic nuclei may playa role in cranial vasculature or in central pain control pathways
7 Right-to-left cardiac shunt: From PFO, ASD or pulmonary AVMs Venous blood contains vasoactive substances, normally inactivated in lungs. OR paradoxical embolism causing cerebral ischemia
8 Tension-type headache (TTH) The most prevalent type of HA. Mild to moderate intensity, bilateral, nonthrobbing, "dull," "pressure," "head fullness", "head feels large,"or "like a tight cap".
9 TTH Diagnostic criteria: At least two of the following Location bilateral in either the head or neck Pain is steady (eg, pressing or tightening) and nonthrobbing Intensity is mild to moderate. No aggravation by physical activity. Treat with:tricyclic and behavioral therapy (eg, stress management).
10 Medication overuse headache MOH diagnostic criteria Headache present on 15 days/month. Regular overuse for >3 months. 10 days/month
11 Cervicogenic headache Strictly unilateral. Referred pain from the upper cervical. Increased by movement of the head Radiates from occipital to frontal.
12 OTHER Types of HA. Sinus headache Cluster HA Giant cell arteritis Paroxysmal hemicrania Post traumatic headache
13 Ergotamine/DHE( arterial vasoconstrictor ): Worsen nausea and vomiting May cause rebound headaches Valvular heart disease Aoid in CAD(sustained coronary constriction). Avoid in Pts with HTN renal or liver disaese. Migranal(DHE): 1 mg IV, up to 6 mg/week.
14 ANTIEMETICS IVMetoclopramide(10 mg Reglan) IV Chlorpromazine(25 mg Thorazin) IV Prochlorperazine(10 mg Compazin) Use along with :IV Diphenhydramine( mg Benadryl) to prevent akathisia.
15 STEROIDS: Effective for reducing recurrence in 24 to 72 hrs. No additional benefit for immediate relief. Use Dexamethasone (10 mg IV) to reduce risk of early headache recurrence.
16 Choice of triptan A meta-analysis triptan trials, better success with: Rizatriptan /Maxalt (10 mg) Eletriptan/Relpax (80 mg), And Almotriptan /Axert (12.5 mg). Naratriptan /Amerge: slowest onset of action. Rizatriptan /Maxalt: fastest onset of action. Frovatriptan/Frova: longest half life. If no response well to one triptan may respond to another.
17 Acute RX of Migraine in PEDS Triptans are widely used but off-label. Most studies used: Nasal Sumatriptan and Nasal Zolmitriptan. Begin with oral triptans because ease of use. Use NSAIDs Antiemetics: promethazine(phenergan), Dimenhydrinate
18 Prophylactic RX in PEDS Insuffiecient data for: Beta blockers, Cyproheptadine, Amitriptyline & Valproate. Conflicting results for Topiramate. Biofeedback/relaxation
19 Migraine in pregnancy Most women (70%) report improvement. 5% worsening. Start with: Tylenol, Reglan, Caffeine(Safe less than 200 mg from all sources), NSAIDs, Antihistamins(Phenergan..). Then:, Dexamethasone, magnesium IV, Opioids, Triptans(class C)
20 Beta-blockers Prophylactic treatment in pregnancy Calcium channel blockers(verapamil) Magnesium TCA, SSRIs, SNRIs Antihistamis Gabapentin
21 Estrogen-associated migraine/menstural When estrogen declines, serotonin also falls. Treat as regular migraine with Triptans, Magnesium, Hormone Therapy: to minimize premenstrual decline in estrogen. 1 st line: estrogen-progestin contraceptive pills in an extended cycle. then menstrually-targeted supplemental estrogen.
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