Different triggers

Sometimes 1-2 times a month

Giving opiates!

Opiates cause rebound pain

• Recognized triggers for the HA
• Activities
• Foods
• alcohol, red wine, cheese, MSG
• Stress
• Menstrual cycles
• Do something about the triggers
• e.g., migraine "meds" can be contraceptives that interrupt the cycles

• Visual changes (scotoma) or visual loss
• Photophobia, phonophobia
• Nausea
• Odd head sensations
• Smell auras
• Some have TIA-like symptoms (that mimic stroke but resolve within hours)

Taken early

in a combination of NSAID or ASA and caffeine

(Excedrine migraine)

In caffeine-naive patients - can use strong espresso

migraine HA

prophylaxis of migrane

alpha adrenergic blocker

• Nausea
• peripheral vasoconstriction
• uterine stimulation w. decreased placental blood flow (abortive)
• HTN
• Can trigger MI
• Chemically related to LSD, so can change neurological status and induce hallucinations

"triptans"

Sumitriptan

Solmitriptan

Effect: stimulate 5-HT receptors on cranial blood vessels

Action: Cranial vasoconstriction, inhibit inflammatory neuropeptides

Admin: oral, nasal, injectable forms

Megabolism: peak and t 1/2 depend on agent

• Nausea/vomiting
• Weakness, tingling, flushing
• Can precipitate stroke, cerebral hemorrhage, MI
• Pain/pressure in chest, neck throat, jaw
• "heavy arms"
• Dizziness, drowsiness

Major concern: CV symptoms

• Ischemic heart disease, history of MI
• Uncontrolled HTN
• Caution in renal or hepatic dysfunction, CVA
• Don't give within 24 of ergotamine
• Potential toxicity when used with common anti-depressants (SSRI's)
• Serotonin syndrome
• Prozac, paxil, zoloft, etc.
• Most are not allowed more than 6 tabs a month

• Beta blockers and CCB (calcium channel blockers) have efficacy when taken chronically (Prophylactically)
• Keeps vessels dilated so less vasoactive tendencies
• Anti-seziure meds
• Valproic acid / Valproate (Depakote)
• Topiramate (Topomax)
• Prevent the generalized depolarization of the cortex that is associated with migraines
• TCA (tricyclic antidepressants)