​Kembara Xtra - Medicine - Migraine - Headache

​Kembara Xtra - Medicine - Migraine - Headache 
Introduction 
A disorder causing recurrent headaches, with bouts lasting 4–72 hours. Common characteristics include unilateral location, pulsing quality, moderate to severe intensity, and accompanying nausea as well as photophobia and/or phonophobia.

Most common migraine subtypes:
>80% of migraines, vomiting, photophobia, and/or phonophobia are defined as having no aura.
- With aura: visual or other symptoms (formerly known as basilar or hemiplegic migraine, motor, sensory, or brainstem symptoms); totally reversible neurologic condition, emerge gradually over 5 minutes and persist up to 60 minutes.
Menstrual migraine is defined as migraine attacks that begin 1 to 2 days before menstruation or up to day 3 of menstruation, occur in 2 of 3 menstrual cycles, and occur at no other time during cycle. Menstrually related migraine is defined as menstrual migraine plus migraine attacks at other times during cycle. Rare but significant subtypes (1) include:
Long-lasting aura symptoms, which can last up to 7 days and indicate status migrainosus, should lead secondary causes to be taken into account
Vertiginous: a migraine with vertigo or dizziness. Ocular: recurrent attacks of monocular visual impairment, including scintillations, scotomata, or blindness, with migraine. Acephalgic migraine (migraine aura without headache): a migraine aura without the associated headache.

Epidemiology 

Male:female ratio is 3:1.
Impacts more than 28 million Americans

Pathophysiology and Etiology 
Trigeminovascular: Trigeminal sensory neurons in the brainstem that are hyperexcitable are triggered and release neuropeptides such substance P and calcitonin gene-related peptide (CGRP), which cause vasodilation and neurogenic inflammation.
The most commonly recognized theories for migraines with aura are cortical spreading depressions, which describe changes in electrical activity coupled with decreased blood flow that cause aura.
>80% of patients have a history of genetic disorders.

Risk Elements 

Menstrual cycle in women; disturbed sleep patterns; diet: skipped meals (48%); alcohol (32%); chocolate (20%); cheese (13%); excessive caffeine usage (14%); monosodium glutamate (MSG) (12%); artificial sweeteners (12%); and
Vasodilators and estrogens are medications.

Prevention 
The mainstays are changes to one's way of life, including good sleep hygiene, stress management, a nutritious diet, enough hydration, and frequent exercise.

 Preventative medicine for recurrent attacks

The following conditions are related to irritable bowel syndrome: depression, anxiety, and PTSD; sleep problems (such as sleep apnea); cerebral vascular disease; seizure disorders; and medication overuse headache (MOH).


Clinical diagnosis; advice for a thorough medical history and neurological assessment


Presenting History Validated migraine screening tool: ID migraine Did you experience any of the following headache symptoms in the recent three months: Feeling dizzy or queasy in the stomach?
Did you find that light bothered you more than it did before your headache? Have headaches ever prevented you from working, studying, or performing other daily tasks?
– Yes to both inquiries 81% chance of migraine; 93% chance if three questions are answered in the affirmative (2).
● Typically, a headache starts out mildly before progressing to unilateral (30–40% bilateral), throbbing (40% nonthrobbing), and lasting 4–72 hours. If the headache is side locked, does not change sides, or has secondary reasons (such as a tumor or systemic diseases), this should trigger assessment for a different diagnosis.
Movement-induced intensification of symptoms such as nausea, vomiting, diarrhea, photophobia, phonophobia, pain in the muscles, dizziness, and vertigo.
Aura may precede the onset of the visual disturbances, which are most frequently scotoma, hemianopsia, fortification spectra, geometric visual patterns, and on occasion hallucinations.
- Somatosensory disturbance in the arms or face - Speech issues
Identify potential triggers (e.g., stress, sleep disturbance, food, caffeine, alcohol) and keep a headache diary. The migraine disability assessment (MiDAS) is a useful tool to determine the degree of disability and correlates well with headache diaries.

clinical assessment 
To rule out other explanations, a neurologic examination should include a fundoscopy:
Gait abnormalities and other cerebellar findings, altered mental status, short-term memory loss, loss of gross and/or fine motor function

Differential Diagnosis Other main headache disorders (such as trigeminal autonomic cephalgia [TAC] and idiopathic intracranial hypertension [IIH])
Secondary headaches: vascular pathology, MOH, tumor, infection, inflammation, and drug use

Laboratory Results 

With worrisome symptoms and/or an anomaly on exam, neuroimaging is necessary. 
Additional warning signs include the following:
The following criteria must be met: New onset in patients over 50; Modification of the established headache pattern; Atypical pattern or unremitting/progressive neurologic symptoms.
Extended or unusual/change in the usual ambiance
EEG NOT needed until investigating LOC or AMS. Consider systemic disease (i.e., hypothyroidism, SLE, and vitamin deficiencies) in the appropriate clinical setting and evaluate accordingly. CT head for fear of brain hemorrhage; brain MRI more common imaging procedure.

Child Safety Considerations
NSAIDs and triptans are efficient for treating acute conditions; NSAIDs should be used first.
Rizatriptan is FDA-approved for children over the age of six, whereas sumatriptan succinate, almoptriptan, and zolmitriptan nasal spray are FDA-approved for patients over the age of twelve. 

pregnant women's issues
In the second and third trimesters, frequency may decrease.
Preeclampsia and venous sinus thrombosis should be taken into consideration if pregnant headaches suddenly start.
No migraine medication is FDA-approved for use during pregnancy or breast-feeding.
- For severe headaches, acetaminophen, antiemetics, and short-acting opioids may be used.
– The majority of the evidence (for sumatriptan) show that triptans do not have increased teratogenicity. Triptans are permitted when absolutely necessary.
- Ergotamines should not be used.
- Skip using natural remedies.
Blockers and calcium channel blockers are useful preventative measures.
- Lidocaine and bupivacaine trigger point injections are safe, as are occipital nerve blocks.

Management Regular eating and sleeping schedules Application of cold compresses to the area of pain


Medication - Acetaminophen is beneficial; when taken with metoclopramide, provides alleviation rates comparable to triptans - for mild to moderate attacks:
[A]
NSAIDs are successful in up to 60% of situations.
 Excedrin Migraine (aspirin, acetaminophen, and caffeine) (5)[B]
- Mild to moderate attacks: triptans when over-the-counter medications don't work OR first line for moderate to severe attacks
100 mg of sumatriptan orally. Sumatriptan 3 or 4 or 6 mg SC; maximum 200 mg/24 hr; repeatable after two hours.
Repeatable after one hour; maximum dose of 12 mg/24 hours; quick onset; recommended for severe GI discomfort and waking headaches; 20 milligrams of sumatriptan for inhalation. After two hours, you can repeat; the maximum daily dose is 40 milligrams.
10 mg of rizatriptan or 5 mg if propranolol is being used as prophylactic. After two hours, you can repeat; your daily maximum is 30 mg
2.5 mg of naratriptan orally. Zolmitriptan 2.5 mg PO; 5 mg intranasally; repeatable after 4 hours; maximum 5 mg/24 hr. Frovatriptan 2.5 mg PO; maximum oral dosage of 5 mg; maximum nasal spray dosage of 10 mg per 24 hours. Eletriptan 40 mg PO; may be repeated after 4 hours; maximum 5 mg/24 hours. Can repeat after two hours; maximum 80 mg per 24 hours
Frovatriptan and naratriptan are best for long-lasting migraines and menstrual migraines since they have slow onsets but lengthy half-lives.
Dopamine antagonists as additional antiemetics- Inhibitory conditions: Avoid triptans and ergots if you have uncontrolled hypertension or coronary artery disease.
- Safeguards
 MOH can be brought on by the frequent use of acute-treatment medications, particularly Excedrin, triptans, and butalbital.
Common side effects of triptans include paresthesias, weakness, flushing, and chest pain.
Before considering yourself a class failure, we advise trying more than one triptan.
Dihydroergotamine is the preferred medication for status migrainosus and triptan resistance or failure. In comparison to intramuscular injections, ergotamine oral tablets and dihydroergotamine nasal sprays are more practical and secure.
- Lasmitidan 50 and 100 mg, an agonist for the 5-HT1F receptor.
restricted substance listed as Schedule V. After eight hours, the patient shouldn't drive; it's safe with CV risk factors.
- Rimegepant 75 mg ODT: 1 daily PRN dosage; max 75 mg/24 hr - Ubrogepant 50 and 100 mg: can repeat after 2 hours; max 200 mg/24 hr - First-line preventative treatment: lifestyle changes, trigger reduction, and CBT
- If your quality of life is significantly impacted by six or more headache days per month, four headache days per month with moderate intensity, or two headache days per month with severe impairment, you should think about preventative medication.
 Abortives do not relieve migraines.
 Constant, bothersome, or prolonged auras
To lessen frequency and as a preventative measure for migraines, take divalproex, topiramate, metoprolol, and propranolol.
Other choices include amitriptyline, venlafaxine, lisinopril, and candesartan.
– If predictable triggers (menses, etc.) exist, NSAIDs can be a helpful preventative measure.
- Monoclonal antibodies against CGRP:
 Galcanezumab-gnlm partial CGRP receptor antagonist; 225 mg monthly SC injections or 675 mg quarterly SC injections Erenumab 70 and 140 mg, complete CGRP receptor antagonist; 1 SC/month. 240 mg as a loading dose, then 120 mg SC injections every month
Eptinizumab-jjmr 100 mg/mL should be diluted with 0.9% NaCl and infused for 30 minutes.
- Small-molecule antagonists of CGRP
Atogepant 10, 30, and 60 mg: 1 tablet daily - For chronic migraine, onobotulinum toxin A (Botox) (6). Rimegepant 75 mg ODT: 1 tablet every other day.
[A]
QUESTIONS FOR REFERENCE
Uncertain diagnosis, resistance to standard therapy, and major coexisting medical diagnoses

Alternative Therapies 
Acupuncture is just as effective as preventative medication therapy with fewer side effects. Riboflavin (vitamin B2): 400 mg/day; Magnesium: 400 mg/day; MIG-99 (Feverfew): 6.25 mg TID.

Patient Follow-Up Monitoring
When headaches are not adequately controlled, make quarterly or more frequent appointments. Also, keep track of how often you get headaches by keeping a headache diary.

● Consider cholesterol testing and other risk reduction methods, such as quitting smoking, if you have migraines, especially if they come with an aura. Due to a higher risk of stroke, estrogens should be avoided by women who suffer from migraines with aura.


Identifying and avoiding triggers can greatly reduce headache frequency.
Setting expectations is crucial, especially with preventative drugs when success is defined as a 50% decrease in headache severity or a decrease in headache-related disability.

After several weeks of treatment, preventive drugs may start to show their benefits.

The severity, frequency, and impairment of attacks decrease with age (including menopause), and most attacks resolve within 72 hours.

Status migrainosus (more than 72 hours)
MOH: probability with butalbital > opiates > triptans > NSAIDs; headache 10 or more days per month for >3 months due to frequent overuse of a rescue headache treatment.
Rare cerebral ischemic events