Recap and review the top pearls from recent episodes #341 Migraine Headaches Update and #350 Acute Hypoxemia with Watto and Paul. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
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Featuring Kevin Weber of OSU, production by Chris Chiu and Isabel Valdez, and graphics by Edison Jyang
Headaches can be classified as migraine, tension-type, and other. The latter group warrants a neurologist or headache specialist.
Headache red flags include (but are not limited to) a history of malignancy, headache plus fever, age of onset over 50, positional headache, sudden or abrupt onset, and change in severity or frequency. Use the SNNOOP10 mnemonic to identify patients who might have a secondary cause of the headache and thus, warrant neuroimaging (Phu Do, 2019). MRI of the brain without contrast is adequate imaging for most unless malignancy or CSF leak is suspected.
Dr. Weber asks about cervical symptoms because in his expert opinion many patients with chronic migraine headaches have a cervicogenic component. He treats with physical therapy.
Dr. Weber said, “I tell my patients to think about migraine like it’s an irritable old miser set in their ways and your brain is set in its ways, and doesn’t like changes in routine. It doesn’t like lack of sleep, it doesn’t like being hungry, it doesn’t like being thirsty, it doesn’t like changes in the weather.”
It’s okay to take OTC abortive medications (acetaminophen, NSAIDS, and aspirin/acetaminophen/caffeine) along with triptans, ditans, and gepants (expert opinion).
Dr. Weber likes rizatriptan and naratriptan because they are both generic and have fewer side effects than sumatriptan (expert opinion). Rizatriptan has a quicker onset of action while naratriptan has a longer duration of action but slower onset. Don’t forget to warn your patients that triptans may cause chest tightness as a common side effect! In general, avoid triptans in patients with known cardiac or cerebrovascular disease. However, the concern for serotonin syndrome has not been seen in practice (Michelle Kerr, Daniel Krashin, Natalia Murinova
Neurology Apr 2019, 92 (15 Supplement) S27.005)
The newer CGRP-receptor blockers and ditans can be used in patients with vascular disease (unlike triptans)! CGRP-receptor blockers can be abortive (like ubrogepant twice daily or rimegepant once daily by mouth) or preventative (rimegepant every other day or Atogepant daily oral or injectable monoclonal CGRP medications like fremanezumab, erenumab, and galcanezumab or eptinezumab via injection or infusion). Lasmiditan works much like triptan for abortive treatment without causing vasoconstriction but comes with an 8-hour driving restriction!
It’s well within the wheelhouse of a primary care doc to trial preventive medication for migraine headaches. Many medications can be dual-purposed based on a patient’s other medical conditions e.g. hypertension, depression, obesity, chronic pain.
Kashlak Pearl: Dr. Weber notes that most insurance companies want patients to have tried two abortive therapies or preventive therapies before approving the newer and more expensive agents like gepants, ditans, CGRP monoclonal antibodies. It helps to give medical contraindications for specific therapies (e.g., low blood pressure, history of kidney stones, etc.).
Magnesium supplements are safe and seem to be effective for migraine prevention (von Luckner, 2018). A few different modalities for neuromodulation have been approved, but the cost is a barrier. One device is available OTC as a sticker that attaches to the forehead and stimulates the supraorbital nerve.
Featuring Nick Mark of the OHSU, production by Cyrus Askin, and graphics by Edison Jyang
Kashlak Pearls:
Differentiate between the six buckets of hypoxemia using the A-a gradient (aka A-a difference)!
Listeners will recall key pearls from recent Curbsiders episodes
After listening to this episode listeners will…
The Curbsiders report no relevant financial disclosures.
Williams PN, Watto MF. “#362 Migraine Headaches, Acute Hypoxemia: A Rapid Review (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date October 26, 2022.
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