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N46 Neurology
Sleep Disorders
Toronto Notes 2019
Pharmacological Treatments for Acute Migraine
Pain 2002;97:247-257
Study: Meta-analysis of 54 double-blind, placebo- controlled RCTs of pharmacologic treatment of acute migraine of moderate to severe intensity (21,022 patients in total).
Data Extraction: Number of patients, dosing regimens, details of study design, and timing or type of rescue medication. Outcomes include headache relief at 1 and 2 h, freedom from pain at 2 h, sustained relief for 24 h, and adverse effects within 24 h.
Main Results: Data were available for 9 oral medications, 2 intranasal medications, and subcutaneous sumatriptan. For headache relief at 2 h, all interventions were effective except Cafergot®, with NNTs ranging from 2.0 for sumatriptan 6 mg SC to 5.4 for naratriptan 2.5 mg. The lowest NNT for oral medication was 2.6 for eletriptan 80 mg. For patients pain free at 2 h, the lowest NNT was 2.1 for sumatriptan 6 mg SC, with the lowest NNT for oral medication being 3.1 for rizatriptan 10 mg. For sustained relief over 24 h NNT ranged from 2.8 for eletriptan 80 mg to 8.3 for rizatriptan 5 mg. Side effects could not be analyzed systematically. There were no drug-to-drug comparisons.
Conclusion: Overall, most treatments were effective. Subcutaneous sumatriptan and oral triptans were most effective.
Elements of Sleep History
• Initiation of sleep
• Events prior to bed
• Lights
• Latency (estimated)
• Restless legs
• Hallucinations
• Maintaining sleep
• Number of wakeups per night
• Sleep walking/talking
• Snoring/gasping
• Dreams/nightmares
• Consequences of sleep
• Restorative
• Morning headache
• Falling asleep in inappropriate setting
Signs and Symptoms
• stagesofuncomplicatedmigraine
1. Prodrome (hours to days before headache onset) 2. Aura
3. Headache
4. Postdrome
•
• •
aura
■ fully reversible symptom of focal cerebral dysfunction lasting <60 min
■ examples: visual disturbance (fortification spectra – zigzags; scintillating scotomata – spots),
unilateral paresthesia and numbness or weakness, aphasia prodrome/postdrome:appetitechange,autonomicsymptoms,alteredmood,psychomotoragitation/ retardation
classificationofmigraines
■ common migraine: no aura
■ classic migraine: with aura (headache follows reversible aura within 60 min) ■ complicated migraine: with severe/persistent sensorimotor deficits
◆ examples: basilar-type migraine (occipital headache with diplopia, vertigo, ataxia, and altered level of consciousness), hemiplegic/hemisensory migraine, ophthalmoplegic migraine
■ acephalgic migraine (i.e. migraine equivalent): aura without headache
Treatment
• avoidtriggers
• mildtomoderatemigraine
■ 1st line: NSAIDs (ibuprofen, naproxen) • moderate to severe migraine
■ triptans (most effective), ergots (dihydroergotamine, dihydroergotamine mesylate [DHE])
• migraineprophylaxis:anticonvulsants(divalproex,topiramate,gabapentin),TCA(amitriptyline,
nortriptyline), propranolol, calcium channel blocker (verapamil)
Sleep Disorders
Overview of Sleep
Definition
• newborn:18hsleep(50%REM),adolescents:10h,adults:7-9hbutmostgetinsufficientamounts • manyelderlyhavereducedsleepasaconsequenceofunderlyingsleepdisorders
Sleep Architecture
• polysomnogram(PSG)measures:EEG,eyemovements(electro-oculogram–EOG),EMG, respiratory effort, oxygenation, ECG
Table 24. Sleep Stage Characteristics
Waking State Stage N1 (~5%)
Stage N2 (~50%)
Stage N3 (previously 3 and 4)/Slow Wave/Delta Sleep (~20%)
Rapid Eye Movement Sleep (~25%)
EEG
Alpha waves: high frequency (8-12 Hz), low voltage
Less than 50% Alpha waves (see above), mixed with slow wave activity
K complexes (high voltage negative and positive discharges) with sleep spindles (11-16 Hz)
Delta waves: low frequency (<2 Hz), high voltage (>75 μV)
Sawtooth waves, mixed frequency, low voltage
EOG
Rapid, blinking
Slow, roving eye movements
Still
Still
Rapid eye movements
Muscle Tone
High
High, but gradually dropping
High
Low
Very low
Other Characteristics
Marker for very light quality sleep or sleep disruption
Homeostatic sleep Reduced BP, HR, cardiac output, RR Growth hormone release
Irregular respiration Arrhythmias, heart rate variation
Classical dreaming state