35. Migraines Flashcards
Jeff comes into the pharmacy to drop off a prescription for an antibiotic to treat bronchitis. The patient mentions that he has migraine headaches from time-to-time and that his doctor told him to take something over the counter. The patient reports having a severe reaction to acetaminophen. What OTC product would you recommend for this patient?
A. Tylenol
B. Motrin
C. Excedrin Migraine
D. The store brand medication labeled “non aspirin” pain reliever.
E. Axert
B. Some patients with occasional migraines find acceptable relief with OTC products, including NSAIDs or Excedrin Migraine (acetaminophen + aspirin + caffeine). Most stores have a store-brand (less expensive) formulation of this product.
Which of the following represent possible “triggers” for migraine attacks and should be avoided, if possible, in susceptible patients? (Select ALL that apply.)
A. Changes in hormone levels
B. Lemon and orange juice
C. Stress
D. Alcohol
E. Bright lights
A, C, D, E. Other triggers include certain foods (including monosodium glutamate, or MSG, and red wine), changes in wake/sleep, and changes in weather. Stress is a major instigator in migraines, as well as hormonal changes in women. Pre-menstrual migraine is the most common type of migraine headache.
Triggers: hormonal changes in women (fluctuations in estrogen; monophasic OC may help reduce migraines; progestin-only OC in migraines with aura), food (alcohol, aged cheeses, chocolate, aspartame, caffeine overuse, MSG, salty foods, processed foods), stress, sensory stimuli (bright light, sun glare, loud sound, scents), changes in wake-sleep pattern, changes in environment (weather or barometric pressure)
Dihydroergotamine (DHE) products contain the following boxed warning:
Serious and life threatening peripheral ischemia have been associated with the use of DHE and use of which of the following:
A. Nitrates
B. Calcium channel blocking drugs
C. CYP 3A4 Inhibitors
D. CYP 3A4 Inducers
E. CYP 2D6 Inhibitors
C. Protease inhibitors, macrolides (clarithromycin, erythromycin) and other 3A4 inhibitors are contraindicated with DHE.
Ergotamine Drugs
Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin
dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)
A pharmacist has a prescription for Migranal Nasal Spray for a patient using the following medications: lisinopril, metformin, atenolol, chlorthalidone and cimetidine. Select the reasonable option/s: (Select ALL that apply.)
A. Do not fill; contact the prescriber.
B. Change the H2RA to Pepcid.
C. Change the prescription to Cafergot.
D. Fill as written.
E. Fill as written after confirming the patient is pregnant.
A, B. The ergot products are pregnancy Category X and contain a boxed warning not to use with strong/moderate CYP 3A4 inhibitors (such as cimetidine) due to the risk of cerebral ischemia with higher drug levels.
A patient gave the pharmacist a prescription for Imitrex 50 mg PO at first sign of migraine, repeat x 1 if needed. Which of the following is an appropriate generic substitution for Imitrex?
A. Almotriptan
B. Sumatriptan
C. Rizatriptan
D. Eletriptan
E. Zolmitriptan
B. The generic name of Imitrex is sumatriptan.
sumatriptan (Imitrex, Alsuma): PO, injection, nasal spray, transdermal. PO dosed 25, 50, and 100mg, can repeat x1 after 2 hours (max 200mg/day). Comes in many forms (Sumavel injection; STATdose SC injection; nasal spray; Zecuity transdermal), CI with MAOIs
rizatriptan (Maxalt): PO, ODT. CI with MAOIs
eletriptan (Relpax): PO. CI with strong CYP 3A4 inhibitors (it’s a 3A4 substrate)
frovatriptan (Frova): PO, longest half life (26 hours)
naratriptan (Amerge): PO, 2nd longest half life after frovatriptan
almotriptan (Axert): PO
zolmitriptan (Zomig): PO, ODT, nasal spray. CI with MAOIs
Which of the following medications is in accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations to treat pre-menstrual migraine with aura in a female patient? (Select ALL that apply.)
A. Alesse
B. Nor-QD
C. Nora-Be
D. Lybrel
E. Camila
B, C, E. If the migraine has aura and a birth control pill will be used to help control the migraines, a progestin-only pill should be chosen as this type of migraine has a higher risk of stroke; estrogen should be avoided.
You are counseling a new patient on the appropriate use of a Zomig Nasal Spray. Please select the following counseling point that does not apply?
A. Prime the nasal spray.
B. Blow your nose gently before use.
C. Do not press the plunger until you have put the tip into your nostril.
D. May repeat in 2 hours, if needed.
E. Remove the protective cap.
A. Usually nasal sprays are primed since it takes a few sprays to get the medication to come out. With these one-time devices, including the Zomig and Imitrex nasal sprays, if they are primed, the dose is lost.
Charles was recently discharged from the hospital for liver failure. His doctor is aware that Charles has a long history of migraine headaches, but he does not want to exacerbate his current liver condition. What agent is the most reasonable option for this patient?
A. Divalproex
B. Felbamate
C. Topiramate
D. Excedrin Migraine
E. Tylenol
C. Felbamate is not used for migraine prophylaxis. It is a drug reserved for refractive epilepsy due to the risk of hepatotoxicity. Topiramate represents the lowest risk among the agents listed.
divalproex (Depakote), valproic acid (Depakene): SE: liver toxicity, pancreatitis, sedation, weight gain, tremor, teratogenicity, thrombocytopenia, alopecia, nausea, polycystic ovarian syndrome, pregnancy (X) for migraine and (D) for others.
topiramate (Topamax): SE: nephrolithiasis, open angle glaucoma, hypohydrosis, depression, metabolic acidosis, weight loss, reduced efficacy of OC, cognitive impairment, pregnancy (D)
Dihydroergotamine (DHE) products are generally tried after triptans are found to be ineffective for treating acute migraine headaches. DHE has many warnings, including which of the following?
A. Severe hypotension, including loss of consciousness
B. Severe rash, including risk of SJS/TEN
C. Intense vasoconstriction, resulting in peripheral ischemia and possible gangrene
D. Hypogonadism, including infertility
E. Excessive fertility, including multiple fertilization
C. DHE products can cause pleural fibrosis (primarily with long-term use), cardiovascular events and heart valve fibrosis.
Ergotamine Drugs
Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin
dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)
What is the pregnancy category of Migranal?
A. Pregnancy category A
B. Pregnancy category B
C. Pregnancy category C
D. Pregnancy category D
E. Pregnancy category X
E. Dihydroergotamine products are contraindicated in pregnancy.
Ergotamine Drugs
Primarily used when contraindications to triptans or do not respond to triptans. Stimulates cerebral vasoconstriction and has some effect on serotonin
dihydroergotamine (Migranal): IM/SQ, intranasal. For nasal spray: need to prime 4 times away from face, spray once into each nostril and if needed can repeat after 15 minutes. Boxed warning: peripheral ischemia with potent 3A4 inhibitors. Warnings: cardiac valvular fibrosis (valve thickening), cardiovascular effects (vasospasm, strokes), ischemia (possible gangrene). SE (nasal): rhinitis, dysgeusia (distortion of taste), nausea, dizziness. Pregnancy (X)
Which of the following drugs used for migraine prophylaxis are best avoided in a female of child-bearing age?
A. Propranolol
B. Timolol
C. Valproic acid
D. Topiramate
E. Amitryptiline
C. Of the list above, valproic acid is the most teratogenic and should not be used in this patient population; many pregnancies were not planned at the time of conception.
divalproex (Depakote), valproic acid (Depakene): SE: liver toxicity, pancreatitis, sedation, weight gain, tremor, teratogenicity, thrombocytopenia, alopecia, nausea, polycystic ovarian syndrome, pregnancy (X) for migraine and (D) for others.
topiramate (Topamax): SE: nephrolithiasis, open angle glaucoma, hypohydrosis, depression, metabolic acidosis, weight loss, reduced efficacy of OC, cognitive impairment, pregnancy (D)
A patient is using ibuprofen for acute migraine treatment. He reports that it works fine. He told his doctor that he has occasional migraines which he self-treats with an over-the-counter medicine. His physician is not a good listener, and when the patient left the doctor’s appointment he found that the physician had left a prescription for sumatriptan for him at the front desk. Choose the correct statement:
A. Some patients find acceptable treatment for migraines with OTC products such as NSAIDs or acetaminophen-aspirin-caffeine combo drugs.
B. Aspirin-butalbital-caffeine is considered the first-line agent for acute migraines.
C. All patients receive higher efficacy with the use of prescription agents-these are considered first-line.
D. He should use naproxen instead of ibuprofen since ibuprofen lasts too long.
E. All of the above.
A. Some patients are treated well using triptan therapy. Others require both an NSAID and a triptan for adequate pain relief. OTC agents, in some patients, are the best option. Naproxen has a longer duration of action (Q12H) than ibuprofen.
Samantha has 2-3 migraines monthly. They reduce her ability to function for 2-3 days. Her daily medications include fosinopril for hypertension and a multivitamin. Choose the correct statement:
A. She should start daily therapy with sumatriptan.
B. She should start daily therapy with rizatriptan.
C. She should begin prophylaxis therapy to reduce her migraine incidence.
D. She does not need a daily prophylactic agent since she uses fosinopril.
E. She should begin daily therapy with Fiorinal.
C. If a patient uses acute treatment more than twice weekly, or has severe symptoms, or requests prophylaxis, an agent can be used to decrease migraine frequency. These agents can be antidepressants, anticonvulsants, vitamins or natural products, and are tried at a reasonable dose for 2-6 months. Female patients who have pre-menstrual migraines may find benefit with an oral contraceptive.
A pharmacist will help a patient identify common migraine triggers. Which of the following could be contributing to a migraine? (Select ALL that apply.)
A. Too much sleep
B. Too little sleep
C. Stress
D. Spicy foods, hot red pepper
E. Tomatoes
A, B, C.
Triggers: hormonal changes in women (fluctuations in estrogen; monophasic OC may help reduce migraines; progestin-only OC in migraines with aura), food (alcohol, aged cheeses, chocolate, aspartame, caffeine overuse, MSG, salty foods, processed foods), stress, sensory stimuli (bright light, sun glare, loud sound, scents), changes in wake-sleep pattern, changes in environment (weather or barometric pressure)
A pharmacist is dispensing eletriptan to a patient who has not used a triptan previously. She should counsel her on the likelihood of this side effect:
A. Electric shock sensations
B. Chest pressure/heaviness
C. Alopecia with chronic use
D. Activation/insomnia
E. Rash, with hives possible
B. Side effects from triptans: somnolence (sleepiness, not activation), nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness.
Triptans
MoA: Triptans are serotonin-receptor agonists (5HT-1 receptor agonists) causing vasoconstriction of cranial blood vessels, inhibiting neuropeptide release and decreasing pain transmission.
CI: cerebrovascular events (rare), cerebrovascular disease or uncontrolled hypertension, MAOIs (with Imitrex, Maxalt, Zomig only), caution with concurrent serotonergic agents (counsel patients to report restlessness, sweating, poor coordination, confusion, hallucinations when used with other serotonergic agents)
SE: somnolence, nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness. Triptan sensations include pressure in the chest or heaviness or pressure in the neck region and usually dissipate after administration
