9. Headache PHARM

Question 1

3 drugs that are good for acute migraine treatment? (analgesic/abortive)

Answer 1

sumatriptan (triptan)
ergotamine tartrate
dihydroergotamine

Question 2

6 drugs that are for preventative migraine treatment?

Answer 2

prolanolol
amitryptaline
valproate
topiramate
verapamil
botulinum toxin

Question 3

migraine cause: what nerve is triggered? what does it do?

Answer 3

trigeminal nerve (CN5): releases peptides backwards (antidromic peptide release)

Question 4

migraine pain in general is from what?

Answer 4

cortical neuronal changes

irritated meningeal arteries

Question 5

the acute migraine meds work how?

Answer 5

serotonin agonists, vasoconstrictors

Question 6

ergotamine tartrate: how does it abort migraine? SEs? contraindications?

Answer 6

vasoconstrictor and serotonin agonist.
SEs: can cause MI, chest tightness, sedation, nausea.
contra: coronary disease, stroke

Question 7

dihydroergotamine (DHE): how does it work? SEs? contraindications?

Answer 7

milder form of ergotamine tartrate.
vasoconstrictor and serotonin agonist.
SEs: can cause MI, chest tightness, sedation, nausea.
contra: coronary disease, stroke

Question 8

Triptans (ex sumatriptan): how does it work? SEs? contraindications? efficacy?

Answer 8

serotonin 1B and 1D agonist.
vasoconstrictor 
SEs: chest tightness, sedation, nausea.
contra: coronary disease, stroke
70% improvement in 2 hours

Question 9

triptans: interactions?

Answer 9

SSRI, SNRI

Question 10

how can physicians avoid undue influence by pharma reps?

Answer 10

avoid all contact with pharma representatives.

Question 11

indication for putting someone on a migraine med?

Answer 11

if using acute meds more than 2x/week (possible analgesic rebound)
if they get the type of migraine you don’t want ppl to have (causing hemiplegia, confusion)

Question 12

what is propanolol? how does it work?

Answer 12

beta blocker (b1 and b2). vasoconstriction, also bronchoconstriction.

Question 13

amitriptyline: what kind of med? mechanism? SEs?

Answer 13

TCA antidepressant. tertiary amine, metabolized to secondary amine. SNRI.
not used much for depression, more for pain/headache.
mech: NE, serotonin agonist.
SE: wt gain, QT prolongation

Question 14

valproate: what kind of med? mech? SEs?

Answer 14

anti-epileptic, reduces CNS excitability. Na channel blocker.
SEs: wt gain, alopecia, liver tox. BAD side effects.

Question 15

topiramate: what kind of med? mech? SEs?

Answer 15

anti-epileptic, reduces CNS excitability. GABA agonist (stimulates Cl entry)
SEs: cog decline, wt loss, kidney stones

Question 16

Botulinum Toxin: mech? efficacy? SEs?

Answer 16

blocks acetylcholine release at NMJ.
efficacy unclear (hard to blind studies)
SEs rare (weakness)

Question 17

how effective are antimigraine prophy meds?

Answer 17

50% reduction in migraines

Question 18

what would we use for migraine tx during preg?

Answer 18

acetaminophen, opioids, NSAIDs in tri1, tri2,

Question 19

general mech of analgesic rebound?

Answer 19

receptor changes and subsequent withdrawal

Question 20

38 yo woman with nearly daily headaches, some associated with photophobia. takes daily NSAID and sumatriptan. Topiramate and amitryptaline have not been helpful. exam, MRI normal. pt likely has what?

Answer 20

migraine without aura

med overuse headache

Question 21

prevention of tension-type headache?

Answer 21

TCAs, beta-blockers, NSAIDs, behavior changes

Question 22

Cluster headaches: treatment (prophy)

Answer 22

need to break the cycle.

corticosteroids, ca channel blocker, lithium, valproate

Question 23

Cluster headaches: treatment (acute)

Answer 23

02, sumatriptan, dihydroergotamine

so, similar to acute migraine tx

Question 24

lithium: used for what conditions? mech? AEs?

Answer 24

bipolar and cluster headaches
mech unknown
many side effects (incl long QT), narrow therapeutic window (lots of side effects occur)

Question 25

Verapimil: mech? AEs?

Answer 25

Ca channel blocker
AE: edema, decr BP, constip
benefit: anti-HTN