17 - Migraines Flashcards Preview

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Flashcards in 17 - Migraines Deck (94):
1

Higher prevalence among ______

females

2

_____ predisposition to migraines

genetic

3

List 3 migraine triggers (more on slide 4)

-emotional stress
-smoke
-not eating

4

Describe a typical migraine headache

-Unilarteral (most often) - but not always on the same side
-Throbbing, pulsating (recall the trigeminal influence on the arteries of the dura
-Attack progressively worsens over hours
-Often N & V (vomiting less common)
-Photophobia/Phonophobia very common (sensitive to light and sounds) - often migraine sufferer will need to rest in dark, quiet room because of this
-Osmophobia and cutaneous allodynia

5

What are some red flag symptoms?

-Age > 50
-severe and abrupt onset
-worsening over days/weeks
-stiff neck, focal signs, reduced consciousness
-abnormal speech, motor reflex, cognitive impairment
-fever, rash, n,v
-new onset of cancer, lyme disease or HIV

6

What are some differential diagnoses for migraines?

-Mass/lesion, CVE, meningitis
-Hemorrhage
-Subdural hematoma
-Encephalitis, meningitis
-Metastasis, opportunistic infection, etc.

7

What is acute drug treatment?

Abortive medications "relievers"
-Taken prn for headache symptom relief (ex. sumatriptan, ibuprofen, ergotamine)

8

What is preventative drug treatment?

aim to decrease migraine frequency, taken on a regular basis (ex. amitriptyline, topiramate, metoprolol)

9

When do you consider migraine prophylaxis?

-Frequent and/or long-lasting and/or severely debilitating migraines
-CI to acute therapies
-Failure of acute therapy (either poor efficacy &/or intolerable SEs)
->2 attacks per week (risk of MOH) - medication overuse headache

10

Goals of migraine prophylaxis

reduce attack frequency by > 50% and severity, reduce associated disability, prevent transition from acute > chronic migraine

11

List 5 NHPs for migraine

-butterbur
-feverfew
-riboflavin
-coenzyme Q10
-magnesium

12

Butterbur:
Scientific name of butterbur

Petasites hybridius

13

Butterbur:
Lots of extracts of butterbur have been used, but in migraine the ______ extract has been primarily evaluated

rhizome

14

Butterbur:
Is butterbur for prevention or treatment of migraines?

prevention

15

Butterbur:
List a few other things that people use butterbur for

pain, stomach upset, gastric ulcers, headache, etc.

16

Butterbur:
What is butterbur most possibly effective for?

migraines, allergic rhinitis and somatoform disorders

17

Butterbur:
Dosage for migraine management of butterbur?

migraine prophylaxis in adults: 50-75 mg BID for 4 months

18

Butterbur:
Safe?

possibly safe

19

Butterbur:
Butterbur products should be labeled "PA Free" which means what?

They are free of pyrrolizidine alkaloids, which is a hepatotoxic agent. Repeated use can cause veno-occlusive disease, can be carcinogenic.. effects can be systemic if used on broken skin.

20

Butterbur:
Can butterbur be used in pregnancy or lactation?

likely unsafe
-may be teratogenic

21

Butterbur:
Adverse effects ?

GI symptoms, including nausea, flatulence and belching

22

Butterbur:
Is it deemed effective ?

yes - for migraine prevention

"possibly effective"

23

Butterbur:
What does turcotte think after reviewing the evidence?

-seems to reduce frequency of migraines when used over a period of 16 weeks in adults
-can reduce frequency, intensity and duration of migraines

24

Butterbur:
What does it interact with?

CYP 3A4 if it contains the hepatic pyrrolizidine alkaloid and could cause even more hepatotoxicity

25

Butterbur:
What are potential cross allergies ?

Asteraceaea/ composite family - ragweed, chrysanthemums, marigolds, daisies and other herbs

26

Butterbur:
Due to potential "PA" contamination, patients with _____ dysfunction may want to avoid butterbur

liver

27

Butterbur:
MOA of anti-inflammatory action of butterbur ?

might have an effect by inhibiting leukotriene synthesis

28

Butterbur:
MOA of smooth muscle relaxant/VD effect ?

anti-spasm effects of smooth muscle and vascular wall

29

Butterbur:
Should we recommend ?

Yes as long as no significant interactions and they are monitoring for adverse effects

30

Scientific name of CoEnzyme Q10 ?

Mitoquinone Ubidecarenone

31

CoEnzyme Q10:
Produced _____ in the body and plays multiple vital roles

endogenously

32

CoEnzyme Q10:
Levels decline with ?

age and chronic illnesses including CV disease, muscular dystrophies, parkinson's, cancers, diabetes, HIV/AIDS

33

CoEnzyme Q10:
For prevention or treatment of migraines

prevention

34

CoEnzyme Q10:
What has been shown to deplete body stores ?

smoking cigarettes

35

CoEnzyme Q10:
What do people use it for?

migraines, male fertility, neurological disorders, diabetes, Prader-Willi syndrome, CV disease

36

CoEnzyme Q10:
Dose?

300mg daily split up in 100mg TID

(A dose of 1200 mg/day) showed promise in patients with end-stage renal disease at high cardiac risk.

37

CoEnzyme Q10:
Safe ?

Likely lmao

38

CoEnzyme Q10:
What does Canadian headache society say?

strong recommended based on low quality evidence for migraine prophylaxis

39

CoEnzyme Q10:
What does American headache society say?

Level C recommendation - possibly effective, ineffective or harmful

40

CoEnzyme Q10:
What does European Federation of Neurological Societies say ?

Level C recommendation - possibly effective, ineffective or harmful

41

CoEnzyme Q10:
Side effects?

stomach upset, loss of appetite, nausea, vomiting and diarrhea

42

CoEnzyme Q10:

Effective ?

possibly

43

CoEnzyme Q10:

Important drug interactions ?

Warfarin, decreases BP, might lower effectiveness of doxorubicin

Statins lower CoQ10 levels

44

CoEnzyme Q10:

How does it effect BP ?

thought to lower BP (interacts with antihypertensives)

45

CoEnzyme Q10:

Safe in pregnancy or lactation ?

evidence is lacking

46

CoEnzyme Q10:

What is the MOA ?

CoQ10 is the cofactor in the electron transport chain and protects against mitochondrial collapse/degradation during respiratory chain - involved in oxygenated ATP production

Low CoQ10 associated with mitochondrial dysfunction in occipital lobes of patients with migraines

Theory is to supplement the CoQ10 deficiency

47

Feverfew:
Scientific name ?

Tanacetum parthenium

48

Feverfew:
The leaves of the plant are generally _____ prior to being used medicinally, though fresh leaf extract is also used.

dried

49

Feverfew:
Prevention or treatment of migraines?

prevention

50

Feverfew:
What do people use it for?

Oral: fever, headaches, menstrual irregularities, arthritis, psoriasis, allergies

Topical: insecticide and tooth ache reliever

51

Feverfew:
Standardized to _____ content

Parthenolide

52

Feverfew:
Standardization of parthenolide in clinical trials ranges from which percentages?

0.2% - 0.35%

*impact of standardization on efficacy is not clear

53

Feverfew:
Dose ?

5-15 mg PO of feverfew powder once daily

54

Feverfew:
Describe the making of a feverfew tincture

2.5 fresh leaves with or after food and the tincture can be used in 5-10 drops of 1:5 parts, 25% ethanol tincture

55

Feverfew:
Need to taper ?

Yes - to avoid withdrawal symptoms

56

Feverfew:
Been used in combo with ?

white willow or ginger

57

Feverfew:
Safe ?

Likely safe for short term basis, studies have only been done for 4 months of use

58

Feverfew:
Should we advise people to chew raw (unprocessed, fresh) feverfew leaves?

No - can lead to adverse effects such as oral inflammation, ulceration, swelling of the lips and sometimes loss of taste

59

Feverfew:
Why should it be avoided in pregnancy?

Documented adverse effects (emmenagogue - ejection of placenta and fetal membranes)

Includes uterine contraction

60

Feverfew:
When is feverfew safe ?

safe when used orally and appropriately short-term

61

Feverfew:

Side effects ?

Fairly well-tolerated
-contact dermatitis, GI upset, potential CNS allergic reaction

62

Feverfew:

Effective ?

Possibly

63

Feverfew:
Helps to decrease ____ of headaches

frequency

64

Feverfew:
Important drug interactions?

NSAIDs, anti-platelets, anti-coagulants, salicylates and any natural products that affect coagulation

Multiple CYP interactions (3A4, 2C9, 2C19)

65

Feverfew:

Cross allergies ?

similar to chrysanthemums, chamomile, sunflowers and ragweed

66

Feverfew:
May ____ platelet aggregation and should therefore be avoided in individuals with clotting disorders.

inhibit

67

Feverfew:

MOA

cox - 2 inhibitor, inhibits myocardial angiogenesis and inhibits platelet aggregation

parthenolide acts as a partial agonist of TRPAI, which can cause migraines.

68

Feverfew:

Should we recommend ?

No - lots of side effects and drug interactions and efficacy not proven !!

69

Magnesium:

What contributes to deficiency?

low dietary intake and impaired absorption

70

Magnesium:

Prevention or treatment

both

71

Magnesium:

Deficiency can be linked to various health conditions such as ?

osteoporosis, hypertension, atherosclerotic vascular disease cardiomyopathy, diabetes and stroke

72

Magnesium:

What is it found in?

legumes, whole grains, veggies, seeds & nuts, hard water

73

Magnesium:
RDA for female adults

310 mg/day

74

Magnesium:
RDA for male adults

400 mg/day

75

Magnesium:
Safe?

likely safe

76

Magnesium:
Effective?

-insufficient reliable evidence to rate

-"possibly effective" is not extremely compelling

77

Magnesium:
Side effects?

Oral Mg: loose stool and diarrhea, N, V, GI irritation

IV Mg: flushing sensation, local pain and irritation, dizziness, bradycardia and hypotension

78

Magnesium:
Aside for pentamidine, what are three drugs that can cause MAJOR depletion, often requiring supplementation

ampho B, tacrolimus, PPIs

79

Magnesium:
Normal serum Mg levels ?

0.65 - 1.05 mmol/L

80

Magnesium:
Caution in those with ?

reduced kidney function due to an increased risk of hypermagnesemia

81

Magnesium:

What can hypermagnesemia cause?

can cause heart block

IV formulations are CI in heart block, bleeding disorders (magnesium increases bleeding risk)

82

Magnesium:

MOA

-magnesium is a co-factor in enzymatic reactions in body involving protein synthesis and carb metabolism

-suggested that magnesium plays a central role in establishing a threshold for migraine attacks

83

Magnesium:

Do we recommend it?

Nah - not effective

84

Riboflavin:

What is it?

water-soluble B vitamin known as vitamin B2

85

Riboflavin:

Used for prevention or treatment?

prevention

86

Riboflavin:

What is it found in?

liver, kidneys, dairy products, green vegetables, eggs, whole grain cereals, yeast and shrooms

87

Riboflavin:

dosage for migraine prophylaxis?

400mg/day for up to 3 months

88

Riboflavin:

What are 2 PK/PD properties of riboflavin in the body that are thought to limit any potential toxicity include ?

1) limited absorption into the blood stream due to increased GI motility (only 27mg of the 400mg dose would be maximally absorbed)

2) excretion in the urine

89

Riboflavin:

safe?

likely

90

Riboflavin:

In the US, it is labelled as GRAS , which stands for ?

generally recognized as safe

91

Riboflavin:

Can change _____ color

urine

(bright yellow orange)

92

Riboflavin:

Adverse effects

-weight gain
-dizziness
-GI discomfort

93

Riboflavin:

effective ?

possibly effective

94

Riboflavin:

drug interactions?

if you are on oral contraceptives, it will decrease concentrations of riboflavin