17 - Migraines Flashcards
(94 cards)
1
Q
Higher prevalence among ______
A
females
2
Q
_____ predisposition to migraines
A
genetic
3
Q
List 3 migraine triggers (more on slide 4)
A
- emotional stress
- smoke
- not eating
4
Q
Describe a typical migraine headache
A
- 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
Q
What are some red flag symptoms?
A
- 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
Q
What are some differential diagnoses for migraines?
A
- Mass/lesion, CVE, meningitis
- Hemorrhage
- Subdural hematoma
- Encephalitis, meningitis
- Metastasis, opportunistic infection, etc.
7
Q
What is acute drug treatment?
A
Abortive medications “relievers”
-Taken prn for headache symptom relief (ex. sumatriptan, ibuprofen, ergotamine)
8
Q
What is preventative drug treatment?
A
aim to decrease migraine frequency, taken on a regular basis (ex. amitriptyline, topiramate, metoprolol)
9
Q
When do you consider migraine prophylaxis?
A
- 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
Q
Goals of migraine prophylaxis
A
reduce attack frequency by > 50% and severity, reduce associated disability, prevent transition from acute > chronic migraine
11
Q
List 5 NHPs for migraine
A
- butterbur
- feverfew
- riboflavin
- coenzyme Q10
- magnesium
12
Q
Butterbur:
Scientific name of butterbur
A
Petasites hybridius
13
Q
Butterbur:
Lots of extracts of butterbur have been used, but in migraine the ______ extract has been primarily evaluated
A
rhizome
14
Q
Butterbur:
Is butterbur for prevention or treatment of migraines?
A
prevention
15
Q
Butterbur:
List a few other things that people use butterbur for
A
pain, stomach upset, gastric ulcers, headache, etc.
16
Q
Butterbur:
What is butterbur most possibly effective for?
A
migraines, allergic rhinitis and somatoform disorders
17
Q
Butterbur:
Dosage for migraine management of butterbur?
A
migraine prophylaxis in adults: 50-75 mg BID for 4 months
18
Q
Butterbur:
Safe?
A
possibly safe
19
Q
Butterbur:
Butterbur products should be labeled “PA Free” which means what?
A
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
Q
Butterbur:
Can butterbur be used in pregnancy or lactation?
A
likely unsafe
-may be teratogenic
21
Q
Butterbur:
Adverse effects ?
A
GI symptoms, including nausea, flatulence and belching
22
Q
Butterbur:
Is it deemed effective ?
A
yes - for migraine prevention
“possibly effective”
23
Q
Butterbur:
What does turcotte think after reviewing the evidence?
A
- 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
Q
Butterbur:
What does it interact with?
A
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
