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NAPLEX 2024 > 59. Migraine > Flashcards

59. Migraine Flashcards

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1
Q

Most migraines cause ____

A

N/V and sensitivity to light and sound

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2
Q

~1/3 of pts, migraines are preceded or accompanied by ____

A

senosory warning symptoms or signs (auras)

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3
Q

A headache accommpanied by ______ could indicate a serious cardiovascular, cerebrovascular, or infectious event and pts should seek immediate medical attention

A

Fever, stiff neck, rash, confusion seizures, double vision, weakness, numbness, chest pain, SOB, or aphasia (trouble speaking)

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4
Q

The cause of migraines is not well understood. They may be caused by increased neuronal activity, which results in an imbalance of NT (including ____) and/or activation of the trigeminal nerve (with release of _____)
These NT and neuropeptide changes ultimately lead to neurogenic inflammation and vasodilation in cranial blood vessels

A

serotonin
calcitonin gene-related peptide (CGRP)

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5
Q

A common type of migraine is ____ in women

A

Menstrual-associated migraine (MAM)

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6
Q

Menstrual-associated migraine (MAM) can be treated with ___

A

oral contraceptives, estradiol patch or creams to decrease frequency

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7
Q

Women who has migraine with aura have higher risk for ___ and should not use ___-containing contraceptives

A

Stroke
Estrogen-containing contraceptives

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8
Q

Common migraine triggers

A

Hormonal changes in women
Foods - alcohol (esp beer, red wine), aged cheese, chocolate, aspartame, overuse of caffeine, MSG, salty foods, processed foods
Stress
Sensory stimuli - bright lights, sun glare, loud sounds, certain scents
Changes in environment (weather or pressure)

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9
Q

Migraines can be dx when an adult has at least ___ attacks (not attributed to another disorder) fulfilling the following criteria:
1. headaches last ____ and recur sporadically
2. Headaches have ≥2 of the following characteristics: _____
3. One of the following occurs during the headache: _____

A

5 attacks
1. 4-72 hrs
2. unilateral location, pulsating, mod-severe pain, and aggravated (or causing avoidance of) routine physical activity
3. Nausea and/or vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound)

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10
Q

Natural products used for migraines

A

Riboflavin (Vit B12), Magnesium, butterbur, feverfew
Others: peppermint (topical) and coenzyme Q10

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11
Q

Medication overuse headaches (“rebound”) can result from the overuse of most acute headache medications. To prevent MOH, limit acute treatment meds to ___ times per week.

A

2-3x/week

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12
Q

OTC options for migraines

A

Acetaminophen, aspirin, Advil Migraine (contains only ibuprofen), naproxen, and combo products such as Excedrin Migraine (aspirin, APAP, caffeine)

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13
Q

Rx options for migraines

A

Serotonin receptor agonists (triptans), selec=ct CGRP receptor antagonists, ergotamine drugs, NSAIDs (high dose, and lasmiditan

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14
Q

What medications are not recommended in migraines d/t decreased efficacy, abuse/dependence potential, and risk of rebound headache?

A

Butalbital-containing products, opioid, tramadol, and tapentadol

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15
Q

Triptans MOA

A

Selective agonists for the 5-HT1 receptor (vasoconstrict cranial blood vessels)

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16
Q

What medication is first line for acute treatment for migraines?

A

Triptans

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17
Q

Rizatriptan formulations

A

Tablet, ODT

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18
Q

sumatriptan formulations

A

Tablet, SC (autoinjector, prefilled syringe and solution), nasal spray

Imitrex - tablet, nasal spray, SC injection

Imitrex STATdose system, Zembrace SymTouch - SC autoinjector

Onzetra Xsail - nasal powder

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19
Q

Sumatriptan PO dose frequency

A

can repeat x1 after 2 hrs

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20
Q

Sumatriptan SC Imitrex, Imitrex STATdoes System vs Zembrace SymTouch dose frequency

A

Imitrex, Imitrex STATdoes System = repeat x1 after 1 hr
Zembrace SymTouch = can repeat up to 4x/day, wait a minimum of 1 hr between doses

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21
Q

Sumatriptan intranasal spray vs powder dose frequency

A

Spray (Imitrex) = 1 nostril, can repeat x1 after 2 hrs
Powder (Onzetra Xsail) = each nostril, can repeat x1 after 2 hrs

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22
Q

zolmitriptan (Zomig ZMT) formulations

A

Tablet, ODT, nasal spray

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23
Q

Zomitriptan intranasal dosing frequency

A

1 nostril, can repeat x1 after 2 hrs

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24
Q

Contraindications of triptans

A

Cerebrovascular disease (stroke/TIA), uncontrolled HTN, ischemic heart disease, use within 24 hrs of another triptan or ergotamine-type medication

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25
Warnings for triptans
Risk of increased BP, serotonin syndrome
26
Side effects for triptans
Paresthesia (tingling/numbness) Others: dizziness, hot/cold sensations, chest pain/tightness, dry mouth, somnolence, nausea Triptan sensations (pressure or heaviness in chest or neck region) usually dissipate after administration
27
ODTs, nasal sprays, and injection formulations of triptans are useful if ___ is present. Nasal sprays and injections work faster
Nausea
28
Triptan nasal sprays contain __ dose
1 dose (do not prime)
29
T/F: Triptan nasal sprays require priming before use
False - they only contain 1 dose
30
Sumatriptan/naproxen (Treximet) dispensing requirements
Protect from moisture, dispense in original container
31
Rixatriptan (Maxalt-MLT), Zolmitriptan (Zomig ZMT) ODTs contain phenylalanine and should not be used in pts with ___
phenylketonuria
32
Which triptans are approved for children and adolescents ≥12 yo? 6-17yo?
≥ 12 yo: Almotriptan tablets, zolmitriptan nasal spray, and sumatriptan/naproxen (Treximent) 6-17yo: Rizatriptan
33
Which triptan has the longest half-life?
Frovatriptan (26 hrs) - considered long-acting but onset is slower
34
Which triptans are considered long-acting but onset is slower? Typically used if headache recurs after dosing, lasts a long time or can be anticipated (e.g. MAM)
Frovatriptan and naratriptan
35
All sumatriptan injections are injected (IV/IM/SC). Preferred site is _____
SC Lateral thigh or upper arm
36
Which triptans come as PO tablets?
All
37
Which triptans come as ODT?
Rizatriptan (Maxalt-MLT) Zolmitriptan (Zomig ZMT)
38
Which triptans come as nasal sprays?
Sumatriptan (Imitrex) Zolmitriptan (Zomig)
39
Which triptans come as nasal powders?
Sumatriptan (Onzetra Xsail)
40
Which triptans come as SC injection?
Prefilled syringe - sumatriptan Autoinjector - sumatriptan (Imitrex STATdose system, Zembrace SymTouch)
41
Which triptans are contraindicated with MAO inhibitors or within 2 weeks of stopping?
Sumatriptan, rizatriptan, zolmitriptan
42
Ergotamine MOA
Nonselective antagonist of serotonin receptors >> causes cerebral vasoconstriction
43
Dihydroergotamine (D.H.E. 45, Migranal) formulations
Injection (IM/SC/IV) Nasal spray
44
Boxed warning for ergotamine drugs
Contraindicated with potent CYP3A4 inhibitors d/t life-threatening peripheral ischemia
45
Contraindications for ergotamine drugs
Uncontrolled HTN, ischemic heart disease, pregnancy Others: angina, MI, peripheral vascular disease, hemiplegic or basilar migraine, renal/hepatic impairment, sepsis, use with pressors/vasoconstrictive drugs, use within 24 hrs of serotonin agonists (triptans) or other ergotamine-type drugs Dihydroergotamine: avoid use during or within 2 weeks of d/c MAOi
46
Warnings for ergotamine drugs
CV effects (avoid in any pt with baseline risk Cerebrovascular events Potentially serious drug interactions Others: ergotism (intense vasoconstriction resulting in peripheral vascular ischemia and possible gangrene), cardiac valvular fibrosis
47
T/F: Dihydroergotamine nasal spray requires priming before use
True - prime by pumping 4 times (do not inhale deeply (to let drug absorb into skin in nose)
48
___ and ___ are oral CGRP receptor antagonists used for acute treatment. CGRP contributes to vasodilation and neurogenic inflammation in the pathogenesis of migraines; blocking the CGRP receptor helps reduce or eliminate migraine pain
Rimegepant (Nurtec) - ODT Ubrogepant (Ubrelvy) - PO
49
___ is an oral CGRP receptor antagonist approved to treat migraine attacks and ___ is approved to prevent AND treat acute migraine attacks
Treat only = Ubrogepant (Ubrelvy) Treat + prevent = rimegepant (Nurtec)
50
____ is a first-in-class serotonin agonist that is selective for 5-HT1F receptor subtype. Unlike triptans and ergotamine drugs, this drug does not cause vasoconstriction.
Lasmiditan (Reyvow) - C-V
51
___ is a barbiturate found in Fioricet and Fiorinal. Butalbital-containing products are not recommended for treating acute migraines d/t abuse/dependence issues and lower efficacy. Taper when d/c.
Butalbital
52
Preventative treatment should be considered who use acute migraine treatments ≥ ___ days/week or ≥ ____ times per month, have migraines that decrease QOL, if acute treatments are ineffective or contraindicated, or requested by pt
≥2 days/week ≥3 times per month
53
Which antihypertensives can be used as ppx therapy for migraines?
Beta-blockers, best evidence with propranolol (Inderal)
54
Which antiepileptic drugs can be used as ppx therapy for migraines?
Topiramate (Topamax) and valproic acid
55
___ causes weight loss in many pts, making it a popular choice for migraine ppx
Topiramate
56
2 oral CGRP receptor antagonists approved for ppx of migraines
Rimegepant (Nurtec and atogepant (Qulipta) (Note: other CGRP antagonists used for migraine prevention are injectable monoclonal antibodies)
57
Side effects of valproic acid, divalproex (Depakote)
Weight gain, thrombocytopenia, increased ammonia, alopecia Others: N/V, somnolence, tremor, PCOS
58
Side effects of topiramate (Topamax)
Weight loss (6-13%), somnolence, cognitive impairment Others: paresthesia, reduced efficacy of oral contraceptives
59
Warnings of valproic acid, divalproex (Depakote)
Fetal harm, hepatic failure, pancreatitis
60
Warnings of topiramate (Topamax)
Fetal harm, metabolic acidosis, nephrolithiasis, increased ammonia, open angle glaucoma, and visual field defects, oligohirosis
61
CGRP receptor antagonist for migraine ppx: Vyepti dosing frequency
IV every 3 months
62
CGRP receptor antagonist for migraine ppx: Aimovig dosing frequency
SC once monthly
63
CGRP receptor antagonist for migraine ppx: Ajovy dosing frequency
SC monthly or higher dose SC every 3 months
64
CGRP receptor antagonist for migraine ppx: Emgality dosing frequency
Once monthly
65
Botox is from chronic migraines only (≥ ___ headache days per month)
15
66
Onzetra Xsail nasal powder administration notes
Insert nosepiece deeply into nose and rotate device to place the mouthpiece into your mouth Blow into device with your mouth for 2-3 seconds to deliver medication into your nose Repeat for second nostril

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