Agents for Migraines and Headaches Flashcards
(24 cards)
What are the types of primary headaches?
Migraine, Tension-type, and cluster headaches
What are secondary headaches?
Symptoms of an underlying medical condition
Describe migraine headaches with respect to location, characteristics, duration, and associated symptoms.
Location - typically U/L; possibly bifrontal or global
Characteristics - may be preceded by an aura, crescendo pattern, and aggravated by activity
Duration - 2 hours to 3 days
Associated Sx - photo-/phonophobia, N/V
Describe tension headaches with respect to location, characteristics, duration, and associated symptoms.
Location - B/L; headband distribution
Characteristics - waxing and waning tension/tightness
Duration - variable
Associated Sx - none
Describe cluster headaches with respect to location, characteristics, duration, and associated symptoms.
Location - U/L always; near temple or eye
Characteristics - sudden in onset with deep, excruciating pain
Associated Sx - I/L lacrimation, orbital hyperemia, and rhinorrhea
Describe the pathophysiology of migraines and how serotonin may play a role.
The distribution of the trigeminal nerve involves intracranial arteries. These nerves release neuropeptides such as CGRP, which are potent vasodilators. These neuropeptides also induce dural perivascular edema –> mechanical stretching of dura. Serotonin binding to the trigeminal neurons –> inhibition of neuropeptide release.
What is the 5HT-1B/1D agonist prototype?
sumatriptan
Describe the MOA, uses, ADRs, and CIs for sumatriptan?
MOA - binds 5HT-1B/1D receptors on the trigeminal nerve inhibiting the release of vasodilating peptides
Uses - 1st line Tx for acute mild to severe attacks
ADRs - Think carcinoid neoplasm Mx.s; Specifically: altered sensations, dizziness, muscle weakness, fatigue, and coronary vasospasm
CIs - Any ischemic heart disease, uncontrolled HTN, or recent ergotamine and MAOI therapy
What are the prototype ergot alkaloids used for migraine treatment?
Dihydroergotamine (DHE) and ergotamine (sometimes with caffeine)
Describe the ergot alkaloids with respect to MOA, uses, ADRs, and CIs.
MOA - vasoconstriction of peripheral and cranial blood vessels; partial agonist at 5HT-1B/1D receptors
Uses - Migraines; DHE for intractable attacks and ergotamine for severely prolonged attacks
ADRs - N/V/D
CIs - Uncontrolled HTN, ischemic heart disease, collagen diseases, renal/hepatic dysfunction, and gangrene
What analgesic is most commonly used for the treatment of migraines?
Combination aspirin, acetaminophen, and caffeine (AKA excedrin)
Describe the MOA, uses, ADRs, and CIs of analgesics in migraine therapy.
MOA - prevention of neurogenic inflammation by prostaglandin synthesis inhibition
Uses - Common headache, mild-to-moderate migraines, and migraines previously responsive to analgesics
ADRs - N/V/D, overuse headaches
CIs - peptic ulcer disease and renal dysfunction
What types of drugs are used for prophylactic management of migraines?
Beta-blockers, calcium channel blockers, anti-depressants, and anti-convulsants
Describe the MOA, uses, ADRs, and CIs of beta-blockers with respect to migraines.
MOA - modulates adrenergic and serotonergic pathways in the cortex and subcortex
Uses - 1st line prophylaxis of migraines
ADRs - Drowsiness, fatigue, vivid dreams, memory disturbance, and depression
CIs - Diabetes, heart failure, PVD, dysrrhythmias, and depression
Name two beta-blockers used for migraine prophylaxis
metoprolol and propanolol
Describe the use of calcium channel blockers for the prophylaxis of migraines.
Verapamil has been used “off-label” to reduce vasodilation in patients who suffer from migraines and cluster headaches. There has been some success in the prevention of cluster headaches, but evidence in the prevention of migraines is still WEAK.
Describe the name, MOA, and ADR of tricyclic anti-depressants with respect to migraine prophylaxis.
Drug - amitiyptyline
MOA - downregultes central 5HT-2 receptor and increases synaptic NE
ADR - sedation (give near bed time)
Describe the name, MOA, and ADRs of anti-convulsants with respect to migraine prophylaxis
Drug - topiramate
MOA - increases GABA and modulates glutamate, while inhibiting sodium and calcium channels
ADRs - weight loss, anorexia, taste perversion, parasthesia, and fatigue
What is the Tx approach for mild-to-moderate migraines?
Begin treatment with a simple analgesic
If nausea is concurrent, use an anti-emetic (metoclopramide; D2-like antagonist)
If migraine is refractory to simple analgesic, use a combination analgesic (aspirin + acetaminophen + caffeine)
If migraine continues to be refractory, use sumatriptan. If the migraine continues to be refractory, use higher dosesn, a different triptan, or another class.
What is the Tx approach for moderate-to-severe migraines?
Begin with the use of a triptan.
If the migraine is refractory, use an anti-emetic and ergot alkaloid.
When should preventive therapies for migraines be initiated (4 situations)?
- If significant disability recurs with acute therapy
- Attacks occur >2/week
- CIs or ADRs prevent symptomatic treatment
- Patient prefers prophylaxis
Describe how the choice of prophylactic therapy for migraines is made. (4 situations)
- If migraines occur at a predictable and regular interval, give triptans or NSAIDs
- Healthy or patient with co-morbid HTN or angina, give beta-blockers (CCBs when beta-blockers contraindicated)
- If diagnosed with depression or insomnia, give tricyclic anti-depressants
- Seizure disorder, give anti-convulsants
Describe the acute and prophylactic therapy of tension headaches.
Acute - simple analgesics or NSAIDS
Prophylactic - tricyclic anti-depressants
Describe the acute and prophylactic therapy of cluster headaches.
Acute - oxygen, triptan, or ergot alkaloids
Prophylactic - verapamil, lithium, prednisone, or topiramate
