Exam 1 - HA/Migraine

Question 1

Migraine with aura usually presents in what order?

Answer 1

visual, then sensory, then language

Question 2

Migraine distinction symptoms? (7)

Answer 2

positive visual symptoms, gradual onset, sequential progression, repetitive identical attacks, flurry of attacks midlife, duration < 60 min, headache follows ~50%

Question 3

TIA distinction symptoms? (5)

Answer 3

visual loss, abrupt, simultaneous occurrence, duration < 15 min, headache accompaniment uncommon

Question 4

Recommended treatment options for mild to moderate migraine attacks? (3)

Answer 4

NSAIDs, acetaminophen, caffeinated analgesic combinations

Question 5

Recommended treatment options for moderate to severe migraine attacks? (4)

Answer 5

triptans, DHE, gepants, ditans

Question 6

Recommended treatment options for refractory moderate to severe migraine attacks? (5)

Answer 6

triptans + NSAIDs, gepants, ditans, analgesics + codeine or tramadol, opioids

Question 7

Recommended treatment options for migraines with N/V, etc.? (2)

Answer 7

non-oral formulations, antiemetics (e.g., prochlorperazine)

Question 8

What are the oral NSAID solutions for acute treatment of migraines? (2)

Answer 8

diclofenac potassium (Cambia) and celecoxib (Elyxyb)

Question 9

What are the brands of butalbital/APAP/caffeine combinations? (4)

Answer 9

Fioricet, Bac, Esgic, Zebutal

Question 10

How long can you use barbiturate combinations drugs to avoid MOH?

Answer 10

< / = 3 days/mo

Question 11

Which butalbital combination can cause MOH and is a controlled substance (CIII)?

Answer 11

Fiorinal

Question 12

What is the MOA for triptans?

Answer 12

5-HT selective agonists

Question 13

Are triptans for acute or prohpylactic treatment?

Answer 13

acute

Question 14

What are adverse effects of triptans?

Answer 14

flushing, chest pain, palpitations, dizziness, fatigue, serotonin syndrome

Question 15

How long can you use triptans to avoid MOH?

Answer 15

< 10 days/mo

Question 16

What are contraindications for triptans?

Answer 16

ischemic heart disease, cerebrovascular syndromes, uncontrolled HTN, MAOIs

Question 17

Which triptans are PO only? (4)

Answer 17

almotriptan, eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge)

Question 18

Order of half-life for triptans that are PO only?

Answer 18

longest is frova, nara, almo, ele

Question 19

Which triptans are not PO-only? (3)

Answer 19

rizatriptan (Maxalt), sumatriptan (Imitrex), zolmitriptan (Zomig)

Question 20

What is the onset of action in minutes for sumatriptan’s PO, intranasal, and SQ formulations?

Answer 20

PO = 30, intranasal = 15-30, SQ = 10

Question 21

What is the MOA for lasmitidan (Reyvow)?

Answer 21

5-HT receptor agonist

Question 22

Are ditans for acute or prophylactic treatment?

Answer 22

acute

Question 23

What are adverse effects of ditans?

Answer 23

MUST WAIT 8HRS, CNS depression, serotonin syndrome, decreased HR, increased BP, N/V

Question 24

What is the MOA for gepants?

Answer 24

CGRP receptor antagonists

Question 25

Is rimegepant (Nurtec) for acute or preventive treatment?

Answer 25

BOTH

Question 26

What is the dosing for acute rimegepant (Nurtec)? Prevention dosing?

Answer 26

acute = 75mg PO once; 75mg PO every other day

Question 27

When should rimegepant (Nurtec) be avoided?

Answer 27

CrCL < 15 mL/min, severe hepatic impairment

Question 28

What are adverse effects of rimegepant (Nurtec)? (3)

Answer 28

abdominal pain, dyspepsia, nausea

Question 29

Is ubrogepant (Ubrelvy) for acute or preventive treatment?

Answer 29

acute

Question 30

What is the dosing for ubrogepant (Ubrelvy)?

Answer 30

50-100mg PO once, may repeat dose after 2 hours (max 200mg/day)

Question 31

What is the MOA for ergots?

Answer 31

5-HT receptor agonists

Question 32

What are the BBWs for ergots?

Answer 32

CYP3A4 inhibitors (protease inhibitors, macrolides, azoles)

Question 33

What are adverse effects for ergots? (2)

Answer 33

cardiac valvular fibrosis, ergotism

Question 34

What are contraindications for ergots?

Answer 34

pregnancy/breastfeeding, older adults

Question 35

What should be avoided in acute or preventive migraine treatment?

Answer 35

opioids and barbiturates

Question 36

What is the MOA of topiramate? (4)

Answer 36

blocks voltage-dependent sodium channels, enhances GABA activity, antagonizes AMPA receptors, weakly inhibits carbonic anhydrase

Question 37

What are adverse effects of topiramate?

Answer 37

cognitive dysfunction, CNS effects, nephrolithiasis, metabolic acidosis, angle-closure glaucoma, oligohydrosis/hyperthermia, suicidal ideation, weight loss, paresthesia

Question 38

What are important counseling points for topiramate? (3)

Answer 38

stay hydrated, avoid in pregnancy, may take up to 2-3 months

Question 39

What are BBWs for valproic acid? (4)

Answer 39

hepatotoxicity, patients with mitochondrial disease, fetal risk, pancreatitis

Question 40

What is a contraindication for valproic acid?

Answer 40

pregnancy and childbearing potential without effective contraception

Question 41

Which beta blockers are preferred for migraine?(2)

Answer 41

propranolol, timolol

Question 42

What are adverse effects of TCAs?

Answer 42

anticholinergic effects, cardiac conduction abnormalities

Question 43

Is atogepant (Qulipta) for acute or preventive treatment?

Answer 43

preventive

Question 44

What is the dosing for atogepant (Qulipta)?

Answer 44

10, 30, 60mg po once daily

Question 45

Which mab targets the CGRP receptor? (1)

Answer 45

erenumab (Aimovig)

Question 46

Which mab is also indicated for prevention of cluster headache? (1)

Answer 46

galcanezumab (Emgality)

Question 47

Which mab is dosed IV every 3 months?

Answer 47

eptinezumab (Vyepti)

Question 48

Which mabs are SQ every month? (3)

Answer 48

erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality)

Question 49

Which mab can cause nasopharyngitis and nausea?

Answer 49

eptinezumab (Vyepti)

Question 50

Which mab can cause constipation?

Answer 50

erenumab (Aimovig)

Question 51

What is the most common peripheral nerve block, and what does it use?

Answer 51

greater occipital nerve block, lidocaine/bupivicaine/methylprednisolone

Question 52

What is a good OTC for menstrual migraines?

Answer 52

PO magnesium

Question 53

What are adverse effects of PO magnesium?

Answer 53

diarrhea, N/V

Question 54

What is a good OTC for migraine prophylaxis?

Answer 54

vitamin B2 (riboflavin)

Question 55

What are adverse effects of feverfew? Contraindications?

Answer 55

GI issues; pregnancy

Question 56

What are adverse effects of butterbur? Contraindications?

Answer 56

GI, rash, fatigue; products not labeled as free from pyrrolizidine alkaloids (PA-free)

Question 57

What is a BBW for Botox?

Answer 57

spread of toxin effect

Question 58

What are adverse effects for Botox?

Answer 58

injection site pain, neck pain, myalgia, facial paresis

Question 59

What is treatment for acute cluster headaches? (3)

Answer 59

oxygen, SQ (preferred) or intranasal sumatriptan, intranasal zolmitriptan

Question 60

What is treatment for preventive cluster headache? (1)

Answer 60

verapamil

Question 61

What is treatment for hemicrania continua?

Answer 61

indomethacin

Question 62

What medications can cause pseudotumor cerebri? (3)

Answer 62

growth hormone, tetracyclines, retinoids

Question 63

What are treatments for pseudotumor cerebri? (5)

Answer 63

withdraw offending agent, weight loss, carbonic anhydrase inhibitors, furosemide, migraine preventive meds

Question 64

What is reversible cerebral vasoconstriction syndrome also known as?

Answer 64

thunderclap headache (subarachnoid hemorrhage)

Question 65

What are the cutoffs for medication overuse headache? (5)

Answer 65

non-opioid analgesics = 15, ergots = 10, triptans = 10, opioids = 10, butalbital = 5

Question 66

Explain headache red flags SNOOP acronym?

Answer 66

systemic symptoms/signs/disease, neurologic symptoms/signs, onset sudden and after age 40, pattern change