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Exam 1: Migraine Flashcards

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1
Q

list the 4 primary headache disorders

A
  1. migraine
  2. tension
  3. cluster
  4. hemicrania
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2
Q

list the 7 secondary headache disorders

A
  1. traumatic brain injury
  2. pseudotumor cerebri
  3. brain tumor
  4. reversible cerebral vasoconstriction syndrome
  5. subarachnoid
  6. medication overuse
  7. substance withdrawal
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3
Q

Migraine, no aura dx

A

at least 5 attacks with:
- last 4-72 hours
- 2/4 characteristics:
1. unilateral
2. pulsating
3. moderate-severe pain
4. aggravation by routine activity

AT LEAST 1 of
- photophobia
- phonophobia

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4
Q

Migraine with aura dx

A

at least 2 attacks with:
- one or more reversible aura sx:
>visual, sensory, speech, motor, brainstem, retinal
- at least 3/6 characteristics
1. one aura sx spreads gradually over ≥5 min
2. two or more sx in succession
3. each sx lasts 5-60min
4. at least 1 sx is unilateral
5. at least 1 sx is positive
6. aura w/ headache within 60 min

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5
Q

Migraine Aura sx

A

visual sx
gradual onset, spread
sequential progression
repetitive attacks, identical nature
flurry of attacks midlife
lasts <60 min
50% chance headache

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6
Q

Transient ischemic attack sx

A

Visual LOSS
ABRUPT, stepwise evolution
Simultaneous occurence of symptoms
lasts < 15 minutes (shorter)
no headache usually

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7
Q

Principles of migraine pharmacotherapy

A

BIG dose better
The SOONER given the better
Don’t overuse - more headache

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8
Q

Mild migraine

A

NSAID, APAP, Caffeinated options

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9
Q

Mod-severe
or refractory to OTC

A

triptans>DHE
Gepants, ditans if triptans contraindicated

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10
Q

Refractory mod-severe

A

Triptans + NSAID
Gepants
Lasmiditan
Analgesic w/ codeine/tramadol if infrequent
Opioids if infrequent (butorphanol)

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11
Q

Nasal/injectable formulations

A

for severe N/V, swallowing difficulties
Sx reach max intensity rapidly
inadequate response to traditional oral therapies
+ antiemetics (prochlorperazine, metoclopramide)

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12
Q

NSAID oral solutions use

A

rapid absorption
try if tablet takes too long to kick in
Mix with water
- diclofenac
- celecoxib

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13
Q

When to use Butalbital + caffeine + APAP

A

tension type, or migraine

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14
Q

Risks of Butalbital + caffeine + APAP

A

APAP = BBW hepatotoxicity
Medication overuse headache

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15
Q

AE butalbital + caffeine + APAP

A

cns depression
stomach upset

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16
Q

controlled migraine medications

A

Fiorcet/Fiorinal+codeine CIII
Lasmitidan (reyvow) CV

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17
Q

Triptans use limit for MOH

A

<10 days/month
give early in course of attack
caution in older adults d/t CV risk
start low go slow

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18
Q

Triptans ADR

A

flushing
chest pains
palpitations
dizziness
fatigue
xerostomia
serotonin syndrome

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19
Q

Triptans contraindication

A

hx hemiplegic migraine or w/brainstem aura
Known/suspected heart disease
Arryhtmias/cardiac pathway conduction disorder
Cerebrovascular syndromes
PVD (ischemic bowel disease)
Uncontrolled HTN
use within 24 h ergotamine or other triptan

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20
Q

MAOIs C/I with which triptans?

A

RIZ
SUM
ZOL
(maoi ex: hydrazine)

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21
Q

Triptan CV risk study: Hall

A

only looked at patients w/ less CV risk - inconclusive

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22
Q

Triptan CV risk study: Velentgas

A

excluded pt with history of CV or cerebrovascular in year prior

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23
Q

Triptan CV risk study: Albieri

A

no info on non-migrainers
triptan increased risk for stroke
(migraines worsen CV, not the drug)

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24
Q

Longest half life triptan

A
  1. frovatriptan
  2. naratriptan
  3. eletriptan
  4. almotriptan
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25
pro/con of long half-life triptan
Pro: prevents reoccurrence con: slower onset
26
Renal adjust triptans
Almotriptan ≤30ml.min Naratriptan ≤15 ml/min
27
hepatic adjust triptans
Almotriptan Naratriptan
28
Almotriptan unique
lower chest pain/tightness SULFA group reduce for CYP inhibitor, renal, hepatic better tolerated shortest half life
29
Eletriptan unique
Contraindicated CYP 3A4 inhibitor most lipophillic avoid severe hepatic impairment
30
Naratriptan unique
better than suma, slower onset Contraindicated severe hepatic dose reduce hepatic/renal
31
SQ Triptans
only sumatriptan
32
ODT triptan
RIZ ZOL
33
Intranasal triptans
SUM ZOL
34
Rizatriptan unique
dose reduce if propanolol
35
Sumatriptan unique
SQ 10 min Nasal 15-30 min lowest PO bioavailability
36
Zolmitriptan unique
Dose reduce/d/c if hepatic
37
Lasmitidan unique
give once. repeat dose not helpful AVOID if severe hepatic.... WAIT 8 H between dosing and driving
38
Lasmitidan ADR
CNS depression Serotonin syndrome decreased HR, increased BP, palpitation, dizziness, N/V
39
Lasmitdan onset
30-60 min
40
Gepants
small molecule CGRP antagonist
41
Nurtec (rimegepant) use
Acute: 75 QD Prevent: 75mg every other day
42
Nurtec AVOID
severe hepatic impairment renal ≤15 (not studied)
43
Nurtec benefit
acute and prevention ODT onset ≤2 hrs for acute
44
Nurtec ADR
abdominal pain dyspepsia nausea
45
Ubrogepant (ubrelv) use
ACUTE only: 50-100mg x1 may repeat dose after ≥2 hrs MDD 200mg Affected by high fat meal
46
Ubrelvy contraindication
strong CYP3A4 inhibitors renal <15
47
Ubrelvy ADR
nausea drowsiness xerostomia
48
Quilipta (Atogepant) use
prevention only of episodic 10/30/60mg x 1
49
Atogepant hepatic/renal
severe hepatic avoid renal <30 reduce
50
Atogepant ADR
constipation nausea drowsiness/fatigue weight loss
51
CGPR Mabs pro/con
Pro: long half life, not many DDI con: caution CV
52
Drug interaction CGRP mab
Efgartigimod (vygart) monitor closely
53
CGRP mab for cluster prevention
Galcanezumab (emaglity)
54
CGRP with constipation ADR
Aimovig (erenumab)
55
CGRP with nasopharyngitis, nausea
Eptinezumab (Vyepti)
56
targets ligand
Epitinezumab (Vyepti) Fremanezumab (Ajovy) Galcanezumab (Emaglity)
57
targets receptor
Erenumab (Aimovig)
58
CGRP ab IV
Eptinezumab (Vyepti) Every 3 months
59
CGRP SQ
Erenumab (Q month) Fremanezumab (Q month/3month) Galcanezumab (Q month)
60
Greater occipital nerve block drugs
lidocaine bupivacaine Methylprednisolone (avoid in pregnancy)
61
Nonpharm migraine
Stress reduce, Diet, avoid trigger
62
alt migraine tx
magnesium B2 feverfew Butterbur neuromod device
63
PO magnesium use
prophylaxis, esp aura menstrual migraine 400mg BID citrate>oxide start low go slow
64
PO magnesium ADR
diarrhea n/v
65
B2 riboflavin use
well tolerated prophylaxis good for menstration 400mg QD for 3 months reduce duration/pain
66
Feverfew use
prophyalxis AVOID PREGNANCY - contractions 50-150mg QD for 4 months
67
Feverfew ADR
GI
68
Butterbur (petasites) use
prophylaxis avoid products not labeled "PA free" d/t toxic alkaloid formation
69
Butterbur ADR
GI (belch,n/v/d) drowsiness fatigue pruritis, rash hepatotoxicity (RARE)
70
Ergot BBW
contraindicated with potent CYP3A4 inhibitors - protease - macrolide antibiotics - azole antifungals Causes vasospasm and ischemia
71
ERGOT class serious ADR
cardiac valvular fibrosis ergotism (vasoconstriction/gangrene) Serotonin syndrome
72
Contraindication Ergot
pregnancy/breastfeeding 24 hr or triptans, other serotonin agents, ergot-like agents
73
Ergotamine use
acute mod-severe migraine not for older adults Sublingual tablet
74
Ergotamine ADR
N/V ecg change, HTN, ischemia, vasospasm numbness, paresthesia, gangrene, etc
75
Ergotamine d/c
even after limited use -- withdrawal rebound headache
76
Dihydroergotamine use
SQ/IM/IV: acute cluster headache, migraine nasal spray: acute migraine
77
DHE off label use
medication overuse headache status migrainosus
78
DHE contraindication
CV history post vasular surgery use of other periphera/central vasoconstrictors nasal spray: hemiplegic migraine/brainstem
79
DO NOT USE in Hemiplegic migraine/brainstem headache
Triptans DHE
80
Severe migraine treatment in the ED
IV/IM dexamethasone (decrease recurrence) SQ sumatriptan (fast onset) IV prochlorperazine + diphenhydramine (VERY GOOD) IV DHE + antiemetic IV valproate IV/IM ketorolac IV magnesium
81
Purpose of diphenhydramine
prevent dystonia
82
Topiramate use
Prevention for ≥12 y.o
83
Topiramate ADR
cognitive dysfunction, CNS nephrolithiasis metabolic acidosis angle closure glaucoma oligohidrosis/hyperthermia suicidal ideation weight loss paresthesias AVOID in pregnancy
83
Topiramate off label
cluster headache prevention
84
Topiramate counseling
DRINK WATER - stay hydrated
85
Topiramate MOA
block na channel enhance GABA antagonize AMPA glutamate R weak CA inhibition (acidosis..)
86
Valproic acid use
migraine prevention
87
Valproic acid BBW
hepatotoxicity mitochondrial disease fetal risk pancreatitis
88
Valproic acid ADR
CNS hematologic hepatotoxicity pancreatitis suicidal ideation encephalopathy TEN/SJS/DRESS
89
Valproic acid contraindications
pregnant/childbearing (lack contraception) severe hepatic impairment mitochondrial disorder (increase acute LF)
90
Beta blocker use
prevention timolol, propanolol
91
TCA use
prevention (-triptyline) start low go slow takes 2-3 month for effect
92
TCA BBW
suicide risk
93
TCA ADR
anticholinergic CNS depression cardiac conduction abnormalities SS orthostatic hypotension
94
Venlafaxine use (SNRI)
prevention neuropathic pain
95
Venlafaxine ADR
CNS depression weight loss, anorexia HTN hepatotoxicity hyponatremia acute angle closure glaucoma serotonin syndrome
96
drugs that cause acute angle closure glaucoma
topiramate venlafaxine
97
Menstural migraine treatment
occurs day 1-2 fovatriptan naratriptan zolmitriptan magnesium (if plan to conceive) estrogen contraception
98
AVOID estrogen contraception for menstural headache if
AURA = stroke risk estrogen = risk for ischemic stroke
99
Frovatriptan dose
2.5mg po qd or BID 2 days prior to menses continue 6 days total
100
Naratriptan dose
1mg po BID 2-3 days prior to menses continue 5-6 days total
101
Zolmitriptan
take 2.5mg po BID or TID 2 days prior to menses continue until 5 days after menses (7 days total)
102
Patients with CV disease, what to use for acute migraine?
Gepants Lasmitidan (reyvow) CGRP mab (caution if recent event)
103
Pregnant patient acute migraine
APAP Avoid NSAID if 3rd trimester pregnancy progression helps
104
Cluster headache prevention
1. verapamil 2. glucocorticoids 3. CGRP mab Galcanezumab 4. lithium 5. Topiramate 6. greater occipital nerve block
105
Cluster headache acute tx
oxygen SQ/nasal sumatriptan nasal zolmitriptan
106
Hemicrania continua treatment
1. Indomethacin - botoxA - occipital stimulation - vagus stimulation - peripheral block
107
Subarachnoid headache
thunderclap - max pain in seconds life threatening emergency (hemorrhage) photophobia, neck stiffness, n/v brief loss of consciousness
108
overuse ≥10 days/month
Triptans opioids ergots
109
overuse ≥5 days/month
butalbital
110
≥15 days/month
non opioid pain meds nsaid/apap/asa/etc
111
headache red flags
SNOOP
112
S in SNOOP | HA red flags
Systemic s/s - fever - myalgias - weight loss systemic disease - malignancy/acquired immune deficiency
113
N in SNOOP | HA red flags
neurologic s/s
114
First O in SNOOP | headache red flags
Onset sudden "thunderclap"
115
Second O in SNOOP | headache red flgs
Onset after age 40
116
P in SNOOP | headache red flags
pattern change progressive headache with loss of headache-free periods change in type of headache

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