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MS/HA/Stoke/Sleep > HA > Flashcards

HA Flashcards

1
Q

Migraine phases

A

Premonitory, HA pain phase, and postdrome

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2
Q

Premonitory phase

A

-tiredness, mood change, cravings, light/sound sensitivity
-hrs to days

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3
Q

HA pain phase

A

-throbbing, N/V, sensitivity to senses
-4 to 72 hrs

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4
Q

Postdrome phase

A

-tired, hard to concentrate
-up to 48 hrs

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5
Q

Auras

A

-can occur w/o HA
-last minutes, unilateral, fully reversible visual sensory or other CNS sx that usually develop gradually
-visual&raquo_space; sensory > language

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6
Q

Migraines

A

positive visual sx, gradual onset/evolution, sequential progression, repetitive attacks, flurry of attacks midlife, duration < 60 min, HA follows (50%)

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7
Q

How TIAs are different than Migraines

A

visual loss, abrupt, simultaneous occurrence, <15 min, HA doesn’t usually follow

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8
Q

Mild to moderate migraine attack treatment

A

NSAIDs, APAP, caffeinated analgesic combos

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9
Q

Moderate to severe migraine attack treatment

A

Triptans, DHE, Gepants

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10
Q

Refractory moderate to severe treatment

A

Combo triptan and NSAIDs, Gepants, Ditans, combo of analgesics w/ codeine or tramadol, opioids

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11
Q

Diclofenac Potassium

A

-oral NSAID soln
-can only be added to water bc pH sensitivity
-rapid absorption and shorter time to peak w/ the soln
-used for ACUTE treatment >/= 18 yo

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12
Q

Celecoxib

A

-oral NSAID soln
-used for ACUTE treatment in adults
-can be used in combo with Triptans for more severe cases
-If an NSAID works for a patient but takes too long to kick in use oral soln formulation

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13
Q

Butalbital/APAP/Caffeine (Fioricet)

A

-butalbital is a barbiturate which can be abused
-reserve for last resort , not preferred for migraine
-BBW: hepatotoxicity (APAP)
-available w codeine (CIII)
*medication overuse HA can occur w this med

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14
Q

Triptans

A

-generally 1st line
-used for ACUTE treatment
-limit to < 10 days per month (MOH)
-may combine w NSAIDs (Treximent = Suma/naproxen)

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15
Q

Triptan CI

A

hemiplegic migraine or migraine w brainstem aura, heart disease, wolff-parkinson-white syndrome or arrhythmias, STROKE, TIA, peripheral vascular disease, use within 24 hrs of ergotamine or different triptan, MAOIs (w/ sum, riz, zol only) -SS

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16
Q

Almotriptan

A

-better tolerated than suma
-sulfa group
-dose reduction for 3A4 inhibitors
-CrCl </= 30 ml/min

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17
Q

Eletriptan

A

-Cl w potent 3A4 inhibitors
-not rec in severe hepatic disease
-mostly lipophilic

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18
Q

Frovatriptan

A

longest half life, slow onset

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19
Q

Naratriptan

A

slow onset, second longest half life

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20
Q

Rizatriptan

A

dose reduction w/ propranolol

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21
Q

Sumatriptan

A

lowest oral bioavailability
-PO, intranasal spray, powder, SQ
-SQ is the fastest onset
-Spray is the second fastest onset

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22
Q

Zolmitriptan

A

-reduction or d/c in hepatic disease
-PO, ODT, spray

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23
Q

Lasmiditan

A

-CV
-used for ACUTE treatment in adults
-must wait at least 8 hours b/t dosing and operating heavy machinery or driving
-AE: CNS depression, SS

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24
Q

Gepants

A

-small molecule CGRP receptor antagonists

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25
Q

Rimegepant (Nurtec)

A

-Gepant
-PO, ODT
-used for ACUTE and PREVENTATIVE

26
Q

Ubrogepant (Ubrelvy)

A

-PO
-used for ACUTE treatment
-may repeat dose after >/= 2 hours
-admin w high fat meals delays Tmax by 2 hrs and reduces Cmax by 22%

27
Q

Anti-Migraine Ergots

A

-not used first bc lots of SE/CI
-BBW: CI w potent 3A4 inhibitors including protease inhibitors, macrolide abx and azole fungals
-AE: cardiac valvular fibrosis, ergotism
-don’t use in preg/lac
-do not use within 24 hrs of triptans or serotonin agonists or ergot containing or like agents

28
Q

Ergotamine

A

-Ergot
-used for ACUTE treatment
-considered when migraine lasts for more than 48 hrs or pt has freq HA reoccurrence
-SL tab (available combo w caffeine)
-d/c can result in withdrawal like rebound HA (can occur when doses exceed 10 tab per week)
-grapefruit juice inc ergot levels
-may worsen N/V associated with migraine

29
Q

Dihydroergotamine (DHE)

A

-Ergot
-Injection: ACUTE treatment of cluster HA
-Injection/Nasal spray: ACUTE treatment of migraines
-Off label: MOH, status migrainosus
-fewer SE than Ergotamine
-Intranasal has cafeine
-don’t use within 24 hrs of triptans or another ergot agent
-first does = at a facility (get ECG for pts with CAD risk)
-CI: hemiplegic migraine and migrane w brainstem aura

30
Q

CGRP monoclonal antibodies

A

-use caution in CV or cerebrovascular ischemic events
-Few DDI: Efgartigimod
-Drugs: Ajovy, Vyepti, Aimovig, Emgality

31
Q

Vyepti

A

-CGRP ligand
-IV every 3 months
-Infusion rxn, nasopharyngitis, nausea

32
Q

Aimovig

A

-CGRP receptor
-SQ every month
-Injection site rxn, constipation

33
Q

Ajovy

A

-CGRP ligand
-SQ every month or every 3 months
-injection site rxn

34
Q

Emgality

A

-CGRP ligand
-can also be used to prevent cluster HA
-SQ every month
-injection site rxn

35
Q

Peripheral nerve blocks

A

-Greater occipital nerve block (lidocaine &/or bupivacaine &/ or methylprednisolone
-can’t use methylprednisolone in pregnacy

36
Q

Non pharm

A

-stress reduction, dietary changes, trigger avoidance, Mg2+, vitamin B2 (riboflavin), feverfew, butterbar, neuromodulator devices

37
Q

FDA approved neuromodulator devices

A

-electroCore: ACUTE/PREVENTATIVE
-eNeura: ACUTE/PREVENTATIVE
-CEFALY: ACUTE/PREVENTATIVE
-Neurolief: ACUTE
-Nerivio: ACUTE

38
Q

PO Mg2+

A

-good for menstrual migraine
-AE: diarrhea (titrate slowly)
-improve platelet function
-prevent narrowing of brain blood vessels

39
Q

B2 (riboflavin)

A

-good for menstruating women

40
Q

Feverfew

A

Avoid use in preg (uterine concentrations/abortions can occur)

41
Q

Butterbar

A

avoid products not labeled as free from pyrrolizidine alkaloids (PA-free)

42
Q

Botox

A

-for chronic migraine sufferers
-BBW: spread of toxin effect
-admin every 12 weeks
-AE: ISP, neck pain, myalgia, facial paresis
-Adequate trial = 3 full treatments
-total dose = 155 units
-each dose should be divided and admin bilaterally into 31 total sites

43
Q

Menstral migraines

A

-Frovatriptan
-Naratriptan
-Estrogen contraceptives (avoid in aura patients bc inc stroke risk)

44
Q

Special population

A

-CVD patients: Gepants or lasmiditan
-pregnancy: APAP 1st line - migraines improve during preg (avoid NSAIDs in 3rd trimester)
-lactation: less likely to have migraines if pt breastfeeds

45
Q

Tension HA

A

-30 to 7 days
-bilateral, non pulsating, no N/V, either photophobia or phonophobia
-Acute treatment: NSAIDs/APAP, analgesics w caffeine, combo w butalbital or codeine
-Preventative: AD (TCAs, Mirtazapine, Venlafaxine), AED (Gabapentin, topramax, trigger point injection)

46
Q

Cluster HA

A

-pain on one side
-5 attacks
-acute: O2, sq (preferred) or nasal suma or nasal zolmitriptan
-preventative: verapamil, glucocorticoids

47
Q

Hemicrainia continua

A

-responses to indomethacin
-alternatives: nerve block, vagus nerve stimulation, etc
-unilateral
-conjunctival, nasal, eyelid, forehead SE

48
Q

TBI HA

A

-similar features of migraine &/or tension HA
-HA occurs w/i 7 days of head trauma

49
Q

Pseudotumor cerebri

A

-papilledema (swelling of optic disc)
-med induced (growth hormone, tetracyclines, retinoids
-withdrawal agent, weight loss, carbonic anhydrase inhibitor (topamax, acetazolamide), furosemide

50
Q

brain tumor HA

A

-like tension type HA
-bilateral or on side of tumor
-sx: seizures, cognitive dysfunction, focal weakness

51
Q

Reversible cerebral vasoconstriction syndrome

A

-thunderclap HA
-meds assoc: SSRIs, triptans, ergots, cyclophosphamide, tacrolimus, nasal decongestant, illegal drugs

52
Q

subarachnoid HA

A

-life threatening
-sudden or thunderclap onset of HA
-photophobia, neck stiff, brief loss of consciousness
-worst HA of my life

53
Q

sub withdrawal HA

A

-caffeine
-opioid
-estrogen, TCAs, SSRIs

54
Q

HA red flags

A

-systemic s/s
-systemic disease
-neurologic s/s
-onset sudden (thunderclap)
-onset after 40 yo
-pattern change

55
Q

MOH

A

-inc excitability of neurons
-Ergots: >/= 10 days/month
-Trips: >/= 10 days/month
-opioids: >/= 10 days/month
-non opioid analgesics: >/= 15 days/month
-butalbital: >/= 5 days/month
-treatment: dec or ween off med, initiate prophylaxis w/ prn breakthrough therapy

56
Q

Topiramate

A

-Preventative treatment
-Off label: prevention of cluster HA
-AE: cognitive dysfunction, CNS effects, suicidality, wt loss
-Important to stay hydrated
-Avoid in Preg

57
Q

VPA

A

-Preventative treatment
-BBW: hepatotoxicity, mitochondrial disease, fetal risk, pancreatitis
-AE: TEN, SJS, DRESS, suicidality
-CI: prevention in preg or women not using contraception

58
Q

Beta blockers

A

-Metoprolol, propranolol, timolol, atenolol, nadolol
-indicated for migraine prevention: propranolol, timolol

59
Q

TCAs

A

-Amitriptyline, Nortriptyline
-BBW: suicidality
-AE: anticholinergic, cardiac conduction abnormalities

60
Q

Venlafaxine

A

-BBW: suicidality

61
Q

Atogepant

A

-gepant
-used after previous meds bc of cost

MS/HA/Stoke/Sleep (4 decks)

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