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Pharm I > Headache > Flashcards

Headache Flashcards

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1
Q

Types of overall headaches

A

Primary
-Migraine
-Tension-type
Related to a disease (secondary)

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2
Q

Epidemiology of migraine

A

Occurs in 17.1% of women and 5.6% of men
After age 12, females 2-3x more likely to experience
Prevalence highest between ages 18-44
Pts that have less income and education are more likely to experience migraines

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3
Q

Pathophysiology of migraine

A

Genetic factors play an important role in susceptibility
Partially a neurovascular process
-Caused by changes in trigeminal nerve, decrease in 5-HT, and cranial vasodilation

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4
Q

Migraine without aura

A

At least 5 attacks
HA lasts 4-72 hrs and has 2 of the following characteristics
-Unilateral location, pulsating quality, moderate or severe intensity, and aggravation by or avoidance of routine physical activity
During HA at least 1 must be present and not attributed to another disorder
-N/V, photophobia, phonophobia
Increased risk for ischemic stroke

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5
Q

Migraine with aura

A

At least 2 attacks
Fulfills criteria for typical, hemiplegic, or basilar-type aura
Not attributed to another disorder

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6
Q

Aura

A

Evolves over 5-20 mins, lasts <60 mins
Most often visual, but can also be sensory and motor
Must have at least one of the following
-One symptom that develops gradually over at least 5 mins or different symptoms that occur in succession or both

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7
Q

Visual positive sx of aura

A

Flickering lights, spots or lines

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8
Q

Visual negative sx of aura

A

Loss of vision

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9
Q

Premonitory sx- neurologic

A

Phonophobia
Photophobia
Hypersomnia
Difficulty concentrating

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10
Q

Premonitory sx- psychological

A 
Anxiety
Depression
Irritability
Drowsiness
Fatigue
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11
Q

Premonitory sx- autonomic

A

Polyuria
Diarrhea
Constipation

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12
Q

Premonitory sx- constitutional

A 
Stiff neck
Yawning
Thirst
Food cravings
Anorexia
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13
Q

Resolution phase of migraine

A 
Once HA pain fades
Tiredness
Exhaustion
Irritability
Scalp tenderness
Mood changes
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14
Q

Assessment of migraines

A 
HA hx
HA triggers
Physical exam
Neuroimaging- not routine, only in atypical presentation
Identify HA diagnostic alarms
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15
Q

HA triggers

A 
Fatigue
Alcohol
Tobacco smoke
Weather changes
MSG
Caffeine
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16
Q

Acute tx goals- migraine

A

Treat migraine attacks rapidly and consistently without recurrence
Restore pt’s ability to function
Minimize use of backup and rescue medications
Minimize use of backup and rescue medications
Optimize self-care for overall management
Be cost-effective in overall management
Cause minimal or no adverse effects

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17
Q

Medication overuse

A

One of the most common causes of daily chronic HA
Results in a pattern of increasing HA frequency
HA returns as medication wears off
Discontinuation of the offending agent leads to a decrease in HA frequency and severity
Limit use of acute therapies to 10 days/mo

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18
Q

Nonpharmacologic tx of migraine

A

Application of ice to head
Periods of rest or sleep
Avoidance of common and personal triggers
Behavioral therapy

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19
Q

Acute tx of migraines

A 
Migraine-specific
-Ergots
-Triptans
Nonspecific
-Analgesics
--OTC combo product
-NSAIDS
-Antiemetics
-Corticosteroids
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20
Q

Regimen of acute tx for migraines

A

Should be given at the FIRST sign of sx

Migraine-specific medications used for more severe sx or sx unresponsive to NSAIDs/OTC analgesics

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21
Q

Ergot alkaloids

A

Consider for moderate to severe migraine attacks
Ergotamine tartrate and dihydroergotamine
MOA: nonselective 5-HT receptor agonists
-Constrict intracranial blood vessels
-Inhibit the development of neurogenic inflammation in the trigeminovascular system

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22
Q

Ergotamine tartrate (Cafergot)

A

Routes: oral, SL, rectal
Oral and rectal forms contain caffeine
Has both a daily and weekly maximum dose
Dosed at onset of sx and every 30-60 mins as needed

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23
Q

Dihydroergotamine (Migranal)

A

Routes: intranasal, IM, SQ, IV

Pts can be trained to give IM or SQ at home

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24
Q

Adverse effects of ergot alkaloids

A 
Nausea, vomiting, diarrhea
Abdominal pain
Weakness
Fatigue
Paresthesias
Muscle pain
Chest tightness
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25
Contraindications of ergot alkaloids
``` Renal or hepatic failure Coronary, cerebral, or peripheral vascular disease Uncontrolled htn Sepsis Nursing or pregnant women ```
26
Triptans
First line for mild to severe migraine | Typically want to treat at least 2-3 attacks before judging efficacy
27
MOA of triptans
5-HT (1b/1d) receptor agonists Inhibit release of vasoactive peptide Promote vasoconstriction Block pain pathways in the brainstem
28
Contraindications of triptans
Hx of ischemic heart disease Uncontrolled htn Cerebrovascular disease Hemiplegic and basilar migraine
29
Drug interactions of triptans
Do not give within 24 hrs of ergotamine derivatives | SSRIs/SNRIs potential to cause serotonin syndrome
30
Serotonin syndrome
Muscle rigidity, hypothermia, sweating
31
Adverse effects of triptans
``` Paresthesias Fatigue Dizziness Flushing Warm sensations Somnolence ```
32
Local SQ effects of triptans
Injection site reactions
33
Intranasal adverse effects of triptans
Taste perversion | Nasal discomfort
34
Second generation triptans
``` Almotriptan Eletriptan Frovatriptan Naratriptan Rizatriptan Zolmitriptan ```
35
Sumatriptan (Imitrex) oral dosage
25 mg, 50mg, 100mg | Repeat after 2 hrs
36
Sumatriptan (Imitrex) nasal dosage:
5, 10, 20mg | Repeat after 2 hrs
37
Sumatriptan (Imitrex) SQ dosage
4mg, 6mg | Repeat after 1 hr
38
Sumatriptan (Imitrex) max oral daily dose
200mg
39
Sumatriptan (Imitrex) max nasal daily dose
40mg
40
Sumatriptan (Imitrex) SQ max daily dose
12mg
41
1/2 life of sumatriptan
2-2.5 hrs
42
Onset of oral sumatriptan
20-30 min
43
Onset of nasal sumatriptan
15 min
44
Onset of SQ sumatriptan
10-15 min
45
Oral rizatriptan dose
5mg, 10mg 5mg with propranolol May repeat after 2 hrs
46
Max daily dose oral rizatriptan
30 mg | Pts taking propranolol: 15 mg
47
Onset of oral rizatriptan
0.5-2 hrs
48
1/2 life of rizatriptan
2-3 hr
49
Oral dose of zolmitriptan
1.25 mg, 2.5mg, 5mg | May repeat after 2 hrs
50
Nasal dose of zolmitriptan
2.5mg, 5mg | May repeat after 2 hrs
51
Max daily dose of oral zolmitriptan
10mg
52
Max daily dose of zolmitriptan
10mg
53
Onset of oral zolmitriptan
45 mins
54
Onset of nasal zolmitriptan
15 mins
55
Almotriptan oral dosing
6.25mg or 12.5 mg | May repeat after two hours
56
Almotriptan max daily dose
25 mg
57
almotriptan onset
0.5-2 hrs
58
eletriptan oral dose
20mg, 40mg | May repeat after 2 hrs
59
1/2 life of almotriptan
3-4 hrs
60
naratriptan oral dose
1mg or 2.5mg | May repeat once after 4 hrs
61
Max dose of naratriptan
5mg
62
Max dose of eletriptan
80mg
63
Oral dose of frovatriptan
2.5mg | May repeat after 2 hrs
64
Max daily dose of frovatriptan
7.5mg
65
Analgesics for migraine
First line for mild to moderate migraine Appear to be effective for mild-moderate sx Acetaminophen + aspirin + caffeine (Excedrin migraine) Acetaminophen/aspirin + butalbital + caffeine (Fioricet or Fiorinal) Limit use due to medication-overuse HA and withdrawal
66
NSAIDs for migraine
First line for mild to moderate migraine | ASA, diclofenac, ibuprofen, ketorolac, naproxen
67
MOA of migraine NSAIDs
Prevent neurogenically medicated inflammation in the trigeminovascular system through the inhibition of prostaglandin synthesis
68
Adverse effects of migraine NSAIDs
Dyspepsia N/V/D Somnolence Dizziness
69
Opiates for migraine
Consider last line, when all else fails Meperidine, butorphanol, oxycodone, hydromorphone Frequent use can increase the risk of medication-overuse HA, dependency, and rebound HAs
70
Antiemetics for migraine
Used as an adjunct for N/V that accompanies migraine and the medications used to treat migraines
71
Metoclopramide
Available oral and IV, data is with IV | Appears to be the least effective of the three antiemetics
72
Chlorpromazine
Available oral and IV, data is with IV | Antiemetic
73
Prochlorperazine
Available oral, rectal, and IV, data is with IV
74
Miscellaneous agents for migraine
``` Corticosteroids for status migrainous -IV/IM dexamethasone Intranasal lidocaine -Rapid pain relief within 15 mins -Recurrence is common IV valproate and magnesium sulfate ```
75
Prophylaxis for migraine
Symptomatic therapies are ineffective or cannot be used Very severe recurrent HAs (produces significant disability) Frequency of attacks in a pt requires more than 2 symptomatic tx/wk Uncommon migraine types that can potentially cause permanent neurologic injury
76
Prophylaxis agent for migraine should be selected based on...
``` Tolerability Comorbid conditions Pt response (efficacy) Convenience of the drug formulation To determine maximal benefit, 6 mo trial recommended ```
77
Agents for migraine prophylaxis
``` Beta-blockers Antidepressants -Tricyclic -SNRI Anticonvulsants -Valproate -Divalproex -Topiramate NSAIDs Triptans OnabotulinumtoxinA (Botox) ```
78
Beta-blockers
First-line, established efficacy Metoprolol, propranolol, timolol May be useful in pts with comorbid htn, angina, or anxiety
79
Adverse effects of beta-blockers
Drowsiness, fatigue, depression, bradycardia, hypotension
80
Anticonvulsants
First-line, established efficiency Useful with comorbid seizures, anxiety disorder, or bipolar illness Valproate, divalproex
81
Adverse effects of anticonvulsants
``` N/V Alopecia Tremor Asthenia Somnolence Weight gain Hepatotoxicity ```
82
Contraindications of anticonvulsants
Pregnancy and pts with a hx of pancreatitis or chronic liver disease
83
Topiramate
First-line anticonvulsant
84
Adverse effects of topiramate
``` Paresthesia Fatigue Anorexia Diarrhea Weight loss Difficulty with memory Taste perversion ```
85
Contraindications of topiramate
Use with caution in pts with a hx of kidney stones or cognitive impairment
86
Amitriptyline
``` Second-line TCA Anticholinergic side effects -Increased appetite -Weight gain -Drowsiness -Orthostatic hypotension ```
87
Venlafaxine
``` Second-line SNRI Adverse effects -Nausea -Vomiting -Drowsiness ```
88
Clinical presentation of tension HA
No aura or premonitory sx Mild to moderate pain, bilateral "hatband" pattern Dull, nonpulsatile tightness or pressure Either episodic, frequent, or chronic
89
Nonpharmacologic tx for tension HA
``` Behavioral therapy -Cognitive behavioral therapy -Relaxation training -Biofeedback Physical therapy -Heat/cold packs -Stretching -Massage -Acupuncture ```
90
Pharmacologic tx for tension HA
Analgesics +/- caffeine Fioricet +/- codeine High-dose NSAIDs
91
Consider prophylaxis for tension HA if...
>2 HAs/wk Duration >3-4 hrs Severity results in medication overuse or substantial disability
92
Epidemiology of cluster HA
Most severe Uncommon More common in males than females
93
Pathophysiology of cluster HA
Hypothalamic dysfunction with resulting alterations in circadian rhythms
94
Clinical presentation of cluster HA
``` Attacks daily for 2 weeks to several mos Long pain free intervals Occur suddenly, pain peaks quickly after onset Cranial autonomic sx No aura ```
95
Acute tx for cluster HAs
``` Oxygen Triptans -Subcutaneous -Nasal -Oral: limited use Ergotamine derivatives -Dihydroergotamine: IV -Ergotamine tartrate: SL or rectal ```
96
Prophylaxis for cluster HA
Verapamil -AEs: gingival hyperplasia, constipation -Monitoring: EKG for bradycardia and heart block Lithium -AEs: tumor, lethargy, nausea, diarrhea, abdominal discomfort -Monitoring: lithium levels, renal, and thyroid function Corticosteroids -Taper, HAs may reoccur upon discontinuation

Pharm I (10 decks)

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