Headaches

Question 1

migraine, tension, cluster

Answer 1

primary headache

Question 2

head trauma, vascular disorders, substance

use

Answer 2

secondary headache

Question 3

Recurring severe throbbing unilateral headache interfering with normal functioning

Answer 3

migraine

Question 4

migraine without aura

Answer 4

common migraine

Question 5

migraine with aura

Answer 5

classic migraine

Question 6

migraine prevalence

Answer 6

female, white, lower socio, genetic

Question 7

neuropeptides released in migraines

Answer 7

Calcitonin gene-related peptide (CGRP)
Substance P
Neurokinin A

Question 8

Trigeminovascular System regulated by

Answer 8

serotonin

Question 9

migraine dgx

Answer 9

5+ HA lasting 4-72 hr
at least two: unilateral, throbbing, worsened by movement, moderate to severe
PLUS
nausea or vomiting
or photophobia AND phonophobia

Question 10

migraine with aura dgx

Answer 10

At least one (reversible):
-Positive (flickering lights)
-Negative (loss of vision)
-Speech disorder
-CANNOT BE WEAKNESS
Develops gradually and lasts less than 1 hr

Question 11

SNOOP

Answer 11

systemic signs or symptoms
neurologic
onset
old age
progression of existing HA disorders

Question 12

Migraine test

Answer 12

MIDAS (MIgraine Disability Assessment Test)

Scored by 5’s as I, II, III or IV (0-5, 6-10, etc)

Question 13

Classes used for migraines

Answer 13

Analgesics
NSAIDS
Ergot Alkaloids
Serotonin Agonists (Triptans)
Opiates
Antiemetics

Question 14

Use caution with Analgesics/NSAIDs

Answer 14

Ulcer dz
Renal Dz
Cardiac Dz
Hypersensitivity

Question 15

Analgesic/NSAID DOC for migraines

Answer 15

Ibuprofen and naproxen
Aspirin
Combination: Acetaminophen, aspirin, caffeine

2nd Line:
Acetaminophen, isometheptene, dichloralphenazone
Acetaminophen, butabital, caffeine

Question 16

Analgesic/NSAID MOA

Answer 16

Inhibition of prostaglandin synthesis

Question 17

Ergot Alkaloids MOA

Answer 17

5HT1 agonists – constrict intracranial blood vessels
Inhibition of the trigeminovascular system
-Activation of 5-HT1 receptors on sensory nerve endings of
the trigeminal system results in the inhibition of pro-
inflammatory neuropeptide release
-Prevention of neurogenic inflammation

Question 18

Severity of migraine to use Analgesics/NSAIDs

Answer 18

Mild - Moderate

Question 19

Severity of migraine to use Ergot Alkaloids

Answer 19

Moderate - Severe

Question 20

Analgesic/NSAID ADE’s

Answer 20

Renal, GI (bleeding, dyspepsia, nausea), CNS (dizziness)

Question 21

Ergot Alkaloids used in migraines

Answer 21

Ergotamine Tartrate (more potent arterial constrictor)
Dihydroergotamine (DHE) - (less potent)

Question 22

Ergotamine Tartrate routes

Answer 22

Oral
SL
Rectal

Question 23

Dihydroergotamine (DHE) routes

Answer 23

Nasal

Parenteral

Question 24

Ergotamine Tartrate can be combined with:

Answer 24

Caffeine

• Enhances absorption
• Aides in analgesia

Question 25

Dosing for Ergot Alkaloids

Answer 25

Ergotamine Tartrate has strict dosing to prevent rebounds -Daily and weekly dose PR 4 mg/day 10 mg/wk PO 6 mg/day 10 mg/wk

Question 26

Ergot Alkaloids ADE's

Answer 26

Nausea/Vomiting -Stimulation of the chemoreceptor trigger zone -Pretreatment with antiemetic needed: Ergotamine tartrate IV DHE Systemic constriction -Paresthesias, chest tightness, cold hands Severe systemic constriction – (rarely) -Ischemia: brain, bowel, heart, extremities (ergotism) -Less with DHE

Question 27

Ergot Alkaloids Contraindications

Answer 27

Systemic vasoconstriction -MI, angina, coronary vasospasm, PVD, hemiplegic migraine, uncontrolled HTN, ischemic CVA, sepsis Use of triptan within 24 hours Use of MAOI within 2 weeks Use with any potent CYP 3A4 inhibitor -Azole antifungals, PI, macrolide antibiotics -The risk for vasospasm leading to cerebral ischemia and/or ischemia of the extremities is increased.  Pregnancy

Question 28

DHE Nasal Pt Education

Answer 28

- Before using each nasal spray vial, prime the pump by spraying 4 times into the air, away from the face - Use 1 spray into each nostril - Do NOT tilt your head back, sniff through your nose, or blow your nose while spraying or immediately after. Use another spray into each nostril 15 minutes after the first sprays if needed - Do not use more than 4 sprays for a single attack

Question 29

Serotonin Agonists (Triptans) MOA

Answer 29

5HT1 agonists – constrict intracranial blood vessels Inhibition of the trigeminovascular system -Activation of 5-HT1 receptors on sensory nerve endings of the trigeminal system results in the inhibition of pro- inflammatory neuropeptide release -Prevention of neurogenic inflammation

Question 30

Serotonin Agonists on mkt

Answer 30

``` Almotriptan Eletriptan Frovatriptan Naratriptan Rizatriptan Sumatriptan Zolmitriptan ```

Question 31

DOC for mod - severe migraines

Answer 31

Serotonin Agonists (Triptans)

Question 32

Selection of Triptans

Answer 32

``` Onset -Injection vs nasal vs oral -ODT – faster onset? Duration -Prevention of recurrence -Menstrual migraines Drug Interactions - metabolism Patient variability to response -Can not be predicted -Failure on one does NOT mean class -12 week trial ```

Question 33

Triptan ADE's

Answer 33

Usually mild to moderate Paresthesias, flushing, warm sensation Local side effects based on route -Injection site reactions -Nasal irritation “chest symptoms”: heaviness, pressure, tightness -5HT2A receptors within the coronary vessels -Isolated cases of cardiac events have been reported -Unlikely in patients with normal coronary vessels

Question 34

Reason for migraines during menstruation

Answer 34

lowest levels of estrogen during cycle