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NEURO PHARM > Migraine > Flashcards

Migraine Flashcards

1
Q

What is the usual treatment for cluster headaches?

A

nasal or SC triptans/ergots + burst taper steroid like prednisone

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2
Q

What is the usual treatment of tension headaches?

A

self-medicate w/ NSAIDS

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3
Q

What is the normal treatment for the following headaches?

  1. mild-moderate or menstrual
  2. moderate-severe migraine
  3. prophylaxis of migraine
A
  1. NSAIDS
  2. Short acting Triptan - sumatriptan most effective
  3. Topiramate, valproate, propranolol, timolol, or metoprolol
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4
Q

Mechanism of migraine?

A

Peripheral - altered sensittization/neuro-inflammation. 5HT receptors cerebral vessels leads to dilation and sensitization from release of CGRP/SubP and leads to central sensitization (wind up).

  • also there is spreading depression wave causing aura.
  • all of this is typically happening in CN V
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5
Q

What areas are activated that lead to the symptoms of migraines?

A
  1. Dilation of meningeal blood vessel - throbbing
  2. activation of area postrema - N/V
  3. activation of hypothalamus - hypersensitivity
  4. activation of cervical trigeminal system - muscle spasm
  5. activation of cortex and thalamus - head pain
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6
Q

What what step do the following drugs work in terms of modulating CGRP and SP?
NSAIDS
Triptans

A
  1. NSAIDS - decrease inflammatory stimuli, decreasing peripheral sensitization, COX inhibition
  2. 5HT1 B receptor at blood vessels –> vasoconstriction
  3. 5HT 1D receptor on nerve terminals –> presynaptic inhibitino of trigemnovascular inflammatory response
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7
Q

ADE of NSAIDS

A

gastric irritation w/ chronic use

additive nephrotoxicity - fluid retention, HTN, edema, and rarely CHF

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8
Q

Drug interactions of NSAIDS

A
  • ACE/ARB (need the PGs)
  • beta blockers
  • vasodilators (alpha 2 agonists, and alpha 1 blocker)
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9
Q

When are NSAIDS contraindicated?

A

late pregnancy b/c of effect on patency of ductus arteriosus, prolonged labor and delivery

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10
Q

What are NSAID combinations?

A
  1. Acetaminophen/butalbital/caffeine

2. Aspirin/butabital/caffeine

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11
Q

What are you worried about in terms of acetaminophen?

A
  • G6PD def, but it can be given during the 1st trimester of pregnancy
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12
Q

What is butalbital

A

barbiturate - has sedative/hypnotic effects via GABA

  • drowsiness, sedation, diminished cerebral function
  • strongly linked to analgesic overuse syndrome
  • CYP inducer and CNS/respiratory depressant
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13
Q

What will caffeine do in the NSAID combo

A

cerebral vasoconstriction, potential CV interactions

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14
Q

MOA Triptans

A

5HT1B and 1D agonists

  • selective intracranial/extracerebral vasoconstriction
  • inhibition of CN 5 activation by vasoactive peptides
  • inhibition of trigeminal cervical complex activation
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15
Q

What is the the triptan w/ the shortest onset and the longest onset

A
  • shortest onset : Sumatriptan and Zolmitriptan

- longest onset : Frovatriptan (has longest half life) and Naratriptan

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16
Q

ADE of triptans

A

dizziness, drowsiness, fatigure, heaviness of tightness of chest
- may cause coronary and peripheral vasospasm

17
Q

Contraindications for triptans

A
  • heart disease, uncontrolled HTN/ischemica bowel disease
  • <24 hrs following ergot/triptan treatment
  • propanolol, MAOIs, CYP3A4 drugs, SSRI/SNRI
18
Q

MOA of ergot alkaloids

A
  1. moderate doses - vasoconstriction of small arteries –> used to control hemorrhage and to promote uterine contraction and migraines
  2. large doses - paralyzes nerve endings of sympathetic fibers
19
Q

What is ergotism?

A

mental disorientation, convulsions, muscle cramps, dry gangrene of the extremities

20
Q

What is a complete contraindication for pregnancy?

A

Ergots - also don’t use while breast feeding b/c Cat X

21
Q

When are narcotics ok to use in migraines

A
  • when there is allodynia –> should consider using ketorolac but not opiates b/c there is dependence and other problems
22
Q

What are the neurotransmitters that are involved in emesis?

A
  1. Dopamine - at floor of 4th ventricle
  2. Ach in vestibular system
  3. Histamine in peripheral pain receptors
23
Q

MOA Metoclopramide

A

Central D2 blocker
Prokinetic by increasing Ach effects
- concern of increasing prolactin levels leading to gynceomastia

24
Q

MOA Prochlorperazine and Chlorpormazine

A

Central D2 blocker

Cholinergic and alpha adrenergic blockade

25
Q

ADE of Prochlorperazine and chlorpormazine

A

Dyskinesia, hypotension, glaucoma, urinary retention, BPH

26
Q

MOA promethazine

A

Cholinergic blockade

H1 and weak D2 blockade

27
Q

ADE of promethazine

A

glaucoma, urinary retention, BPH, drowsiness, Parkinsonian like syndromes

28
Q

What is the only drug proven to be effective for migraine prophylaxis in kids?

A

Propranolol

29
Q

MOA of amitriptyline

A

decreased reuptake of NE and serotonin, strong anticholingeric action

30
Q

MOA of divalproex and valproic acid

A

Na channel blocker, increase GABA activity

31
Q

How is botox thought to help w/ migraine treatment?

A
  • high placebo rate

- may decrease release of mediators or decrease muscle activation of nerves

32
Q

What is analgesic overuse syndrome?

A
  1. cause of chronic headaches due to regular med overdose
  2. headache gets worse despite treatment
  3. headache reverts after discontinuing med
  4. trigeminovascular system sensitiziation
  5. reduced 5HT levels
  6. cellular adaptation and free radical damage in PAG
33
Q

What drugs have a high RR of developing analgesic overuse syndrome?

A
  1. Aspirin/acetaminophen/caffeine
  2. Butabital containing combos
  3. Opioids
    - Moderate rate –> triptans and short acting NSAIDS
34
Q

What are some mind-body therapies that work for migraines

A

Biofeedback
Cognitive behavior therapy
Relaxation training

35
Q

What are some alternative therapies for migraines?

A

Riboflavin, Coenzyme Q10, feverfew, butterbur (mild GI upset exists – look for PA free products)
- these are not recommended for pregnant women

36
Q

What are contraindications for ergots?

A

vascular dz, sepsis, MI, HTN, etc

- interacts w/ beta blockers/Dopa, CYP3A4, triptans

NEURO PHARM (10 decks)

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