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Flashcards in migraine Deck (42):
1

Ergotamine tartrate (Ergomar)

ergotamine tartrate/caffeine/l-belladona alkaloids/sodium pentobarbital (30mg) (Ercaf, Wigraine); ergotamine/caffeine (Cafergot suppository)

Ergot Alkaloids and drugs that act at 5-HT1B receptors and 5HT1D (inhib. rel of pro-inflamm. NTs) *SLD*

-potent vasocontrictors
(ha due to vasodilation)

-caffiene may help absorption

-"dirty" drug: interacts with serotonin, dopamine, and adrenergic receptors

-only use after triptans fail

-GI upset (use with metoclopramide- anti-emetic)

2

Sumatriptan (Imitrex)

Specific 5-HT1B/1D agonists,*FLDs*
first generation (SubQ, nasal spray, oral, transdermal patch)

-use for acute tx mod-sev. migraine if OTC analgesic/NSAIDs fail, relieve N/V, photo/phonophob

vasoconstriction of dilated intracranial arteries, inhibit rel. of vasodilator/proinflamm. mediators from trigeminal nerve endings

-metab. by MAO

-SE: peripheral vasoconstriction, MI

3

Zolmitriptan (Zomig, Zomig ZMT)

Specific 5-HT1B/1D agonists
second generation (*nasal or oral*)

acts at peripheral trigeminal (vasoconstriction, inhib. vasodilator release)
AND acts centrally: inhibits pain transmission in trigeminal nucleus
-access deep within CNS (more lipophilic) @ 5HT rec

4

Metoclopramide (Reglan)

Dopamine Antagonists – Antiemetics (IV, IM or oral)

-tx N/V and ha
-use when unresponsive to triptans or oral analgesics
-can give in combo with NSAIDs or sumitriptan

5

Prochlorperazine (Compazine)

Dopamine Antagonists – Antiemetics (IV, IM or oral)

-tx N/V and ha
-use when unresponsive to triptans or oral analgesics
-can give in combo with NSAIDs or sumitriptan

6

Chlorpromazine (Thorazine)

Dopamine Antagonists – Antiemetics (IV, IM or oral)

-tx N/V and ha
-use when unresponsive to triptans or oral analgesics
-can give in combo with NSAIDs or sumitriptan

7

ASA

analgesic

8

Acetaminophen

analgesic
-effective at tx photophobia, phobia, pain

excedrin: combo of acetaminophen, NSAID (ASA) and caffeine

9

Ibuprofen

analgesic

10

propranolol

B-blocker
-ppx to prev. migraines
-ones that lack partial agonist activity have best effect

tox: B-blockers may augment vasoconstriction from ergotamine

11

timolol

B-blocker
-ppx to prev. migraines

12

atenolol

B-blocker
-ppx to prev. migraines

13

amitriptylin (Elavil)

antidepressant
-ppx to prev. migraines
-down-reg of central 5-HT2 and adrenergic receptors (essentially like up-regulating 5-HT1)

-SEs: sedation, anticholinergic SEs

14

Valproate (Depakote)

anticonvulsant
-similar global brain affect btw seizure and ha

-many drug interactions, only use for severe

-dec. neuronal activity: facilitate GABA NT, modulate glutamate, inhib. Na+ and Ca2+ channels

15

topiramate (Topamax)

anticonvulsant
-similar global brain affect btw seizure and ha

16

gabapentin
(Neurontin)

anticonvulsant
-similar global brain affect btw seizure and ha

17

Botulinum toxin type A (Botox)

migraine tx, inhib. rel. ACh
effect may last up to 3 months
*only med good for medication rebound/overuse ha*

18

migraine prevalence

44.5 million US
F>M
genetic factors
$13 billion lost due to dec. work productivity

19

migraine effects

decrease oral absorption of drugs during migraines
dec. GI motility
*caffeine helps
90% N/V -consider parenteral admin

20

migraine prodrome

21

migraine aura

migraine w.out aura (common migraine)

migraine w. aura (classic migraine)

visual disturbance-"fortification" spectrum-light disturbance, looks like a fort
narrowing of visual fields

22

headache characteristics

dull ache--intense pulsations
typ. Unilat
N/V
photophob/phonophobia
lasts 4-72 hrs
improve w. resting in dark room
worse with physical activity
W>M

23

postdrome

During this phase some patients may feel tired/depressed or refreshed/euphoric

24

menstrual migraine

onset of menstruation, due to hormone changes

25

tension type

muscle contraction headaches - Dull persisting, non-pulsating, non-debilitating, bilateral pain (hatband pattern), not aggravated by physical activity, usually an absence of nausea/vomiting, and absence of aura and photophobia/phonophobia


26

cluster ha tx

abortive:
O2 inhalation
ergotamine tartrate, dihydroergotamine
subcutaneous sumatriptan

ppx:
verapamil
lithium carbonate
ergotamine tartrate
prednisone

27

physio of migraines

dilated/enlarged BVs-->sensory to brain-->pain perception

(Ergot alkaloids/sumatriptan, zolmiltriptan)
drugs act on 5HT receptors to constrict
AND
5HT1D to inhibit release of pro-inflammatory NTs:
CGRP, NKA, SP

28

vascular theroy

aura: vasoconstric
pain: vasodil

29

spreading depression

spreading dec. in cortical e- activity

30

serotonergic abnormalities

IV inj. of 5-HT can abort spontan./drug-ind. migraine
act at level of serotonin type 1 receptors

31

abortive tx
OTC NSAIDs, excedrin, tylenol, advil

home: triptans-->ergot alkaloids, dihydroergotamine-->butorphanol nasal spray (last resort)

ER: IV NSAID + metoclopramide-->dihydroegotamine + metoclopramide-->metaclopramide + dexamethasone

32

> 3 attacks per wk

ppx tx

33

rebound ha

med overuse ha, can't take >2x week
combination analgesics, opiates, ergotamine and the triptans
*botulinum toxin is only relieving for med overuse ha*

34

NSAIDs mechanism

dec. PG formation-->dec. inflammation in trigeminovascular system-->lessens pain sensitization

35

Dihydroergotamine (D.H.E.45) (IV, IM, SC, nasal) dihydroergotamine mesylate nasal spray (Migranal)

Ergot Alkaloid, acts at 5-HT1 receptor

acute tx of mod-severe migraine
-like Ergotamine, less vasoconstriction
*dirty drug: acts @ catechoamine, serotonin, dopamine receptors

36

ergotamine contraindications/interactions

Do not use in pts with peripheral vascular disease
Do not use with B- blockers

*potentiate vasoconstriction

37

Dihydroergotamine tox

GI upset: stim. CRTZ-->N/V

transient bradycardia, leg wkness, vasospasm (less than ergotamine, less vasoconstr, more a-blocking)

38

sumatriptan tox

CV: MI, arrhythmia, vasospasm if taken with ergot

"triptan symptoms": chest/throat tighness, diff breathing, panic, parethesia, feeling of heaviness

39

do not use sumatriptan with..

MAO inhibitor (phenelzine, isocarboxazid) w.in 2 week time span

40

evaluate ppx therapy

-stay on for 2-3 mos to see if effective
-continue for 3-6 mos then examine for remission

41

tension ha tx

abortive:
self medicate w. OTC analgesics
relaxation techniques

ppx:
amitriptyline
botulinum toxin inj.

42

ha tx for kiddos

1. Ibuprofen, acetominophen
2.don't use metoclopramide for antiemetic (extrapyramidal SEs), domperidone may be better
3. triptans
4. B-blockers for ppx