Migraine

Question 1

What is a primary HA?

Answer 1

MC-No identifiable underlying cause.

Question 2

What is a secondary HA?

Answer 2

Organic cause. 2. Dental infx 3. Brain Tumor 4. Subarachnoid hemorr

Question 3

What is diff btwn cluster

Answer 3

severe- U/L lacrimating temporal TX- verapamil, prednisone

Question 4

What is diff btwn Tension

Answer 4

MC- B/L TX-OTC

Question 5

What is diff btwn migrain?

Answer 5

debilitating- U/L, W 15-30yo-Trigger-trigeminal nerve-vasodilation-inflammation-nociceptive-peripheral sensitization. Prodrome- mood, food. Aura- tingling lips, motor speech. HA- UL throbbing 4-72hrs, pain INC activity HA- reverts to vomiting spontaneous, Postdrome-fatigue, AN (pseudo seizure)

Question 6

What are trigger for Migraine?

Answer 6

Stress, mood, light, hunger, MSG, tyramine, Nitrites, chocolate, menses,

Question 7

What is best method for Acute Migraine tX?

Answer 7

Large single dose. 2. parenteral best

Question 8

What is benefit of caffeine in Excedrin OTC used for acute migraine?

Answer 8

helps absorb faster- NOT REC for single agent. OK for peds and Pregs

Question 9

What is ideal for tension HA?

Answer 9

Fiorinal-caffeine+aspirin/APAP

Question 10

How are NSAIDs use in HA?

Answer 10

Mild to mod 2. Avoid 3rd trimester 3. Metoclopramide for absorption 4. Avoid excess d.t rebound HA

Question 11

What can be used as monotherapy for HA antiemetic?

Answer 11

Injection-prochlorperazine, metoclopramide, chlorpromazine 2. Used with diphenhydramine to prevent ADEs akathisia/dystonic rxn

Question 12

What are ADEs and use of metoclopramide?

Answer 12

1. USE- delay gastric emptying so better absorption. 2. ADE- sedation, confusion dyskinesia

Question 13

What is not first line for migraine HA?

Answer 13

Opioids- INC rebound HA- meperidine, codeine, Stadol

Question 14

What is REC for intractable severe migraine?

Answer 14

Ergot-Dihydroergotamine DHE-LONG LAST HA ADE-n/v rebound HA, NEVER MONO, Used in ED, poor absorption

Question 15

Which ERgot interacts with serotonin and cause vasoconstriction and vasodilation?

Answer 15

Ergotamine Tartrate- LAST RESORT-FOR MIGRAINE AND CLUSTER RECURRENCE OR PROLONGED ATTACKS

Question 16

What are ADE of ergotamine

Answer 16

GI, *peripheral vasoconstriction: cold, DEC pulses, tingling. AVOID in PVD and CAD, PregX, Ischemic bowel dz, CVA, . BB may INC effects. TX OD- Nitroglycerin

Question 17

What are DI of ergotamine tartrate?

Answer 17

Triptains! and CYPs INC Ergo TARTRAte in serum, INC toxicity

Question 18

This MOA is 5HT1b, 1d agonist receptors located in CNS, PNS that stimulate vasoconstriction in cranial vessels, and inhib trigeminal nerve 1d, dec neuropeptides responsible for vasodilation and reduce transmission?

Answer 18

Triptans- suma, riza, nara, zolmi, frova, ele. The IRanian triptans

Question 19

WHich triptan should be avoided in elderly, short t 1/2, quickers relief SC?

Answer 19

Sumatriptan- GMa suma like natural

Question 20

What are ADE of SUMA?

Answer 20

1st GEN GMa- gets chest to throat pressure, SOB, Signs of GAD. Anxious Grandma. Resolves in 30 min. Patch scars

Question 21

What is concern with Suma in women?

Answer 21

PREG C- excreted in breastmilk.

Question 22

What BB inhibits Rizatriptan and thus Riza must be DEC by 50% if pt on BB?

Answer 22

Propranolol- “Aunt Riza and her CHF”. Riza- has a fast onset w/ good response. “But Riza so helpful”

Question 23

Which triptan is best tolerated, LOWEST recurrence?

Answer 23

Aunt Nara- “nice and slow Aunt Nara”

Question 24

Which triptan has CYP many DI, short duration bc INC lipo, Well tolerated, LOW recurrence?

Answer 24

Almotriptan- “Crazy Aunt Almo never getting along with family bc her short tempe with wt talks”

Question 25

Which triptan is ideal for AURAs LONGEST t/1/2, slow relief, low HA recurrence?

Answer 25

FRovatriptan- "Aunt Frova forever long mystical stories but she never repeats?

Question 26

Which triptan is avoid 72 hr with other drugs due to CYP inhib?

Answer 26

Eletriptan- "Aunt Ele is live 72hr away"

Question 27

Which Triptans have consistent success?

Answer 27

Riza, Ele, Almo- Trials said oral are effective. Choice individualized. Switch if one not working

Question 28

Which drugs have least ADE?

Answer 28

Nara and Frova

Question 29

Which drug has most delivery options?

Answer 29

Sumatriptan- GMa got all the recipes

Question 30

Which Triptan CANNOT be repeated 2hrs?

Answer 30

Nara-Slow AUNTy. All other can repeat 2 or >2hrs. EXCEPT Sumatriptan SC- 1hr

Question 31

What have nasal spray option?

Answer 31

Zolmi and Suma

Question 32

What RX can be used in 2-3 trimester for migraine?

Answer 32

APAP+metoclopramide. AVOID-nsaid, ergos, triptans preg c

Question 33

When can prophylaxis be used?

Answer 33

HA > 3day/mo, or >2 day/week or severe long lasting >12hr

Question 34

How should prophylaxis be dosed?

Answer 34

Lowest effective dose, slowly, Trial 2-3mo, Avoid other RX meds. Re-evaluate 1 yr via slow taper

Question 35

What BB is most studies, but overall any BB has 60-80 complete or partial relief, DOC bc safe, effective, tolerable?

Answer 35

Propranolol- may take 3-6 mo of max. Titrate to max dose 325 mg

Question 36

What are ADEs of BB?

Answer 36

AVOID asthma,DM, cardiac arrhythmias. Fatigue, exercise intolerance, MDD, ortho hypotension

Question 37

What CCB is used in migraines?

Answer 37

Verapamil- 50% relief ADE- dizzy, edema, flushing, constipation, tolerance

Question 38

What is the most effective prophylaxis antidepressant?

Answer 38

Amitriptyline-TCA ADE- sedation, wt gain, anticholinergic (dry as dessert). USE- best if PMH of MDD, GAD, insomnia, tension HA. AT NIGHT

Question 39

Which AED meds are used in migraines, but are PREG X?

Answer 39

Valproate and Topiramate-

Question 40

Which ADE is double whammy with prevent migraines and WT LOSS?

Answer 40

Topiramate- Kids age 12+ ADE- birth defect

Question 41

What new prophylaxis is LAST resort?

Answer 41

Calcitonin gene related peptide- for trigeminovascular pain- Drug Mabs-ADE- cardiovascular, pulmonary, psych. AVOID- children, preg, elderly. 3 deaths

Question 42

Should transcranial magnetic stimulation be used on epilepsy migraine pts?

Answer 42

NO- 2nd for pt w/ intolerances

Question 43

What is prophylaxis for cluster HA?

Answer 43

Verapamil, Steroids, Topiramate, Lithium

Question 44

What is ideal Tx for cluster HA?

Answer 44

Oxygen. Triptans-Suma, Zolmi, Nasal Lidocaine

Question 45

What can be used has prophylaxis of Tension HA?

Answer 45

TCA-amitriptyline.