Migraine/Gout

Question 1

What other symptoms accompanied by a headache should a patient seek medical attention?

Answer 1

Fever
Stiff neck
Rash
Confusion
Seizures
Double vision
Weakness
Numbness
Chest pain
SOB
Aphasia (trouble speaking)

Question 2

What is a common type of migraine in women? How is it treated?

Answer 2

Menstrual-associated migraine (MAM)

Tx: oral contraceptives or estradiol patch to decrease the frequency

women who experiences migraine with aura are at a higher risk for stroke; estrogen-containing contraceptives should be avoided

Question 3

Common migraine triggers

Answer 3

1. Hormonal changes in women
2. Foods (alcohol, aged cheeses, overuse of caffeine, salty & processed foods)
3. Sensory stimuli (bright lights, sun glares, loud sounds, certain scents)
4. Changes in Wake-Sleep Pattern
5. Changes in the Environment

Question 4

Diagnosis in adults

Answer 4

At least 5 attacks:

1. Headaches lasting 4-72 hours
2. Unilateral location, pulsating
3. N/V, photophobia (sensitivity to light), phonophobia (sensitivity to sound)

Question 5

Natural products used for migraines

Answer 5

Caffeine
Butterbur
Feverfew
Magnesium
Riboflavin

Question 6

Acute (abortive) treatment used for headache that is already present.

Answer 6

OTC:

     - acetaminophen
     - Advil Migraine (only ibuprofen)
     - Excedrin Migraine (ASA + ibu + Naproxen)
     - Aleve (Naproxen)

Question 7

Prescription options for acute treatment

Answer 7

Serotonin receptor agonists (Triptans)

Question 8

What types of drugs are not recommended due to abuse/dependence issues for migraines?

Answer 8

Opioids, butalbital-containing products, tramadol and tapentadol

Question 9

Triptans MOA

Answer 9

selective agonists for the 5-HT1 receptor and can cause vasoconstriction of cranial blood vessels

Question 10

Triptans agents (generic/brand)

Answer 10

rizatriptan (Maxalt-MLT)
sumatriptan (Imitrex)
zolmitriptan (Zomig ZMT)

Question 11

Which triptan has the longest half life? What is the half life?

Answer 11

frovatriptan (Frova) - 26 hours

Question 12

Triptans that have a shorter half life have a faster onset. Which are?

Answer 12

almotriptan
eletriptan
rizatriptan
sumatriptan
zolmitriptan

Question 13

What are the formulations available for triptans?

Answer 13

sumatriptan (nasal spray, powder, prefilled syringe & auto-injector)

zolmitriptan (nasal spray & ODT)

rizatriptan (ODT)

All Triptans are available as tablets

Question 14

Triptan drug interactions

Answer 14

Sumatriptan, rizatriptan & zolmitriptan are contraindicated with MAOIs (or w/in 2 weeks of stopping)

Question 15

Ergotamine MOA

Answer 15

nonselective agonist of serotonin receptors

*used if patients do not benefit triptans**

Question 16

Ergotamine agent

generic/brand; formulation, Boxed warnings, contraindications

Answer 16

dihydroergotamine (D.H.E. 45, Migranal)

Formulations: IM/SC/IV, nasal spray

Boxed warnings: CI with potent CYP3A4 inhibitors due to peripheral ischemia

Contraindications: uncontrolled HTN, pregnancy, ischemic heart disease

Question 17

Name the oral CGRP receptor antagonists approved to treat acute migraine attacks.

(generic/brand)

Answer 17

rimegepant (Nurtec ODT)

ubrogepant (Ubrelvy)

Question 18

What drug is a first-in-class serotonin agonist that is selective for the 5-HT1F receptor subtype?

(generic/brand)

Answer 18

lasmiditan (Reyvow)

C-V

Question 19

Fioricet generic

Answer 19

acetaminophen + butalbital + caffeine

Question 20

Fiorinal generic

Answer 20

aspirin + butalbital + caffeine

C-III

Question 21

Prophylactic drug treatment is considered when?

Answer 21

acute treatments > 2 days/week or > 3 Xs/month, if the migraine decrease their QOL

Question 22

Oral prophylactic therapies include

Answer 22

Antihypertensives: beta-blockers - propranolol

Antiepileptics: topiramate* (popular = weight loss) and valproic acid

Antidepressants: amitriptyline or venlafaxine

MAM: monophasic and extended-cycle OCs if not aura

Question 23

Monoclonal antibodies typical dosing range

eptinezumab-jjmr (Vyapti)

Answer 23

IV Q3 months

Question 24

Monoclonal antibodies typical dosing range

erenumab-aoor (Aimovig)

Answer 24

SC monthly

Question 25

Monoclonal antibodies typical dosing range fremanezumab-vfrm (Ajovy)

Answer 25

SC month or SC Q3 months

Question 26

Monoclonal antibodies typical dosing range galcanezumab-gnlm (Emgality)

Answer 26

SC monthly

Question 27

What agent is used for chronic migraines ONLY? What is considered as chronic?

Answer 27

Botox > 15 headache days per month

Question 28

Why are migraine medications limited to acute treatment to 2-3 times per week, at most?

Answer 28

Medication overuse headaches (MOH) aka rebound headaches

Question 29

Counseling point for sumatriptan nasal powder Brand?

Answer 29

Brand: Onzetra Xsail CP: place mouthpiece into your mouth; blow into the device with your mouth for 2-3 seconds to deliver medication into your nose

Question 30

Define gout

Answer 30

build up of uric acid (UA) crystals primarily in the joints

Question 31

What is the medical name of the joint for the big toe?

Answer 31

metatarsophalangeal joint **most common joint where gout occurs*

Question 32

Risk Factors for Gout

Answer 32

Male gender Obesity Excessive alcohol

Question 33

Drugs that increase uric acid

Answer 33

``` Aspirin, lower doses Calcineurin inhibitors (tacrolimus and cyclosporine) Diuretics (loops and thiazides) Niacin Pyrazinamide Select chemotherapy (with TLS) Select pancreatic enzyme products ```

Question 34

Foods to avoid to prevent gout attacks

Answer 34

Organ meats High-fructose corn syrup Alcohol

Question 35

Prophylactic drugs are used to do what?

Answer 35

lower UA levels (goal: < 6 mg/dL)

Question 36

Gout Treatment Basics

Answer 36

1. Treat acute pain w/ anti-inflammatory drugs - Colchine - Steroids - NSAIDs (often starting in high doses) 2. Once gout has struck, treat chronically to prevent future attacks - Xanthine oxidase inhibitor (XOI): allopurinol** or febuxostat * *an acute gout flare can occur when an XOI is started, so give initially with colchicine or an NSAID 3. if XOI didn't work well enough and UA remains > 6 mg/dL - Add probenecid or lesinurad to daily XOI - replace the XOI with IV pegloticase (Krystexxa)

Question 37

Steroids used in gout

Answer 37

prednisone/prednisolone methylprednisolone (Medrol, Solu-Medrol)

Question 38

NSAIDs used in gout

Answer 38

indomethacin (Indocin) naproxen (Aleve) celecoxib (Celebrex)

Question 39

What drug is a urate-oxidase enzyme used in the treatment of tumor lysis syndrome (TLS) and is contraindicated with G6PD deficiency?

Answer 39

rasburicase (Elitek)

Question 40

What is the MOA of pegloticase (Krystexxa)?

Answer 40

Recombinant uricase: converts uric acid to allantoin IV formulation - must be premedicated with antihistamines and steroids due to anaphylactic reactions **Reserved for refractory disease**

Question 41

Patients at risk risk of a severe Allopurinol hypersensitivity reaction should be screened what prior to drug use?

Answer 41

HLA-B*5801 allele **if positive - (esp. Asians) do not use drug**