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PHAR 255 > Migraines > Flashcards

Migraines Flashcards

1
Q

What are some simplified pathophysiologies for migraines?

A
  1. Some people have sensitized neurons (unclear why)
  2. A migraine trigger comes along
  3. The brain releases potent vasodilators (CGRP, NO) and inflammation reactions
  4. Vasodilation = big pain, inflammation begets for more inflammation (positive feedback loop)
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2
Q

What is a migraine aura?

A

An aura occurs in around 30% of patients

Visual symptoms (flickering bright lights, blindspots)

Sensory Disturbances (tingling, numbness, pins and needles)

Speech Disturbances (difficulty word-finding)

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3
Q

What are some migraine triggers?

A
  • Stress
  • Meal-skipping
  • Certain foods (chocolate or soft cheese)
  • Alcohol (especially red wine)
  • Caffeine withdrawal
  • Dehydration
  • Obesity
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4
Q

What pharmacological options showed the highest efficacy in migraine treatment?`

A

Combination products (ex. NSAID+oral triptan) and triptans showed the highest response rates

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5
Q

What is the treatment ladder for migraine treatment ranked by first-line to last line?

A
  1. NSAIDs (affordable, response in 4 to 5 patients per 10)
  2. Triptans (response in 5 to 6 patients per 10)
  3. NSAID + triptan (response in 6 to 7 patients per 10)
  4. Subcutaneous Sumatriptan (early attack on inflammation, best single product
  5. Refractory Patients (try other alternative combination products, start migraine prophylaxis, DHE nasal spray)
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6
Q

When are NSAIDs taken in migraine treatment?

A

Taken on the earliest onset of migraine pain and an empty stomach (food delays onset, minutes count in migraine treatment)

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7
Q

When are triptans taken in migraine treatment?

A

Take triptan at the earliest onset of migraine pain (fast acting triptans are preferred)

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8
Q

How can triptan therapy be optimized with adjunct therapies?

A

Add acetaminophen, an NSAID, or metoclopramide (improves GI motility and increases the speed at which migraine drugs reach small intestine for absorption)

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9
Q

What are the fast-acting triptans?

A

Almotriptan
Eletriptan
Rizatriptan
Sumatriptan
Zolmatriptan

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10
Q

What are the only slow-acting triptans?

A

Naratriptan or frovatriptan

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11
Q

Why are T3s avoided in migraine treatment?

A

They contain opiates (codeine) and they double the risk for medication overuse headache compared to other agents

Caffeine dose is subtherapeutic (only has 15mg, need 100mg for migraine efficacy)

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12
Q

What are some side effects associated with triptans?

A

They are potent vasodilators (chest discomfort/tightness, palpitations, dizziness, facial flushing)

They are also potent serotonin agonists (nausea)

Injection site reactions and bad taste with nasal spray

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13
Q

What are some contraindications for triptans?

A

Contraindicated in the following situations:
- CVD (uncontrolled HTN, previous MI, previous stroke)
- Within 24 of taking an ergot (ex. DHE) due to additive coronary vasospasm
- MAOIs (risk of serotonin syndrome especially when used with other serotonergic drugs)

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14
Q

What triptans provide the quickest relief?

A

10-15 minutes for any subcut or nasal formulations; however these have higher cost

ex. Sumatriptan subcut, Suma nasal, Zolmitriptan nasal

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15
Q

What triptans provide the best efficacy at 2 hours after administration?

A

Likely sumatriptan subcut (works in 80% of patients)

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16
Q

What triptans are best tolerated?

A

The slow onset triptans (nara or frova). they have lower nausea and other adverse effects

But have lower efficacy than faster onset agents in migraine treatment

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17
Q

What is the effect of a high metoclopramide dose?

A

Can cause decreased dopamine activation in the brain (can cause pseudo-Parkinson’s). These patients show tremors, issues with movement

An alternate is using Domperidone to avoid experiencing pseudo-Parkinson’s but also have the benefit of increasing oral absorption of migraine drugs

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18
Q

What triptans are best for long-acting migraine attacks?

A

Naratriptan and Frovatriptan (long half-life)

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19
Q

What triptans are best for privacy (discretely administered)?

A

Any ODT product (Rizatriptan and Zolmitriptan)

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20
Q

Rank oral dosage form triptans by cost (most expensive to least expensive)

A

Almo PO, Suma PO, Zolmi PO, Riza PO

21
Q

What are the best triptans if the patient experiences vomiting during their migraine attacks?

A

Any subcut or nasal option avoids the GI tract and eliminates risk of loosing drug in vomit

OR

add anti-emetic like metoclopramide or domperidone

22
Q

Will an effective triptan show benefit for the first migraine attack?

A

Not always, so try a triptan for 3 migraines before giving up, and try 3 triptans before giving up on the drug class

23
Q

Do ODT triptans have faster onset compared to regular tabs?

A

No, ODT triptans are no faster than regular tabs

24
Q

How many days can a patient use triptans before medication overuse headaches become a concern?

A

9 days

25
Q

What is the maximum number of days that opioids can be taken without medication overuse heachaches?

A

9 days

26
Q

What is the maximum number of days that NSAIDs or acetaminophen can be used before medication overuse headaches become a concern?

A

14 days

27
Q

How many days can a patient use combination migraine products before risking medication overuse headaches?

A

9 days

28
Q

What are menstrual migraines?

A

In some patients, migraines increase during menstruation (perhaps due to changing hormone levels)

Often requires pretreatment (start 2 days before anticipated menstruation)

29
Q

What pharmacological options are used in menstrual migraines?

A

Naproxen 500mg BID
Naratriptan 1mg BID
Frovatriptan 2.5mg BID
Estradiol gel 1.5mg (can use combined birth control, but officially contraindicated if patient has migraine with aura, but used off-label)

30
Q

What is the newest migraine treatment drug class?

A

anti-CGRPs (CGRP receptor antagonists)

ex. Ubrogepant used for treatment and Atogepant used for prevention

31
Q

What are some characteristics of CGRP receptor agonists?

A

ADRs: Nausea and somnolence(drowsiness)

Not contraindicated in CV disease, unlike caution for triptans

Very low risk for medication overuse headaches

32
Q

Review slide 23 for summary of testable content

A
33
Q

Who should get migraine prophylaxis?

A
  • Patient preference
  • Frequent attacks (more than 6 headache days per month)
  • Severely disabling attacks (especially if more than 3 per month)
  • Difficult to treat attacks (acute treatment doesn’t work well)
34
Q

How should migraine prophylactic therapy be initiated?

A
  1. Start a headache diary
  2. Start a migraine prevention drug at low dose (beta-blockers, ACEi/ARB, TCA, SNRIs)
  3. Increase dose gradually, every 1 to 2 weeks as guided by target dose range
  4. Remain at that dose for 8 to 12 weeks to assess effectiveness and tolerability
  5. Assess and decide whether to continue, increase dose, or taper or d/c the drug
35
Q

What migraine prophylactic agents have the best efficacy (need to know doses)?

A

Amitriptyline 75mg/day
Propranolol 160mg/day
Metoprolol 200mg/day
Topiramate 100mg/day

36
Q

What migraine prophylactic agents have the fewest adverse effects (need to know doses)?

A

Candesartan 16mg/day
Magnesium 600mg/day
Riboflavin 400mg/day

37
Q

If the patient smokes, what is the best migraine prophylactic agent?

A

Nortriptyline

38
Q

If the patient has insomnia, what is the best migraine prophylactic agent?

A

Amitriptyline

39
Q

If the patient has HTN, what is the best migraine prophylactic agent?

A

Beta-blocker, candesartan, lisinopril, or verapamil (240mg/day) are good choices

40
Q

If the patient has chronic pain, what is the best migraine prophylactic agent?

A

Amitriptyline, venlafaxine, duloxetine, topiramate, or even gabapentin

41
Q

If the patient has depression, what is the best migraine prophylactic agent?

A

Venlafaxine (150mg/day) , duloxetine, amitriptyline

Optimize non-drug options (CBTi)

42
Q

How long should migraine prophylactic trial last before switching agents?

A

At least 8-12 weeks before deciding if prophylaxis is helping

43
Q

What migraine prophylactics pose risk for fetal defects?

A

Topiramate
Divaloprex
Candesartan
Lisinopril
Flunarizine

44
Q

What are some significant drug interactions between migraine prophylaxis and other commonly used drugs?

A

Propranolol slows rizatriptan metabolism (increases levels by 70%
- Increases risk for coronary vasospasm

Therefore use rizatriptan 5mg, if a patient is also using propranolol for prophylaxis

45
Q

What are some emergency red flags for acute headache?

A
  • Worst headache
  • Impairment of speech, strength, consciousness
  • Fever or neck stiffness
  • Eye symptoms (acute angle closure glaucoma)
  • Head trauma
46
Q

What are some urgent red flags for acute headaches?

A
  • First ever headaches
  • Headache with exercise or sex
  • New headache if age over 50
  • HIV
  • Cancer
  • Lyme disease
  • Pregnancy
  • Older adult with cognitive changes
47
Q

Review slide 30 to help differentiate migraines, tension type, and cluster headaches (will be on exam)

A
48
Q

Review slides 34 to 40 for migraine cases

A

PHAR 255 (15 decks)

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