MIgraines Flashcards

Question

What is the benefit of an ODT?

Answer 1

Some triptans are orally disintegrating tablets – do not need to take it with water

Answer 2

Start migraine prophylaxis – hoping for less migraines, will actually decrease the intensity of migraines – can boost the efficacy of other drugs by decreasing the intensity of migraines

Answer 3

DHE – Dihydro-ergotomy nasal spray - do not use much anymore – hits serotonin receptors causing vasoconstriction but also hits other receptors – lots more side effects – more nausea, feeling weird

Answer 4

Avoid opioids – Medication Overuse Headaches – twice as likely any other drugs to cause ,edication overuse headache Opiod/Barbituate – Do nothing for inflammation (just masking the pain) – opiates are not good choice to shut down the inflammation

Answer 5

Opioids have double the risk of medication overuse headache compared to other agents. Caffeine dose is subtherapeutic. ~100mg needed for migraine efficacy; ~15mg in one Tylenol #3 tab (migraine perspective not doing anything) Acetaminophen dose is often subtherapeutic. Best evidence is for 1000mg of acetaminophen; would need three Tylenol #3 tabs Codeine metabolism is unpredictable. ~10% of the population do not adequate activate the codeine into morphine T3 – All 3 drugs are subtherapeutic/not good for migraines, A LOT OF PRESCRIBING – any other drug for migraines

Answer 6

Triptans are potent vasoconstrictors Triptans are potent serotonin Agonists

Answer 7

Triptans can cause chest discomfort/tightness; palpitations; dizziness; facial flushing Contraindicated in cardiovascular disease (e.g. uncontrolled hypertension, previous MI, previous stroke, etc.) Contraindicated within 24 hours of ergots (e.g. DHE) due to additive coronary vasospasm; also do not combine triptans Migraines – Vasodilation – rush of blood to the brain Narrow the blood vessels – vast majority is a feeling more than anything bad Only so much triptan in one day (do not combine) – too much vasoconstriction (coronary vasospasm)

Answer 8

Sumatriptan – 25, 50, 100 mg tabs – Max a day is 200 mg Explicit directions on how much you can take a day Generally, max dose times by 2 – max dose for a day

Answer 9

Triptans can cause nausea (think of: the opposite of ondansetron) Triptans are contraindicated with MAOIs (risk of serotonin syndrome) and cautioned with other serotonin drugs (SSRI, SNRI, etc. – often just increase monitoring) Triptans can cause nausea – nausea can already occur in migraine Ondansetron – serotonin antagonist (prevents nausea) – mechanism makes sense SSRI, SNRI – Monitor but not a complete C.I.

Answer 10

Remember: triptans have unique dosage forms = unique s/e E.g. injection site reactions with injection; bad taste with the nasal spray Nausea can still occur with injection

Answer 11

Best efficacy at 2 hours – sub cut Slow acting have the worst efficacy at 2 hours

Answer 12

Onset of 10 mins – subcut Tabs – 30-60 min ODT and tabs are the same speed of regular tabs

Answer 13

If attack lasts long time, aborting an attack completely is better – treating hard, fast and aborting it in an hour – Encourage patients to be more aggressive

Answer 14

Mettoclopramide USA dos not have Domperidone; so very comfortable using it as metoclopramide Metoclopramide can get into blood brain barrier, (antipsychotic, parkinsons dx component – Block dopamine) Parkinsons – lack dopamine – can cause pseudo-parkinsonisms – EPS symptoms for dopamine blocker Domperidone does not get into BBB, so less EPS – Big s/e is the cardiac conduction (prolong QTc interval, torsades des pointes) – adding an anti-emetic can be useful ]

Answer 15

The highest efficacy triptan is subcutaneous sumatriptan Works in up to 80% of patients. Useful if vomiting / severe nausea with oral agents as can guarantee absorption. Generic and brand products have an auto-injector Not affordable for everyone

Answer 16

Try a triptan for 3 migraines before giving up, and try at least 3 triptans before giving up on the class. Acetaminophen alone or combination can be helpful (but overall is less powerful than an NSAID). Nausea/vomiting is common with migraines – an orally disintegrating tablet can be useful; an antiemetic can be useful; an intranasal dosage form can be useful; injectable sumatriptan can be useful.

Answer 17

NO ODT is slower – Not a buccal tab, needs to absorb in the small intestine – add water, absorption matches ODT without water – sits in the mouth Nausea lean towards to nasal spray ODT triptans are no faster than regular tabs

Answer 18

Max days per month of acute medications to help avoid medication overuse headache

Answer 19

Medication overuse headache – taken so many meds that you are causing migraines with the acute drugs Drugs that use to help are sensitizing them Hypersensitizing the brain – constantly in withdrawal of the medications

Answer 20

More than 15 migraine in on e month, majority due to acute drugs

Answer 21

Triptans come in packs of 6 – one per month, they are probably doing fine – more than one pack, red flag to do something Approach conversation appropriately – approach from perspective, improve things for you and make it better

Answer 22

Cut them off drug that caused problem (stop triptan, start NSAID) Add prophylaxis Both at the same time

Answer 23

For some, migraines  during menstruation (perhaps due to changing hormone levels)

Answer 24

Option for pre-treatment (starting ~2 days before mensturation): Naproxen 500mg BID x ~6 days ($5) Naratriptan 1mg BID x ~6 days ($100) Frovatriptan 2.5mg BID x ~6 days ($200) Estradiol gel 1.5mg daily x ~7 days ($40) – menopause product Treat menstrual migraines like other migraines – some we have option for pre-treatment - Frovratriptan has best evidence

Answer 25

Option for prevention with continuous combined hormonal contraceptives But: CHCs + migraine with aura --> contraindicated E.g. CHCs + migraine with aura + smoking = 7x stroke risk Somewhat controversial – the real risk is when other risk factors like smoking start getting thrown in there.

Answer 26

Continous combined hormonal contraception – give someone mireena IUD and shut down menstrual cycle (does not work, works more locally) – Mireena IUD not changing hormonal levels, more local Cmbined – progestin and estrogen (not progestin alone)

Answer 27

Anti-cGRPs Two types: Monoclonal antibody (prophylaxis) and receptor antagonist oral CGRP is a vasodilator Antibody mops everything up – just prophylaxis

Answer 28

Ubrogepant approved in Canada 2022. Treatment dose: 50-100mg stat Rimegepant and Zavegepant approved in USA (not yet in Canada). Atogepant approved in Canada for prevention of migraines. Prevention dose: 10-60mg daily;

Answer 29

Adverse effects: nausea, somnolence. Not contraindicated in CV disease. (Big potential over the triptans)

Answer 30

Likely NOT as effective as triptan for acute migraine, although not compared head-to-head. Appears to have very low risk of medication-overuse headache (more likely no risk – really safe in medication-overuse) Weaker drugs from acute treatment side of things – a bit too slow to block CGRP receptor Cost is not good; expensive

Answer 31

Depends on severity, 6 headache days per month (may start earlier – 3 really bad migraines a month) – May still think of prophylaxis based off of career if cannot miss day of work - 3 if severe, 6 if less severe – prophylaxis

Answer 32

Start at low dose, build up tolerability – can cause s/e – ease people into it - Target dosage range – want to get people to the target dose – want to be at target for 8-12 weeks – need some time to see efficacy – give it a good try as can be one shot for some

Answer 33

Reasonable Goal of TX : Reduction in 50% of frequency or intensity

Answer 34

Make it to 10 days, s/e become more tolerable – at beginning, no benefit and s/e – need to push through – encouragement on our end

Answer 35

Cost does not really play a role Mainly choose around efficacy, s/e and comorbidities

Answer 36

Best efficacy – 60%ish of the time, propranolol up to 80% A/e – up to 40% Cgrp – up to 40%, up to 60%

Answer 37

Beta-Blocker - Propranalol, Metoprolol, Timolol TCA - amitriptylline, Notriptylline Anti-convulsant - Topiramate, Divalproex ACEi/ARB - candesartan, Lisinopril SNRI - Venlafaxine, Duloxetine CCB - Flunarazine, Verapamil 5HT2- Inhib - Pizotifen Herbal: Magneisum oxide/citrate, riboflavin, butterbur, co-enzyme Q-10 Anti-CGRP - Fremanezumab, Eptinezumab, ernumab, Galacanezumab, Atogepant, Rimegepant Other: Memantine, BOTOX | Before tony asks about s can people head away

Answer 38

Do not really know why beta-blockers work in migraines High-blood pressure Hypothesis – if we beta-blockade, blood vessels on vasodilated side already – less room for them to dilate them more – may explain why it takes long to see effect

Answer 39

Not every beta-blocker – may need drugs to penetrate Brain – drugs in classes and not whole classes Heart rate, blood pressure

Answer 40

exercise intolerance is a big deal for younger pt’s (cant go as fast as you want to go) - hold patients back – older pts better tolerate as not working out Coldness in your fingers (not as much blood in the fingers)

Answer 41

TCA – serotonin, norepinephrine, hit anti-histamines and other recptors as well - One theory – may be some downregulation of serotonin receptors if on long enough – migraine cascade is less likely to happen Other – can be used for chronic pain, numbing some pain areas in the brain so if cascade happens, it happens a little less

Answer 42

Amitriptylline is more likely to cause drowsiness – Tertiary AMine Notriptylline has smoking cessation indication – tough to tolerate for migraines - secondary amine

Answer 43

Anti-convulsants – slow down the brain a little bit, less likely to run into big cascade of pain - topiramate is best efficacy but very hard to tolerate - pregnancy risk (anti-convulsants) – child-bearing age more worried here

Answer 44

Specific for two drugs – nice cheap, well tolerated drugs - S/e – orthostatic hypotension, acei cough, less common with ARB (can happen), renal and elctrolytes  Can cause hyperkalemia - Blood pressure – dizziness or fall risk – often normotensive pts. So dizziness may be prevelant

Answer 45

Serotonin and norepinephrine - Just two – venlafaxine has the most evidence - No SSRI’s – trials do not show that they help - Dry mouth, increase in anxiety/agitation, insomnia, sexual dysfx – tough to discontinu - Nauseau when starting

Answer 46

Discontinuation Syndrome Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating) Insomnia (with vivid dreams or nightmares) Nausea (sometimes vomiting) Imbalance (dizziness, vertigo, light-headedness) Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) Hyperarousal (anxiety, irritability, agitation)

Answer 47

Venlafaxine – short t1/2 – very hard to stop, tough to quit

Answer 48

CCBS – NON-DHP’s – best data with flunarizine – really sedating Verapamil – constipation is reallyy present

Answer 49

NOOOOOOOOOO

Answer 50

Pitzoifen – serotonin antagonist - blocking from serotonin receptors, less serotonin receptors to bind

Answer 51

Herbals just target dose; recommended daily intake of magnesium is 300 mg – main side effect is diarhhea - if having constipation, magnesium may be the way to go 2 tabs of magnesium Magnesium citrate may be better tolereated but given twice a day Riboflavin – 1mg per day (RDI) - Turn urine neon yellow colour

Answer 52

all 4 of the drugs (first) – Biologics – antibodies that bind to cGRP – only migraine prophylaxis – too slow to work for acute (may change) - EDS – fail two drugs for prophylaxis – 40%ish response in 3 months, 60%ish in 8 months

Answer 53

atogepant is indicated for prophylaxis – works about 60%ish a time

Answer 54

Memantine – never used; used for alzheimers – NDMA antagonist

Answer 55

Botox – interesting as helps chronic migraine (more than 15 headache pers month) and less efficacy for someone who has episodic migraines (less than 15 month per month)

Answer 56

Treat at target dose for 8-12 weeks before deciding if prophylaxis is helping.

Answer 57

Two high of rizatriptan – extra vasoconstriction – higher risk of coronary vasospasm

Answer 58

Monoclonal antibody targeting calcitonin gene-related peptide E.g. fremanezumab, erenumab, galcanezumab, eptinezumab

Answer 59

Response in about 40% of patients. Often onset in days (but give 3-6 months for adequate trial).

Answer 60

Some covered in Sask and by NIHB if failed at least two oral prophylactic agents.

Answer 61

Some have option to give q3months – but likely monthly preferred. Allowed to dose some of these cGRPs every 3 months – resistance building up – body could mount an antibody to the antibody (an anti-drug antibody)

Answer 62

Adverse effects: injection site reactions, hypertension. Patients with CV risk were excluded from trials. Cost: ~$600/month

Answer 63

Atogepant approved in Canada for prevention of migraines. Prevention dose: 10-60mg daily

Answer 64

Fever/Neck Stiffness – Meningitis

Answer 65

remeber tension type prophylaxis TCA

MIgraines Flashcards

(110 cards)