Migraines Flashcards Preview

Pharmacology > Migraines > Flashcards

Flashcards in Migraines Deck (55):
1

Migraine pathophysiology

neurovascular, Trigeminal nucleus caudalis, serotonin neurotransmission, calcitonin gene related peptide

2

5HT receptors

5HT1 agonists: migraine treatment, 5HT2 antagonists: migraine prevention, 5HT antagonists: treatment of N/V

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Phases of the migraine

irritable, depressed, neck stiffness, fluid retention, thirst, drowsiness

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Migraine aura

neurologic symptoms, visual and somatosensory most common, speech, language, sx evolve slowly, 20-60 min before migraine

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Migraine attack

moderate to severe intensity, unilateral, throbbing pain, N/V, photophobia, phonophobia; sleep will alleviate

6

Primary vs secondary headaches

primary: 90%, migraine, tension, cluster; secondary: tumor, meningitis, alcohol-induced

7

Red flags of headache history

age of onset, time form onset to peak, intensity, pain level, aggravating factors, associated sx

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Post headache sx

fatigue, mood changes, decreased appetite, muscle weakness

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Diagnosis of migraine

at least 5 attacks meeting criteria of +/- aura, lasts 4-72 hours, pain 2 of 4 (moderate to severe intensity, unilateral, pulsatile/throbbing, aggravated with activity, N/V, photo/phonophobia

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Diagnosis episodic tension-type headache

bilateral, 30 min-7 days, pain 2 of 4 (bilateral, pressing/tightening, intensity mild-moderate, not aggravated by activity), no nausea/vomiting, +/- photo/phonophobia

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variable headache presentations

migraine +/- aura, episodic/chronic tension-type headache, menstrual migraines, sinus headache

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migraine treatment strategies

all pts diagnosed w/ migraine follow similar med ladder, simple analgesics, combo treatment, specific migraine therapies

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Non-pharm treatment

hydration, biofeedback, relaxation training, behavioral therapy, cold compress, sleep, cool, dark and quiet room, ha diary,

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Complementary treatments

feverfew, magnesium oxide, vit B2, coenzyme Q-10, valerian root, Omega 3

15

Migraine prophylaxis

BB, CCB, TCA, anticonvulsants

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Acute apisodes

Nonspecific treatment: NSAIDs, antiemetics, Specific treatments: triptans, dihydroergotamine

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Lower need options

low-end therapy, NSAIDs, analgesics, triptans

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Moderate need options

combo analgesic/NSAIDs, antiemetics, triptans, prophylactic therapy

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high end need options

opiods, ergots, triptans, prophylactic therapy, consultation

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Acute migraine meds

triptans, ergotamine/dihydroergotamine, NSAIDs, opiods, anti-emetics

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Triptans MOA

serotonin (5HT) agonists, inhibit CGRP gene transcription, prevent release of neuropeptides which cause vasodilation/pain

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Triptans

DOC for acute attacks, not best for tension HA, take as soon as possible to onset, not for prevention

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Triptans metabolism

hepatic CYP450, avoid in hepatic

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Triptan interactions

MAOI: avoid use within 2 weeks of discontinuing MAOI, oral contraceptive potentially increase in [triptan], avoid use of ergot within 24 hours of triptans

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Triptans contraindication and precautions

concern for developing serotonin syndrome, concurrent admin of MAOIs, SSRIs; concern with vasoconstriction, MI, angina, silent ischemia, CAD, uncontrolled HTN, pregnancy cat C

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Serotonin syndrome interaction

rare, potential w/ SSRIs, & SNRIs, S/SX: agitation, confusion, muscle spasms, tachy, BP changes, N/D, diaphoresis

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Triptans ADRs

tingling, warmth, flushing, dizziness, somnolence, abnormal taste, pain at injection site, CX pain, neck pressure or discomfort may be serious sx

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Triptan drugs

Sumatriptan (Imitrex), Rizatriptan (Maxalt), Zolmitriptan (Zomig), Naratriptan (Amerge), Almotriptan (Axert), Frovatriptan (Frova), eletriptan (Relpax)

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Triptan drug with fastest onset

Sumatriptan (Imitrex), injectable

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Triptan drug given nasal spray

Sumatriptan (Imitrex),, Zolmitriptan (Zomig)

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Triptan given orally disintegrating tabs

Rizatriptan (Maxalt), Zolmitriptan (Zomig)

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Triptan with best tolerability and duration

Naratriptan (Amerge), Frovatriptan (Frova)

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Ergot derivatives

Ergotamine and dihydroergotamine, most affective at first sign of a migraine, all are sedating

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Ergot derivatives MOA

high affinity for serotonin 1 receptors, also interact with alpha adrenergic, dopaminergic, and serotonin 3 receptors

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Ergot derivatives ADRs

Severe sx, nonoral route preferred, N/V/D, vasoconstriction of systemic and coronary arteries

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Ergot derivatives FDA Boxed warning

risk of stroke and/or gangrene when taken with certain antibiotics, antiviral and antifungal drugs

37

Antiemetics

Chlorpromazine (Thorazine), Metoclopramide (Reglan), Prochlorperazine (Compazine)

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symptomatic migraine medication

acetaminophen, caffeine, isometheptene (Prodrin), Acetaminophen, isometheptene, dichloralphenazone (Midrin)

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Isometheptene

a sympatomimetic, vasoconstrictor

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Dichloralphenazone

a sedative, prodrug converted to chloral hydrate

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NSAIDs drugs

naproxen, ibuprofen, aspirin

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NSAIDs pearls

beneficial in menstrual migraines, use for pt with infrequent, mild-moderate severity migraines

43

Rescue medication

Opioids, APAP w/ codeine/hydrocodone or butorphanol, meperidine and tramadol; risk of dependency

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Prophylactic treatment

BB, CCBs, anticonvulsants

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Indication for prophylaxis

rule of 2s, HA >2 days per week or 2-4 x per month, use of acute tx >2 days/week, use of rescue > 2 x/month

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Approved prophylactic drugs

propranolol, topiramate, divalproex sodium, botulinum toxin A, also TCA (amitriptyline, nortriptyline), verapamil, gabapentin

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BB for prophylaxis

first line for prevention, chronic daily HA, modulate vascular tone, also anti HTN, contraindicated in asthma and COPD, propranolol, Atenolol, metoprolol

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Anticonvulsants drugs

topiramate (Topamax), Gabapentin (Neurontin), Divalproic acid (Depakote, Depakote ER)

49

Topiramate (Topamax)

blocks Na channels, potentiates GABA activity, dose titrate to response, risk of kidney stones, ADRs: somnolence, wt loss, psychomotor slowing, tingling in extremities, difficulty concentrating, avoid in preg

50

Gabapentin (Neurontin)

possibly effective, beneficial in pt with neuralgia

51

Divalproic acid (Depakote)

reduces frequency, not severity, reduces excitatory amino acids, increases GABA activity, nausea, weakness, somnolence, wt gain, hair loss, liver toxicity, avoid pregnancy

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Botulinum toxin A (Botox)

Neurotoxin, muscle relaxant, anti-spasmotic, small doses injected in to neck every 3 months, starts working in 1 month, $$$$, droopy eyelid, anaphylactic rxn

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TCA drugs

amitriptyline (Elavil), Nortriptyline (Pamelor)

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TCA MOA, ADR, cautions

inhibition of peripheral sensitization, 5HT2 antagonism, increase GABA, sedation, anticholinergic, wt gain, glaucoma, urinary retention, no use in suicidal pts

55

CCB

verapamil, nifedipine, MOA unknown, nifedipine may worsen HA, CT in pt with CHF, hypotension, arrhythmias