Therapeutics - Migrain Part 2

Question 1

which 2 beta blockers are actually indicated for migraine prophylaxis

Answer 1

propranolol

timolol

(others are used off label)

Question 2

true or false

the dose of b blockers is the same for HTN as it is for migraine prophylaxis

Answer 2

FALSE - different

Question 3

beta blockers mask ______

Answer 3

hypoglycemia

use with caution in diabetics

Question 4

name 3 potential antiepileptics for migraine prophyalxis

Answer 4

valproate
divalproex
topiramate

Question 5

true or false

all 3 FDA indicated antiepileptics for migraine prophyalxis are teratogenic

Answer 5

TRUE

if the patient is pregnant, USE BETA BLOCKERS INSTEAD

Question 6

side effects of valproic acid/divalproex

Answer 6

nausea and vomiting

weight gain, alopecia, weight gain, somnolence

Question 7

which formulation of divalproex sodium is best to use and why

Answer 7

ER divalproex sodium – QD and is better tolerated than the enteric coating

Question 8

valproate’s most serious side effect

Answer 8

hepatotoxicity - monitor LFT!

Question 9

true or false

valproate is CI in pregnancy

Answer 9

true

Question 10

valproate is contraindicated in pregnancy

what are some of its other contraindications?

Answer 10

history of pancreatitis or chronic liver disease

Question 11

true or false

valproic acid and divalproex sodium are interchangeable

Answer 11

FALSE - not. there’s a conversion process

Question 12

most extensively studied med for migraine prophylaxis

Answer 12

topiramate

Question 13

**patient is a candidate for migraine prophylaxis and epileptics would be best to use

which particular med?

Answer 13

topiramate!!!! better than valproic acid in this case. AE of topiramate is weight loss (desirable)

Question 14

which particular antidepressants are used in migraine prophylaxis

Answer 14

TCA (tricyclics) and SNRI (venlafaxine)

not SSRI!

Question 15

true or false

the beneficial effects of antidepressants in migraine are INDEPENDENT of their antidepressant activity

Answer 15

TRUE

Question 16

TCA common side effects

thus patients with what 2 disease states shouldnt really get it?

Answer 16

anticholinergic side effects

BPH and glaucoma

Question 17

true or false

the doses used for depression are the same doses used for migraine prophylaxis

Answer 17

false - for migraine prophylaxis they’re used at lower doses

Question 18

triptans are useful for prevention?

Answer 18

YES - menstrual migraine specifically

Question 19

which specific triptans are effective as migraine prophyalxis

Answer 19

frovatriptan is the only one indicated, but naratriptan and zolmitriptan are effective too

Question 20

patient is taking frovatriptan for menstrual migraine prevention

explain to them when they should take it

Answer 20

1-2 days before period, and then throughout the duration of the period. up to 5 days!

Question 21

patient is taking NSAID for migraine prophyalxis

explain to them when they should take it

Answer 21

1 WEEK before the expected onset, and continue no more than 10 days!

Question 22

5 miscellaneous migraine agents

Answer 22

magnesium
riboflavin
petasites
boutlinum toxin (not effective)
coq10

Question 23

magnesium is a potential agent for migraine. it is probably most helpful in which type?

Answer 23

with aura

menstrual migraine

Question 24

true or false

migraines in pregnant women, though uncomfortable, are not a clinical concern

Answer 24

FALSE - they are. increased risk of preeclampsia

Question 25

3 migraine options in pregnancy

Answer 25

acetaminophen ibuprofen (avoid in 3rd trimester!) triptans (sumatriptan preferred)

Question 26

true or false ibuprofen can be used for migraine throughout the entire pregnancy

Answer 26

false - only can be used in 1st and 2nd trimesters. avoid in 3rd

Question 27

name 2 pain meds that should be avoided in pregnant patients who have migraine

Answer 27

aspirin or opiates

Question 28

which antiemetic should always be avoided in pregnancy

Answer 28

metoclopramide

Question 29

2 antiemetics that CAN be used in pregnancy

Answer 29

ondansetron and prochlorperazine

Question 30

if a pregnant patient needs migraine prophylaxis, what should you use

Answer 30

beta blockers

Question 31

medication overuse headaches can be caused by: taking simple analgesics for how long? migraine-specific, opioid, or combo meds for how long?

Answer 31

simple analgesics - for 15 days/month for 3 or more months migraine-specific, opioids, or combo meds - 10 days/month for 3 or more months

Question 32

true or false it is possible that medication overuse can reduce the efficacy of acute and prophylactic migraine treatment

Answer 32

true

Question 33

consideration when fixing a patient's medication overuse headache include some counseling points

Answer 33

GRADUALLY taper them off the med either inpatient or outpatient depending on the severity tell pt the headaches may worsen at first, but will gradually improve

Question 34

most common type of primary headache

Answer 34

tension headache

Question 35

when is a tension headache considered chronic

Answer 35

if had for over 15 days/month

Question 36

do patients get aura from a tension headache

Answer 36

no

Question 37

________ are the mainstay of acute therapy for tension headache

Answer 37

simple analgesics

Question 38

nonpharm tension headache treatment

Answer 38

massage, hot baths, relaxation physical therapy, accupuncture

Question 39

as mentioned, simple analgesics are the main treatment for tension headache explain how long they can be used

Answer 39

if combo analgesic - no more than 9 days if using an NSAID - no more than 15 days ( dont want med overuse headache!)

Question 40

patient has chronic tension headache (over 15 days/months). what can be given

Answer 40

amitryptiline QD limited studies on other stuff

Question 41

what is the most SEVERE of the primary headaches

Answer 41

cluster headache

Question 42

is aura present in cluster headaches?

Answer 42

no

Question 44

abortive therapy treatment regimen for cluster headache

Answer 44

#1 treatment is oxygen - have to go somewhere for it. at least 12-15L/min. effects start 10-20 mins after treatment if O2 isn’t available, triptans are next step than ergots

Question 45

triptans are the second choice for cluster headache explain the specifics of this

Answer 45

subq and intranasal triptans only’ oral triptans have limited use in cluster

Question 47

explain the role of ergotamines as abortive treatment for cluster headaches

Answer 47

sublingual provides relief IV may be given as bolus and then repeated administration over several days to break the cycle of attacks

Question 49

preferred first line prophylaxis for cluster when do benefits appear?

Answer 49

verapamil benefits appear within 2-3 week of therapy

Question 50

what is the more 2nf like prophylactic option for cluster headache

Answer 50

lithium

Question 51

when using lithium for cluster prophylaxis, what should the lithium levels be

Answer 51

between 0.4-1.2 meq/L

Question 52

lithium side effects

Answer 52

tremor thyroid and renal dysfunction

Question 53

name 2 transitional prophyalctic agents for cluster headaches

Answer 53

corticosteroids occipital nerve blocks ie - buy time before the verapamil starts to work