Therapeutics - Migraine Flashcards by amanda kastel

one of the most important nonpharm counseling points for a migraine patient

keep a food diary!!!!!!! can help to prevent

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patient presents with a migraine

they have HBP, or have recently had a stroke.

is it acceptable to just give advil

need to refer to dr
may be due to underlying cause

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migraines are becoming increasingly more prevalent in what age range

children and adolescents

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differentiate between primary and secondary headache in terms of any structural or metabolic abnormalities

primary - no structural or metabolic abnormalities

secondary - there IS structural or metabolic abnormalities

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which type of headache is due to a medical condition

secondary

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name the 3 types of primary headache

migraine
tension
cluster

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what’s the only type of primary headache that is bilateral

tension

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does the patient tend to remain active if they have a primary headache?

depends

yes for cluster and tension

no for migraine

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which type of primary headache is more common in males and smokers

cluster

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true or false

migraines are commonly misdiagnosed

true

commonly they are mistakenly diagnosed as sinus headaches or tension headaches

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true or false

migraines do not cause a huge economic burden

FALSE - they do

for treatment (direct) and indirect by missing work days

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name 3 GENERAL triggers of migraine

food
environmental
behavioral

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name some foods that can trigger migraine

caffeine
alcohol
aspartame

tyramine-containing foods
nitrate-containing (processed meat)

monosodium glutamate (chinese food)

chocolate

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when women have menstruation-related migraines, when do they typically start

around 2 days prior to menstruation (and lasts throughout)

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true or false

migraine with aura is more common than migraine without aura

FALSE - migraine without aura is more common

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which tends to be more DISABLING – migraine with aura or without aura

without aura

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when counseling a patient when to take their abortive/acute migraine therapy, what should you say

if they get migraines with aura – TAKE RIGHT WHEN THE AURA STARTS!!!!!!! med takes time to work

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name 3 types of aura

visual
sensory (unilateral numbness in arms or face)
speech disturbance

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what are the 3 phases of migraine attacks and how long do they last

prodrome
headache
postdrome

prodrome is hours-days BEFORE the actual headache

headache -lasts up to 72 hours

postdrome - lasts up to 48 hours

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what may a patient experience in the prodrome phase of migraine

nonpainful symptoms like fatigue, mood changes, food cravings, difficulty concentration, etc

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2 types of pharmacologic treatment for migraine

abortive/acute

preventative

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*true or false

as long as a patient gets migraines, they are a candidate for prophylaxis

FALSE - there are specific criteria

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name some nonpharm therapies for migraine

ice packs to head (to vasoconstrict)

rest
avoid triggers!

keep a headache diary of the frequency, severity, and duration

relaxation therapy

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true or false

a good counseling point for a migraine patient is to exercise to help with the pain – like go to the gym

FALSE - something like yoga - not the gym

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patient has migraines that are associated with severe nausea and vomiting what pharm treatment is good

pretreat with an antiemetic may not be able to use oral therapies - consider sppository/parenteral/intranasal

patient has a migraine with MILD-MODERATE symptoms explain the treatment regimen

1. start with a simple analgesic like NSAIDS, tylenol 2. if insufficient response, do a combo analgesic like tylenol/aspirin/caffeine 3. if still insufficient response, can do triptans or the ergots. however, we typically start with triptans bc less side effects 4. if STILL inadequate response, combo, rescue therapy (potentially add ergotamine to a triptan)

patient has migraines with SEVERE symptoms explain the treatment regimen

immediately start with either triptan or ergot (typically triptan) if insufficient response on one, combo therapy/rescue therapy

abortive drug therapies for migraine are most effective when given when?

within the 1st hour of onset of the migraine shortens the duration and severity of the migraine

differentiate between when non-specific agents are used vs migraine-specific agents

nonspecific - used for mild-moderate migraine-specific - used for moderate-severe

can ODT be used if the patient is nauseas

YES

in what medical condition should the oral route not be used for migraine treatment and why

gastroparesis (delayed gastric emptying) will reduce absorption of the drug and patient won't get relief - use other route

1st line nonspecific treatment for mild-moderate migraine pain

nonspecific abortive therapies analgesics, NSAIDS

onset dose of tylenol for migraine

1000mg (2 xs tabs)

which nonspecific agent for migraines has little evidence as being effective as monotherapy, and therefore, it's often not used alone for migraine

acetaminophen

a patient asks if there is a specific NSAID she should get for migraine what do you say

really no difference -- all equally effective

2 systems that NSAIDS negatively affect and thus the duration of use for them is limited

GI CNS (somnolence, dizziness)

true or false if a patient doesn't respond to 1 triptan, it is pointless to try a different one

FALSE can try a different one - varying responses

imitrex

sumatriptan

zomig

zolmitriptan

maxalt

rizatriptan

axert

almotriptan

relpax

eletriptan

naramig

naratriptan

frova

frovatriptan

what 2 dosage forms does zolmitriptan come in

oral tabs nasal spray

what dosage forms does sumatriptan come in

a lot injection tabs nasal spray/powder

what dosage forms does rizatriptan come in

regular oral tabs and ODT

2 classes of drugs that are a DDI concern with triptans, and explain the interactions

SSRIs/SNRIs -- serotonin syndrome with triptans ergots - prolonged vasospastic reaction. avoid within 24 hours of each other!!!

triptans contraindication

in uncontrolled BP or CAD!! serious CV events and death due to vasospasm (rare)

pretty common SE of triptans and is this a concern

chest pain or pressure usually not serious and not due to ischemia

true or false ergot alkaloids are nonselective 5HTa1 agonists

TRUE so they basically vasoconstrict everywhere

ergot alkaloid contraindications

LOT OF THEM CAD within 2 weeks of MAO inhibitors pregnancy/nursing renal or hepatic failure uncontrolled HTN with CYP3A4 inhibitors

ergot alkaloids are considered 2nd line agents name 3 scenarios their use is appropriate

-when triptans are ineffective or intolerable -when there is a high risk of recurrence -migraines that last over 48 hours

which ergot alkaloid is more nauseating than the other

ergotamine (with or without caffeine) is more nauseating than dihydroergotamine

why is it important to follow the dose limits for ergot alkaloids

medication overuse headache

which is a more potent vasoconstricor - ergotamine or dihydroergotamine

ergotamine is a more potent vasoconstrictor

how does lasmiditan work

selective 5HT1F serotonin receptor agonist decreases stimulation of the trigemino vascular system

TRUE OR FALSE unlike triptans, lasmiditan does NOT cause undesirable vasoconstriction

true due to selectivity for the 5HT1F serotonin receptor

is lasmiditan a controlled substance

yes - schedule 5

lasmiditan is generally reserved for which patients

who have failed/cannot use NSAIDS or triptans

with triptans, the patient can repeat the dose in 2 hours if their symptoms still persist is this the case for the ditans? (lasmiditan)

NO NO MORE THAN 1 DOSE IN 24 HOURS

brand name lasmiditan

reyvow

AE of lasmiditan

driving impairment CNS depression - dizziness and sedation

CGRP agonists or antagonists are used for migraine

antagonists CGRP is high in migraines, contributing to pain

why are cgrp antagonists not really used, being that they're effective

access and cost

how to recognize the CGRP antagonists that aren't mabs

"pant"

****which cgrp antagonists are indicated for acute treatment?

ONLY rimegepant and ubrogepant (nurtec and ubrelvy) the mabs + qulipta (atogepant) are for prevention!!!!!

5 antiemetics that can be used for migraine patients

promethazine prochlorperazine metoclopramide trimethobenzamide ondansetron

which antiemetic is commonly used as pretreatment before IV dihydroergotamine

reglan (metoclopramide)

explain the method to know if a patient needs a change in their abortive migraine treatment

if they answer "no" to 1 or more of these questions: does your med work for most attacks? does the headache dissapear within 2 hours? are you able to function normally within 2 hours? are you comfortable enough with your med to be able to plan your daily activities? HOWEVER, before changing, we HAVE TO ASSESS THEIR ADHERENCE AND DOSE!!!!!

***Explain when a patient would be a candidate for migraine prophylaxis

-4 or more attacks/month or 8 or more headache days/month -failure/CI/SE of abortive meds -pt preference -impacts pt's daily life despite proper lifestyle management and acute treatment -menstrual migraine

*true or false a woman who gets menstrual migraines is a candidate for prophylaxis

true

when giving prophylaxis for migraines, it's important to give the patient realistic expectations what does this mean

THIS IS NOT A CURE just meant to decrease the frequency and intensity you still most likely will get them

when counseling a pt getting migraine prophylaxis for the 1st time, how long to tell them for it to work?

up to a month and a half to start working

when giving migraine prophylaxis, the treatment should be maintained for t least how long? when can we try to withdraw the drug?

maintain for at least 3 months after 6-12 months, try to withdraw the drug SLOWLY

what dose should migraine prophylaxis be started on

LOW DOSE and increase slowly until therapeutic effects develop, max dose is reached, or AE becomes intolerable

**patient's headaches recur in a predictable pattern - like menstrual migraine. what prophylactic agent should be tried 1st? what if this is ineffective

NSAID OR TRIPTAN then try B blocker (or verapamil if CI or ineffective) then tricyclic antidepressant then anticonvulsant then combo therapy and consult specialist

**patient meets the criteria for migraine prophylaxis. they are healthy OR have comorbid angina what agent should be tried first? explain algorithm

1st - beta blocker or verapamil if b blocker is CI or ineffective -then TCA -then anticonvulsant -then consider combo therapy and see specialist

**pt is a candidate for migrain prophylaxis and has comorbid depression or insomnia what agent should be tried first? explain the algortihm

tricyclic antidepressant first then anticonvulsant then consider combo therapy

*pt is a candidate for migraine prophylaxis and has comorbid seizure or bipolar disorder what agent should be tried first? explain algorithm

anticonvulsant if ineffective, try b blocker/verapamil then consider combo therapy

Therapeutics - Migraine Flashcards

(81 cards)