Anti-Migraine - Goldstein

Front 1

Prodromal phase of migraine attack

Back 1

Cerebral vasoconstriction

Front 2

Headache phase of migraine attack

Back 2

Abnormal dilation of cranial arterioles

Front 3

Classic migraine =

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Migraine with aura

Front 4

Common migraine =

Back 4

Migraine without aura

Front 5

90% of migraine cases begin before age __

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40

Front 6

Avoid migraine by avoiding vasodilating substances such as (2)

Back 6

- Alcohol
- Tyramine

Front 7

Avoid migraine with these 3 lifestyle factors

Back 7

- Proper diet
- Exercise
- Adequate sleep

Front 8

Nonpharmacological ways to tx migraine (4)

Back 8

- Psychotherapy
- Biofeedback
- Physical Therapy
- OMT

Front 9

Acute abortive agents for migraine can be used a max of _____

Back 9

2-3 days/wk

Front 10

More frequent use of acute abortive anti-migraine agents can cause _____-

Back 10

Rebound headache

Front 11

Rebound headache occurs when acute anti-migraine meds are taken to frequently and includes

Back 11

- Head pain becomes constant even with meds

Front 12

If discontinue acute anti-migraine meds, ______ will disappear

Back 12

Rebound headaches

Front 13

A headache that reappears after a pt had obtained significant relief from an abortive agent
- Recurrence occurs within timeframe of migraine attack

Back 13

Recurrent headache

Front 14

Can produce more incapacitation than actual migraine

Back 14

N/V

Front 15

_______ can reduce absorption of antimigraine and antiemetic meds given PO

Back 15

Vomitting

Front 16

Oral meds can be unaffective due to ________ assoc with migraine

Back 16

Decreased GI motility

Front 17

Increased GI motility and thus helps increase the efficacy of acute anti-migraine meds

Back 17

Metoclopramide

Front 18

Rectal, nasal, IM, SC used to tx migraines that are (2)

Back 18

- At max intensity for 60mins or less
- Associated with severe N/V

Front 19

Acute abortive med effective in relieving pain of some attacks

Back 19

Acetaminophen

Front 20

Acute abortive
- Helpful for mild-moderate attacks --> esp if inflm invovled
- ADR incidence is high

Back 20

NSAIDs

Front 21

Acute abortive NSAID
- Can be used alone or with caffeine/butalbital

Back 21

Acetylsalicylic acid (ASA)

Front 22

Acute abortive NSAID
- Inactivates platelets so can't give 7 days before surgery

Back 22

Acetylsalicylic acid (ASA)

Front 23

Acute abortive NSAID
- Has about same efficacy as ergotamine tartrate

Back 23

Naproxen

Front 24

3 more NSAIDs besides ASA and Naproxen

Back 24

- Ibuprofen
- Ketoprofen
- Piroprofen

Front 25

Acute abortive opioid
- Rapid onset --> used in ER

Back 25

Butorphanol

Front 26

2 kinds of acute abortive serotonin agonists

Back 26

- Ergot derivatives
- 5HT1D/5HT1B Agonists

Front 27

Ergot derivatives are agonists at all _____ R's (2)

Back 27

- 5HT1
- 5HT2

Front 28

Probably won't prescribe ergot derivatives --> cause ______ to dec pain

Back 28

Vasoconstriction

Front 29

Ergot derivatives can induce _________ --> causes myocardial or peripheral ischemia

Back 29

Vasospasm

Front 30

Ergot derivatives contraindications (3)

Back 30

- severe CAD
- Peripheral vascular dz
--> Reynaud's
--> Uncontrolled HTN

Front 31

Cause fibrotic complications --> scar tissue in lungs, heart or GIT

Back 31

Ergot Derivatives

Front 32

Ergot derivative
- Not an analgesic --> but decs pain from serotonin effects
- Widely used - esp after analgesic fail
- Mot effective if taken early in attack

Back 32

Ergotamide tartrate

Front 33

Ergot derivative for acute migraine
- Not effective for tension headache

Back 33

Ergotamide tartrate

Front 34

Ergotamide tartrate has high incidence of ADRs (2)

Back 34

- N/V (prevent w/ antimetic)
- Drowsiness (so have to limit use at work)

Front 35

Overuse of ergotamide for acute migraine can cause (2)

Back 35

- Rebound H/A
- 'ergotamide h/a'

Front 36

Has a poor benefit/risk ratio --> there are better drugs for acute migraine

Back 36

Ergotamide

Front 37

Severe ADRs of Ergotamide (aka 'ergotism')

Back 37

- Vascular occlusion
- Gangrene

Front 38

Ergotamide vascular occlusion and gangrene occurs with OD or concomittant use with (3)

Back 38

- Beta blocker
- Erythromycin
- Troleandomycin

Front 39

- Derivative of ergotamine
- Available SC, IM, IV or nasal sprary

Back 39

Dihydroergotamine

Front 40

For acute migraine
- Less vasoconstrictive than ergotamine --> less likely to cause HTN

Back 40

Dihydroergotamine

Front 41

Causes less N/V and HTN than ergotamine

Back 41

Dihydroergotamine

Front 42

For acute migraine
- Little or no risk of rebound h/a
- ADRs - diarrhea + muscle cramps

Back 42

Dihydroergotamine

Front 43

Dihydroergotamine ADRs

Back 43

- Diarrhea
- Muscle cramps

Front 44

5HT1D/5HT1B agonists = aka

Back 44

Triptans

Front 45

Show best results to tx acute migraine
- Safer b/c more targetd action

Back 45

5HT1D / 5HT1B Agonists

Front 46

Category of acute migraine tx'ers
- Largely biotransformed (so dec availablity if PO)

Back 46

5HT1D / 5HT1B agonists

Front 47

Triptan sensations
(prob not cardiac in origin) (4)

Back 47

- Hot/Cold/Pressure
- Heavy/Tight chest
- Tingling and numbness
- Anxiety

Front 48

Used only when clear dx of migraine has been made

Back 48

5HT1D / 5HT1B agonists

Front 49

5 HT1D / 5HT1B agonists can not be used (3)

Back 49

Unrecognized CAD --> esp in:
- Postmenopausal F
- M > 40 yrs
- Pts with risk factors for CAD (HTN, high chol, obesity, DM, fam hx)

Front 50

5HT1D / 5HT1B agonists contraindications (5)

Back 50

- Uncontrolled HTN
- CAD
- Peripheral vasc dz
- Use of other 5HT1 agonists
- Ergotamine or a derivative of in past 24 hrs

Front 51

5HT1D/5HT1B agonist
- Parenteral, tablets or nasal sprary

Back 51

Sumatriptan

Front 52

5HT1D/5HT1B agonist
- Lowest bioavailability of triptans
- study = reduced headache 70% vs 22% placebo

Back 52

Sumatriptan

Front 53

Sumatriptan much more effective at decreasing a severe h/a but ______

Back 53

More likely to have recurrent sx's within 24 hrs

Front 54

ADRs for = 50% vs 33% placebo

Back 54

Sumatriptan

Front 55

5HT1D/5HT1B agonists (7)

Back 55

- Sumatriptan
- Naratriptan
- Rizatriptan
- Almotriptan
- Eletriptan
- Frovatriptan
- Zolmitriptan

Front 56

Prophylactic anti-migraine agents are given ______ even in absence of attacks

Back 56

Daily

Front 57

Realistic goal of prophylactic migraine therapy

Back 57

50% reduction in frequency

Front 58

Preventative agents cause a satisfactory response in ____% of pts

Back 58

60%

Front 59

Clinical trials do not show significant differences in meds used for ____

Back 59

Migraine prophylaxis

Front 60

DOC for migraine prevention

Back 60

Beta blockers

Front 61

3 Beta blockers used to tx migraine

Back 61

- Propanolol
- Metoprolol
- Timolol

Front 62

Migraine prevention
- Do not dec aura
- Caution in pts with DM b/c may mask hypoglycemia

Back 62

Beta blockers

Front 63

Beta blockers ADRs (3)

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- Fatigue
- Depression
- Hypotension

Front 64

Beta blockers contraindicated in (2)

Back 64

- Asthma
- CHF

Front 65

Preventative meds that help if there is a depression element involved

Back 65

Tricyclic Antidepressants

Front 66

TCAs used to prevent migraine (2)

Back 66

- Amytriptyline
- Nortriptyline

Front 67

TCA used to prevent migraine
- 80% improvement in 60% of pts with severe disabiling h/a's

Back 67

Amitryptiline

Front 68

TCA
- Less ADRs than amitryptiline
--> may also be as effective

Back 68

Nortriptyline

Front 69

- Not proven effective for migraine prevention
- Also interact with MAO inhibitors --> limits use

Back 69

SSRIs

Front 70

SSRI to prevent migraine (not proven effective) (3)

Back 70

- Fluoxetine
- Paroxetine
- Venlafaxine

Front 71

Have + and - results in treating migraine (3)

Back 71

Calcium channel blockers
- Verapamil
- Diltiazam
- Nifedipine

Front 72

Commonly used to prevent migraine but there is no clinical evidence to support it

Back 72

Opioids

Front 73

May dec migraine by dec'ing electrical activity --> takes care of neuronal excitability component

Back 73

Anticonvulsants

Front 74

Anticonvulsants used to prevent migraine (3)

Back 74

- Gabapentin
- Divalproex
- Topiramate

Front 75

Anticonvulsant recently FDA approved to prevent migraine in adults
- Most common ADR = tingling in extremities

Back 75

Topiramate

Front 76

NSAID used to prevent migraine

Back 76

Naproxen

Front 77

Alpha-2 adrenergic agonist used to prevent migraine

Back 77

Clonidine

Front 78

Migraine pathway (7)

Back 78

Originates deep in brain --> electrical impulse spread --> change in nerve activity and BF --> visual probs, numbness, dizziness, tingling --> BV dilation and inflm --> irritates CN5 --> severe throbbing pain

Front 79

Serotonin syndrome can occur when combining these two antimigraine meds

Back 79

- SSRIs
- Triptans

Front 80

____ may decrease need for anti-migraine meds

Back 80

OMT