Bipolar Disorder & Headaches

Front 1

Bipolar Disorder

Back 1

manic-depressive disorder is a brain disorder that is responsible for erratic changes in:
1. energy level
2. temperament
3. Mood
4. Thought Process
5. Ability to function

Front 2

Bipolar 1 Disorder

Back 2

manic or mixed episodes, major depressive episodes are typical but not required

Front 3

Bipolar 2 Disorder

Back 3

1 or more episodes of hypomania and a history of depressive episodes

Front 4

Cyclothymic Disorder

Back 4

for at least 2 years, with no symptom-free period of greater than 2 months, presence of numerous episodes of hypomania and depressive symptoms

Front 5

Bipolar disorder NOS

Back 5

manic symptoms present but the patient doesn't meet the criteria for the other types

Front 6

POSSIBLE causes of bipolar disorder

Back 6

1. genetics
2. physiologic (triggers)
3. environmental (triggers)
4. Medical (hyper/hypothyroidism, CNS disorders, infections)
5. Medications (alcohol, antidepressants, steroids, etc)

Front 7

how is diagnosis of bipolar disorder done

Back 7

1. "who's your daddy?" = family history
2. "where's your mama? = additional history from family and friends

Front 8

DSM-IV-TR diagnostic criteria for Major Depressive disorder

Back 8

5+ of following symptoms present nearly every day for >2weeks
1. depressed, sad mood
2. decreased interest and weight loss
3. insomnia and psychomotor retardation
4. fatigue, feelings of guilt, suicidal thoughts

Front 9

DSM-IV-TR diagnostic criteria for Manic Episodes

Back 9

3+ of the following with >1week period of abnormally and persistently elevated, expansive or irritable mood
1. inflated self-esteem
2. decreased need for sleep
3. pressured speech
4. flight of ideas
5. increase in goal-directed activity
6. excessive involvement in pleasurable activities

Front 10

DSM-IV-TR diagnostic criteria for Hypomanic Episodes

Back 10

4 days of elevated, expansive or irritable mood to a lesser degree than Manic
1. inflated self-esteem
2. decreased need for sleep
3. flight of ideas
4. pressured speech
5. increase in goal-directed activity
6. excessive involvement in pleasurable activities

Front 11

DSM-IV-TR diagnostic criteria for Mixed Episodes

Back 11

criteria met for both manic and depressive episodes nearly every day during a one week time frame

Front 12

DSM-IV-TR diagnostic criteria for Rapid Cycling

Back 12

>4 major depressive or manic episodes in 12 months

Front 13

Mood Stabilizing agents used for Bipolar Disorder

Back 13

1. Lithium
2. Anticonvulsants

Front 14

Miscellaneous Agents used for Bipolar Disorder

Back 14

1. Antipsychotics
2. Antidepressants

Front 15

FDA indication for Lithium(Eskalith, Eskalith CR, Lithobid)

Back 15

Mania associated with bipolar disorder

Front 16

usual dosing for Lithium for bipolar disorder

Back 16

900-2400mg/day in 3-4 divided doses OR 900-1800mg/day every 12 hours

Front 17

how often is serum monitoring done for lithium?

Back 17

every 4-5 days during initial therapy then twice a week until stable, then every 1-3 months

Front 18

serum levels of lithium for acute mania

Back 18

0.6 - 1.2mEq/L (~1mEq/L)

Front 19

serum levels of lithium for maintenance

Back 19

0.8-1mEq/L (~1mEq/L)

Front 20

serum levels of lithium for the elderly

Back 20

0.6-0.8mEq/L

Front 21

laboratory monitoring parameters for lithium

Back 21

1. thyroid function tests(TSH, T4, T3)
2. renal function test(BUN, SCr, urinalysis)
3. CBC and electrolytes
4. weight
5. EKG
6. pregnancy test (women)

Front 22

ADRs of Lithium

Back 22

1. GI problems
2. fatigue
3. weight gain
4. polyuria/polydipsia
5. hypothyroidism
6. tremor (treat with propranolol)

Front 23

drugs that alter renal blood flow of sodium excretion can increase lithium levels

Back 23

1. NSAIDS
2. ACE inhibitors/ ARBS
3. Diuretics

Front 24

drugs that decrease lithium levels

Back 24

1. Caffeine
2. Theophyline

Front 25

What pregnancy category are all drugs that treat Bipolar Disorder except SGAs?

Back 25

Pregnancy Category D

Front 26

Anticonvulsants used for the treatment of Bipolar Disorder

Back 26

1. Valproate(Depakote)
2. Carbamazepine(Carbatrol, Tegretol, Equetro)

Front 27

FDA indication for Valproate

Back 27

mania associated with bipolar

Front 28

Initial Dose of Valproate for Bipolar Disorder? Maximum?

Back 28

Initial Dose: 500-750mg/day in divided doses
Maximum Dose: 60mg/kg/day

Front 29

how often should serum monitoring be done for Valproate

Back 29

monthly for the first 3 months of therapy and then every 6-12months

Front 30

what is the toxic serum level of valproate

Back 30

200mcg/ml

Front 31

Laboratory Monitoring Parameters for Valproate

Back 31

1. Chem Profile
2. liver function test (LFTs)
3. CBC
4. weight
5. pregnancy test (women)

Front 32

ADRs for Valproate

Back 32

1. CNS - somnolence, dizziness
2. GI: nausea, vomit, diarrhea
3. tremor
4. mild thrombocytopenia
5. weight gain
6. Alopecia

Front 33

2 possible Black Box Warnings for Valproate

Back 33

1. Rare Hepatoxicity
2. Pancreatitis

Front 34

Major Drug Interaction with Valproate

Back 34

Lamotrigine - decreases levels of drug, and the drug increases levels of lamotrigine

Front 35

FDA indication of Carbamazepine (Carbatrol, Tegretol, Equetro)

Back 35

acute manic and mixed episodes associated with bipolar 1 disorder

Front 36

Dosing for Carbamazepine for Bipolar Disorder

Back 36

initial dose is 200mg BID and can be increased in 200mg increments based on symptoms

Front 37

Important pharmacokinetics of Carbamazepine

Back 37

1. induces hepatic microsomal P450 enzymes(1A2 and 3A4)
2. Autoinduction - clearance doubles with chronic therapy

Front 38

Laboratory Monitoring Parameters for Carbamazepine

Back 38

1. CBC
2. Electrolytes
3. LFTs
4. Pregnancy test
5. EKG if older than 45

Front 39

ADRs for Carbamazepine

Back 39

1. CNS - dizziness, drowsiness, fatigue, ataxia, blurry vision
2. GI effects - nausea, vomiting, diarrhea
3. Leukopenia - CBC monitored and medication stopped if WBC <3000/mm3
4. Hepatoxicity
5. Hyponatremia and SIADH

Front 40

Black Box Warning for Carbamazepine

Back 40

Agranulocytosis and aplastic anemia

Front 41

Drug interactions with Carbamazepine

Back 41

1. drugs that are CYP 3A4 inhibitors and increase concentrations
2. Valproic Acid
3. Lithium

Front 42

Other Anticonvulsants used to treat Bipolar Disorder

Back 42

1. Oxcarbazepine
2. Lamotrigine
3. Topiramate

Front 43

SGAs used to treat Bipolar Disorder

Back 43

1. Risperidone (Risperdal)
2. Risperidone Consta
3. Olanzapine (Zyprexa)
4. Quetiapine (Seroquel)
5. Ziprasidone (Geodon)
6. Aripiprazole (Abilify)
7. Asenapine (Saphris)

Front 44

When should an antidepressant be used for bipolar disorder

Back 44

when patient's primary medication dosing has decreased or eliminated symptoms of mania or hypomania

Front 45

Types of Antidepressants used in combination for the treatment of Bipolar disorder

Back 45

1. SSRIs
2. MAOIs
3. TCAs

Front 46

Benzodiazepines that are preferred agents and maybe useful as adjunctive treatment for acute mania

Back 46

Lorazepam and clonazepam

Front 47

Treatment Guidelines for Acute Mania (Severe Manic or Mixed Episodes)

Back 47

1. Lithium + antipsychotic OR
2. Valproate + antipsychotic

Front 48

Treatment guidelines for Acute Mania (Less Manic)

Back 48

1. Lithium monotherapy OR
2. Valproate monotherapy OR
3. antipsychotic (Olanzapine and Risperadone)

Front 49

If patient fails 1st line medication then what can be added

Back 49

1. carbamazepine or oxcarbazepine OR
2. antipsychotic

Front 50

Treatment Guidelines for Depressive Episodes

Back 50

1. Lithium OR
2. Lamotrigine OR
3. Divalproex

Front 51

when should antidepressants be used for depressive episodes

Back 51

in severe depression

Front 52

What are the preferred antidepressants for depressive episodes

Back 52

1. Venlafaxine
2. Bupropion
3. SSRIs

Front 53

If 1st line treatments fail for depressive episodes

Back 53

1. add Lamotrigine OR
2. bupropion OR
3. Paroxetine

Front 54

Treatment Guidelines for Maintenance Treatment for Bipolar disorder

Back 54

1. Lithium
2. Valproate
3. Alternatives (Lamotrigine or Carbamazepine or Oxcarbazepine)
4. Antipsychotics

Front 55

Treatment Guidelines for Rapid Cycling Bipolar Disorder

Back 55

1. Lithium
2. Valproate

Front 56

What is the 1st line medication for Rapid Cycling Bipolar disorder

Back 56

Valproate

Front 57

Tips for patients with Bipolar Disorder

Back 57

1. seek treatment when episodes are first noticed
2. avoid drug/alcohol abuse
3. regular sleep patterns
4. take all meds and stay on them
5. seek advice prior to OTC meds
6. establish a support system

Front 58

How is pregnancy regarded in terms of Bipolar disorder

Back 58

1. Pre-conception Counseling
2. only get pregnant when stable
3. use an SGA instead (pregnancy category C)

Front 59

Behavioral Headache Triggers

Back 59

1. fatigue
2. menstruation/menopause
3. sleep excess or deficit
4. skipping meals
5. vigorous physical activity

Front 60

Environmental Headache Triggers

Back 60

1. flickering lights
2. loud noises
3. strong smells/tobacco
4. weather changes

Front 61

Medications that are Headache Triggers

Back 61

1. Cimetidine
2. oral contraceptives
3. indomethacin
4. nifedipine
5. nitrates
6. abortive overuse

Front 62

Food that are Headache Triggers

Back 62

1. caffeine intake/withdrawal
2. chocolate/dairy
3. citrus fruits/bananas
4. fermented/pickled

Front 63

Food Containing Headache Triggers

Back 63

1. MSG
2. nitrates/processed meats
3. Saccharin/aspartame
4. Sulfites: shrimp
5. Tyramine: cheese, wine, organ meats
6. Yeast: bread

Front 64

Episodic headache

Back 64

occurs between 0-14 days per month

Front 65

Chronic headache

Back 65

occurs >15 days per month with an average duration of 4 hours or more....usually 3months or longer

Front 66

Comprehensive Headache History

Back 66

1. S-symptoms
2. C-Characteristics(type and quality of pain)
3. H-history(age at onset)
4. O-onset(attack frequency and timing)
5. L-location(radiation, part of brain)
6. A-aggravating factors
7. R-remitting factors

Front 67

Tension Headache

Back 67

1. 10 or more episodes occur <1 day per month or less on average (< 12 days per year)
2. Lasts from 30 mins to 7 days

Front 68

Signs or Symptoms of Tension Headaches

Back 68

1. 2 of the following characteristics:
a. Bilateral location
b. Pressing/tightening quality
c. Not aggravated by routine physical activity

2. Both of the following:
a. No nausea/vomiting
b. No more than one of photophobia or
phonophobia

Front 69

Migraine without Aura

Back 69

1. At least 5 attacks or more
2. 4 – 72 hours in duration

Front 70

Signs or Symptoms of Migraine without Aura

Back 70

1. 2 of the following characteristics:
a. Unilateral location*
b. Pulsating quality
c. Moderate or severe pain intensity
d. Aggravated by or causing avoidance of routine physical
activity

2. During headache at least 1:
a. Nausea and/or vomiting
b. Photophobia and phonophobia

Front 71

Characteristics of a migraine without aura

Back 71

1. S-severe
2. UL-unilateral
3. T-throbbing
4. A-activity worsens headache
5. N-nausea or vomiting
6. S-sensitivity to light or sound

Front 72

Migraine with Aura

Back 72

1. At least 2 attacks or more
2. Migraine w/o aura begins during aura or follows aura within 60 mins

Front 73

Signs and Symptoms of Migraine With Aura

Back 73

1. Aura consisting of 1 of the following:
a. Fully reversible visual symptoms
b. Fully reversible sensory symptoms
c. Fully reversible dysphasic speech disturbance

2. At least 2 of the following:
a. Homonymous visual symptoms and/or unilateral sensory symptoms
b. 1 aura symptom develops at least 5 mins prior
c. Each symptom lasts between 5 and 60 minutes

Front 74

Cluster Headaches

Back 74

1. At least 5 attacks
2. Duration of attack: 15 – 180 minutes if untreated
3. Severe or very severe orbital, supraorbital and/or temporal pain

Front 75

Signs and Symptoms of Cluster Headaches

Back 75

1. At least 1 of the following:
a. Ipsilateral conjuctival injection and/or lacrimation
b. Ipsilateral nasal congestion and/or rhinorrhea
c. Ipsilateral eyelid edema Ipsilateral forehead and facial swelling
d. Ipsilateral miosis and/or ptosis A sense of restlessness or agitation

2. Attacks can occur from 1 every other day to 8/day or more

Front 76

Headache Red Flags

Back 76

1. S = systemic symptoms
2. N = neurologic symptoms
3. O = Onset
4. O = Older
5. P = Previous headache history
6. S = Secondary risk factors

Front 77

Emergency Referral Considerations with headaches

Back 77

1. abrupt onset of worse headache of life
2. age 50 or older
3. headache duration longer than 72 hours
4. headache plus: stiff neck, fever, confusion, inability to walk

Front 78

Long term goals of Migraine Treatment

Back 78

1. decrease frequency, duration, and severity
2. prevent
3. improve quality of life
4. avoid escalation
5. education

Front 79

Abortive Therapy

Back 79

1. for acute management
2. have at least 2 drugs and more than 1 formulation
3. relief of pain
4. NOT for every day use
5. appropriate use: max of 2 days per week

Front 80

Preventative Therapy

Back 80

1. decrease the frequency, severity, and/or duration of headache
2. may improve abortive agents efficacy
3. taken every day
4. require minimum 4-6 week trial for full effects

Front 81

when are preventative therapy normally prescribed for patients

Back 81

1. 4+ headaches a month
2. those where abortive therapy is not consistently effective
3. headache attacks are reliably and/or extremely disabling

Front 82

Classes of medications for Abortive Therapy

Back 82

1. NSAIDS
2. Analgesics
3. Opiate Analgesics
4. Ergot Alkaloids and Derivatives
5. Triptans
6. Phenothiazines
7. Corticosteroids
8. IV Magnesium

Front 83

NSAIDS for Abortive Therapy of Headaches

Back 83

*1st Line Therapy for mild-moderate attacks(previously responsive)*

1. Take with food and plenty of water

Front 84

one NSAID that can be taken for headaches more than 5 days provided maximum doses are not used everyday

Back 84

Ketorolac

Front 85

Analgesics for Abortive Therapy of Headaches

Back 85

*1st Line Therapy of mild-moderate attacks or severe attacks (previously responsive)

Examples: APAP, Fiorcet, Fiorinal, Midrin)

Front 86

Opiate Analgesics for Abortive Therapy of Headaches

Back 86

*Highly recommended to restrict use*

1. Offender of rebound headache and/or medication overuse headache

Front 87

Ergot Alkaloids for Abortive Therapy

Back 87

*1st Line Therapy in treatment of moderate - severe migraine attacks*

1. DO NOT use within 24 hours with Triptans

Examples: DHE, ergotamine

Front 88

Triptans for Abortive Therapy

Back 88

*1st Line Therapy in moderate - severe migraine

Pearls:
1. Subq and intranasal has rapid onset
2. 2nd generations have higher oral availability
3. cant administer some within 24 hours of MAOI
4. serotonin syndrome with use with SSRIs and SNRIs

Front 89

ADRs of Triptans

Back 89

ORAL: fatigue, dizziness, flushing,
SUBQ: injection site reactions
Intranasal: taste perversion

Front 90

1st generation triptan

Back 90

Sumatriptan (Imitrex)

Front 91

2nd generation Triptans

Back 91

Zolmitriptan, Naratriptan, Rizatriptan, Almotriptan, Frovatriptan

Front 92

2 primary uses of phenothiazines

Back 92

1. Antiemetics (metoclopramide, promethazine)
2. Neurotransmitter (chlorpromazine, haloperidol)

Front 93

2 corticosteroids used in Abortive Therapy for headaches

Back 93

1. dexamethasone
2. methylprednisolone

Front 94

3 other classes of drugs used in abortive therapy

Back 94

1. muscle relaxant (orphenadrine, cyclobenzaprine)
2. Antihistamines (hydroxyzine, diphenhydramine)
3. Anticonvulsants (valproic acid, levetiracetam)

Front 95

Abortive Therapies used for Cluster Headaches

Back 95

1. Oxygen
2. DHE (rapid onset)
3. Triptans (6mg subq most effective)
4. Histamine
5. Anesthetics (short relief)

Front 96

Beta Antagonists used as preventative therapies for headaches

Back 96

1. Atenolol
2. Metoprolol
3. Nadalol
4. Propranolol
5. Timolol

Front 97

ADRs and precautions of beta antagonists for headaches

Back 97

ADRs: fatigue, light-headedness, sleep disturbances
Precautions: asthma, depression, diabetes

Front 98

what comorbidities are beta antagonists good for along with headaches

Back 98

1. anxiety
2. HTN
3. angina

Front 99

Calcium Channel Blockers use as preventative therapies for headaches

Back 99

*2nd or 3rd line for migraines*

ADRs: constipation, light-headedness, hypotension, flushing

Front 100

1st line therapy for cluster headaches

Back 100

Verapamil

Front 101

SSRIs used as preventative therapies for headaches

Back 101

USE: comorbid depression, anxiety, and OCD

ADRs: drowsy, constipation, insomnia, upset stomach

Examples: fluoxetine, lexapro, paxil, zoloft

Front 102

SNRIs used as preventative therapies for headaches

Back 102

USE: comorbid depression and/or chronic pain

ADRs: insomnia, constipation, dry mouth, increased BP

Examples: venlafaxine, duloxetine

Front 103

Tricyclic Antidepressants used as preventative therapies for headaches

Back 103

USE: adjunctive with comorbid depression (evening dose)

ADRs: drowsy, dry mouth, increased appetite

Examples: amitriptyline, protriptyline, nortriptyline

Front 104

MAOIs as preventative therapies for headaches

Back 104

USE: refractory headache

1. do not use within 24 hours of a triptan
2. tyramine free diet
3. do not use with decongestants, SSRIs

Examples: selegiline

Front 105

Anticonvulsants used as preventative therapies for headaches

Back 105

USE: migraine prophylaxis/adjunct treatment

Examples: divalproex, valproic acid, topiramate, gabapentin

Front 106

ADRs of valproic acid

Back 106

nausea, vomiting, hepatotoxicity

Front 107

Antipsychotic use in preventative therapies of headaches

Back 107

USE: additional prophylaxis with comorbid bipolar or schiz.

ADRs: drowsiness, increased appetite, hypotension

Examples: quetiapine, olanzapine, risperidone

Front 108

how is dosing for psychotics done for headache prophylaxis

Back 108

much lower than approved indications

Front 109

Lithium use for headaches

Back 109

USE: used in combo with verapamil (Cluster Headaches)

ADRs: tremor, lethargy, nausea, diarrhea (mild)

*thyroid and renal function must be monitored*

Front 110

Non-Pharm treatment for headaches

Back 110

1. regular sleep, physical activity, eating habits
2. smoking cessation
3. limited caffeine
4. relaxation and cognitive therapy
5. biofeedback

Front 111

Medication Overuse Headache (Rebound Headache)

Back 111

1. headache present for 15 days or more per month
2. overuse for more than 3 months of 1+ drugs that can be taken for acute and/or symptomatic treatment of headache
3. headache has developed or worsened during med overuse

Front 112

High probability of over use with these medications

Back 112

1. opioids
2. ergotamine
3. butalbital
4. Caffeine

Front 113

Possible overuse with these medications

Back 113

1. NSAIDS
2. Nasal decongestant