Neuro Test 1 Set 2

Front 1

Pathophysiology of Migraine (5)

Back 1

1)imbalance in activity of serotonin-containing neurons and/or noradrenergic pathways in the brain stem
2)imbalance results in vasodilation of intracranial extracerebral blood vessels and activation of trigeminovascular system
3)this triggers release of vasoactive neuropeptides like CGRP, neurokininA and substanceP
4)these cause vasodilation and extravasation resulting in perivascular inflammation
5)conduction along trigeminovasular fibers transmits pain impulses to the trigeminal nucleus caudalis and info is relayed to cortical pain centers

Front 2

Precipitating factors for migraine
a)psychological (3)
b)environmental (7)

Back 2

a1)stress
a2)anxiety
a3)depression

b1)tobacco smoke
b2)glare
b3)strong odors
b4)loud noise
b5)flickering lights
b6)weather changes
b7)high altitude

Front 3

Precipitating factors for migraine
a)dietary (4)
b)meds (5)

Back 3

a1)alcohol
a2)tyramine foods
a3)chocolate
a4)caffeine

b1)cocaine
b2)estradiol
b3)nicotine
b4)NTG
b5)reserpine

Front 4

Precipitating factors for migraine
a)hormonal (3)
b)life-style (5)

Back 4

a1)menses
a2)pregnancy
a3)menopause

b1)excessive/inadequate sleep
b2)fatigue
b3)dieting
b4)skipping meals
b6)strenuous exercise

Front 5

Migraine without Aura
a)duration
b)has 2 of the following characteristics (4)
c)has 1 of the following during HA (3)
d)2 other

Back 5

a)HA lasts 4-72hrs

b1)unilateral
b2)pulsating quality
b3)moderate/severe intensity
b4)aggravation by routine physical activity

c1)n/v
c2)photophobia
c3)phonophobia

d1)atleast 5 attacks occur fulfilling the above criteria
d2)history/PE do NOT suggest any underlying disease

Front 6

Migraine with Aura
a)typical aura (1 and includes one 1 of 3)

Back 6

1)reversible visual, sensory, speech symptoms, NO motor weakness

1)one symptom that develops gradually over 5min OR different symptoms that occur in succession
2)each symptoms lasts for atleast 5min and for NO longer than 60
3)HA that meets criteria for migraine w/o aura begins during aura or follows aura within 60min

Front 7

Severity Classification of Migraine
a)Mild
b)moderate
c)severe

Back 7

a)can continue daily activities with only minimal disruption
b)daily activities are moderately impaired (person incapcitated for HOURS)
c)unable to continue normal activities or fxn w/o severe disconfort (person incapcitated for 1DAY)

Front 8

Status Migrainosus? (4)

Back 8

1)prolonged migraine (over 72h)
2)w/ n/v and other GI symptoms
3)totally incapacites person
4)MEDICAL EMERGENCY, get em to hospital

Front 9

When to seek medical attention w/ a HA (5)

Back 9

1)severe HA that peaks in seconds
2)no history of similar HAs
3)mental status changes
4)onset w/ physical activity
5)pain spreads to lower neck and/or shoulders

Front 10

Non-pharmacologic tx of Migraine (5)

Back 10

1)ice to head
2)rest/sleep in dark/quite place
3)regular sleep, exercise, eating habits
4)smoking cessation/limit caffeine intake
5)relaxation therapy/biofeedback

Front 11

Abortive pharmacologic drugs for migraine (5)

Back 11

1)analgesics/NSAIDs
2)ergot alkaloids/derivatives
3)serotonin receptor agonists (triptans)
4)butorphanol nasal spray
5)antiemetics

Front 12

Prophylaxis migraine meds (6)

Back 12

1)BB
2)antidepressants
3)anticonvulsants
4)CCB
5)methysergide
6)ALWAYS NEED A RESCUE MED W/ THESE

Front 13

Abortive Migraine therapy considerations (3)

Back 13

1)abortive therapy alone if less than 2 attacks per week
2)antiemetics may facilitate absorption of primary drug
3)avoid opoids agonists (they mask pain w/o suppressing mechanism of attack)

Front 14

Tx algorithm for mild to moderate migraine's (5)

Back 14

1)pretreat using antiemetic if severe n/v
2)simple analgesic (APAP/ASA/Caffeine, NSAIDs); if inadequate response....
3)Combination analgesics (Midrin, Fioricet, Fiorinal); if inadequate response....
4)Triptans or ergotamine/DHT; if inadequate response....
5)opoid combo analgesics or butorphanol spray

Front 15

Tx algorith for severe migraine's (3)

Back 15

1)pretreat w/ antiemetic if severe n/v
2)triptans or ergotamine/DHT; if inadequate response...
3)opoid combo analgesics or butorphanol spray

Front 16

Analgesics/NSAIDs
a)mechanism
b)used for...
c)____ alone is NOT recommended
d)add ____ to improve absorption

Back 16

a)prevent neurogenically mediated inflammation in trigeminal system thru inhibiting PG synthesis
b)MILD migraines
c)APAP
d)caffeine

Front 17

NSAIDs
a)good for... (2)
b)ones used... (3)

Back 17

a)menstruation related migraines OR mild-mod migraines
b)ibuprofen, naproxen, ketorolac

Front 18

Butalbital concern

Back 18

limits over use due to medication overuse HA and withdrawal concerns/addication

Front 19

Midrin
a)good for ___ migraines
b)ADR's (5)

Back 19

a)mild-mod migraines

b1)dizziness
b2)insomnia
b3)n/v
b4)numbness
b5)addiction

Front 20

Antiemetics
a)when to admin
b)ones used (2)
c)ADR's (2)

Back 20

a)15-30min b4 taking abortive agent

b1)metoclopramide
b2)compazine (po/rectal)

c1)drowsy/dizzy
c2)extrapyramidal SE's rare

Front 21

Ergot alkaloids
a)mechanism
b)for ____ migraine
c)adv

Back 21

a)5-HT1 antagonist that constricts intracranial blood vessels and inhibit development of neurogenic inflammation in trigeminal
b)moderate/severe migraine
c)low cost and long experience w/ use (long lasting)

Front 22

Ergotamine
a)PK (3)

Back 22

a1)F is very low (1%)
a2)time to therapeutic levels 0.5-3h
a3)irreversible binding to receptors and long-lasting active metabolites

Front 23

Ergotamine disadvantages (4)

Back 23

1)do NOT know effective dose
2)potent vasoconstrictor effects
3)high risk of overuse and rebound HA's
4)pretreat w/ antiemetic b/c stim chemoreceptor trigger zone (effect is greater w/ ergotamine than DHT)

Front 24

Ergotamine ADR's (4)

Back 24

1)sustained vasoconstrictor effects associated w/ adverse vascular effects
2)muscle cramps
3)malaise
4)ergotism (n/d, pruritis, vertigo, cramps)

Front 25

Ergotamine CI's (5)

Back 25

1)coronary, cerebral or peripheral vascular disease
2)HTN
3)liver/kidney disease
4)pregnancy
5)pts w/ prolonged aura (over 60min)

Front 26

Triptans
a)mechanism (4)

Back 26

1)SELECTIVE for 5-HT1B and 5HT1D
2)resulting in vasoconstriction of pain producing intracranial blood vessels (5HT1B)
2)interruption of pain signal transmission within the brain stem (5HT1D)
3)inhibition of vasoactive neuropeptide release from trigeminal (5HT1D)

Front 27

Triptans
a)ADR's (4)
b)dosing considerations (3)

Back 27

a1)dizzy/fatigue/drowsy
a2)flushing
a3)warm sensations
a4)nausea

b1)give initial dose in presence of HC provider
b2)not effective when administered during aura
b3)large interpatient variance (so lack of response to 1 agent doe NOT preclude use of another in class)

Front 28

Triptans CI (7)

Back 28

1)ischemic heart disease
2)uncontrolled HTN
3)cerebrovascular disease
4)pregnancy
5)severe liver/kidney disease
6)monitor for serotonin syndrome w/ SSRI's
7)do NOT give within 2wks of MAOI or 24h of ergot derivatives

Front 29

Group 1 Tripatans
a)features
b)drugs

Group 2 Triptans
a)features
b)drugs

Back 29

a)fast onset, high potency, higher recurrence
b)all the ones not in group 2

a)slow onset, lower potency, lower recurrence
b)Naratriptan (Amerge)
b)Frovatriptan (Frova)

Front 30

Clinical pearls of Triptans (6)

Back 30

1)Zolmitriptan effective when repeated/redosed
2)Naratriptan/Almotriptan have favorable ADR profile (Nara is best thou)
3)Rizatriptan has highest 2h and sustained pain free rates
4)Eletriptan associated w/ good sustained HA response rates
5)Frovatriptan has longest half-life (BEST FOR MENSES MH)
6)ORAL TRIPTANS ARE MORE SIMILAR THAN DIFFERENT (so if 1 doesn't work rotate thru rest)

Front 31

Triptans w/ different dosage forms (besides tablet) (3)

Back 31

Sumatriptan has nasal spray and SQ injexn

Zomitriptan has ODT, nasal spray

Rizatriptan has ODT

Front 32

Indications for prophylaxis migraine tx (4)

Back 32

1)recurring HA that interfere w/ daily routine (more than or 2 attacks per week)
2)failure or CI to abortive agents
3)overuse of meds
4)PATIENT PREFERENCE

Front 33

MH prophylaxis considerations
a)consider what co-morbids? (4)
b)other (4)

Back 33

a1)asthma
a2)seizure
a3)HTN
a4)depression

b1)start low and go slow
b2)allow 8-12wk trial
b3)only 50% of pts respond well to first agent so be persistent
b4)eval for secondary/precipitating factors

Front 34

Prophylaxis for pt that HA recur in a predictable pattern... (in order!!)

Back 34

1)NSAID @ time of vulnerability
2)BB or verapamil if BB CI or ineffective
3)TCA
4)valproate
5)methysergide

Front 35

Prophylaxis for pt that is HEALTHY or comorbid HTN/angina/ANXIETY (in order!!)

Back 35

1)BB or verapamil if BB CI or ineffective
2)TCA
3)valproate
4)methysergide

Front 36

Prophylaxis for pt w/ comorbid depression or insomnia (in order!!)

Back 36

1)TCA
2)valproate
3)methysergide

Front 37

Prophylaxis for pt w/ comorbid seizure or manic-depressive (in order!!)

Back 37

1)valproate (if this no work then...)
2)BB or verapamil if BB CI or ineffective
3)methysergide (LAST LINE IN ALL CASES)

Front 38

BB
a)prophylaxis mechanism
b)efficacy
c)ones used (4)
d)ADR's (4)
e)CI's (4)

Back 38

a)unknown
b)over 60%
c)propanolol, timolol, atenolol, metoprolol

d1)fatigue/dizzy
d2)depression
d3)nausea
d4)insomnia

e1)asthma
e2)heart block
e3)HYPOtension
e4)unstable HF

Front 39

Antidepressants
a)mechanism
b)ones used and which is best? (4)
c)ADR's (3)
d)CI (2)

Back 39

a)antagonism of 5HT2 on cerebral vessels or suppression of sertonergic neuronal activity in brainstem
b)TCA=BB > SSRI > MAOI

c1)drowsy/orthostasis
c2)anticholinergic SE's
c3)wt gain

d1)BPH
d2)glaucoma

Front 40

Anticonvulsants
a)mechanism
b)efficacy
c)ones used (4)

Back 40

a)inhibits firing of serotonergic neurons of the dorsal raphe nuclei
b)valproate=propanolol

c1)valproate
c2)gabapentin
c3)topamax
c4)tegretol

Front 41

Valproate ADR's (3 of many)

Topimax ADR's (3 of many)

Back 41

a1)hair loss
a2)hepatotoxicity
a3)tremor

b1)paresthesias
b2)abnormal taste
b3)cognitive impairment

Front 42

CCB
a)mechanism
b)efficacy
c)one used and how long to see effect
d)ADR's (4)

Back 42

a)inhibits 5-HT release
b)more effective than placebo
c)Verapamil (8wks)

d1)constipation
d2)edema
d3)bradycardia
d4)AV block

Front 43

Methysergide
a)mechanism
b)efficacy
c)dosing

Back 43

a)semisynthetic ergot, 5-HT2 antagonist stabilizing neurotransmission in trigeminal to block development of neurogenic inflammation

b)60% respond but reserved for refractory pts
c)1-6mg qd

Front 44

Methysergide
a)ADR's (4)
b)dosing schedule

Back 44

a1)drowsy
a2)edema
a3)hairloss
a4)FIBROSIS

b)do "drug holiday" of 3-4wks for every 6mo period on drug

Front 45

Tension-type HA characteristics (5)

Back 45

1)most common HA
2)dull, aching, bilateral
3)HATband distribution around head
4)tightness of neck and shoulder muscles
5)no aura, nausea, photophobia

Front 46

Tension HA
a)onset
b)duration
d)triggers (4)

Back 46

a)gradual
b)8-12h

c1)tension/exercise
c2)stress
c3)depression
c4)eyestrain

Front 47

Tension HA pathophys (2)

Back 47

1)excessive muscle contraction w/ constriction of pain sensitive structures
2)abnormal vascular reactivity AND low platelet serotonin content

Front 48

Abortive Pharmacotherapy of Tension HA (4)

Back 48

1)APAP
2)ASA
3)NSAIDs (ibu, naproxen, ketoprofen, indomethacin) (choose agent based on pt preference)
4)NO MUSCLE RELAXANTS

Front 49

Prophylaxis pharmacotherapy of Tension HA
a)when to consider
b)what to use and how (3)

Back 49

a)if freq is greater than 2 per week or duration is greater than 4h

b)Amitriptylline (response in 2-10d)
a)cont therapy if effective for 3-4 months and then taper
b)resume therapy if HA return

Front 50

Nonpharma therapy of Tension HA (2)

Back 50

1)psychotherapy (ID stress factors & education/counseling on depression and anxiety)
2)PT (health therapy and massage and acupuncture)

Front 51

Cluster HA classifications (2)

Back 51

1)Episodic (90%); short period of severe HA in closely packed groups (1-3/d) followed by long period of remission

2)Chronic (10%); without remission for over 12months and may occur w/ or w/o episodic history

Front 52

Cluster HA characteristics (7)

Back 52

1)M:F; 6:1
2)20-40yo @ onset
3)peaks in 1-3min
4)common @ night and in spring/fall
5)last 15-20min
6)deep, piercing, excruciating, NON-throbbing pain
7)accompanied by miosis, rhinorrhea, congestion

Front 53

Cluster HA
1)location
2)triggers (6)

Back 53

1)ALWAYS UNILATERAL and behind/around eye

2a)even small amounts of alcohol
2b)NTG (vasodilators)
2c)stress
2d)warm weather
2e)missed meals
2f)excessive sleep

Front 54

Abortive tx of Cluster HA (5)

Back 54

1)oxygen (choice therapy in hospital)
2)Sumatriptan (choice therapy outpt; BUT SQ/nasal only)
3)intranasal DHT (ONLY NASAL)
4)intranasal lidocaine
5)intranasal capsaicin

Front 55

Prophylaxis tx of Cluster HA (6)

Back 55

1)verapamil
2)prednisone
3)divalproex
4)topiramate
5)ergotamine
6)MELATONIN

Front 56

Non-pharma therapy of Cluster HA (2)

Back 56

1)psychotherapy (ID/reduce stress factors)
2)PT (health therapy, massage, acupuncture)