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62 Cards in this Set
- Front
- Back
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Are migraines more common in men or women?
What age? |
women
25-44 |
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List five common barriers to migraine care:
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--by the way doctor
--clinicians feel suspicious, burdened --clinicians focus on excluding secondary headache and give nonspecific treatment --patients want information, diagnosis, pain relief --clinicians use step-care believing that it is safe and cost-effective |
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How do triptans work?
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Bind to 5HT1B receptors pre and postsynaptically to reduce vasodilation and inflammation
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What is the nerve in the head that is affected by migraines?
How is this nerve connected to vasculature? |
trigeminal nerve
dilated blood vessels stimulate trigeminal nerve endings to release vasoactive neuropeptides that induce neurogenic inflammation, exacerbate vasodilation and are linked to pain of migraine |
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Are migraine headaches related genetically?
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yes, there is some relation to family history
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What are the phases of the migraine attack?
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pre-HA (prodrome, aura)
headache post-HA (postdrome) |
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What are some prodrome symptoms?
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elated, irritable, depressed, neck stiffness, food cravings, fluid retention, thirsty, drowsy
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What are the two types of aura?
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visual--spots, streaks of light, blurred vision
somatosensory--tingly sensation |
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AUSTIN
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aggravated by activity
unilateral sensitivity to light and sound throbbing intensity is severe nausea/vomiting |
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What are some postdrome symptoms?
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weakness
drowsiness |
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List three primary headaches and three secondary headaches:
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Primary: migraine, tension-type, cluster
Secondary: tumor, meningitis, alcohol use hangover |
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What is the IHS HA diagnosis?
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at least five consistent attacks
Migraine without aura Pain (2 of 4: AUTI) In addition (1 of 2: SN) Tention-type Pain (2 of 4: bilateral, pressing/tightening, mild to moderate, not aggravated by activity) In addition (1 of 2: no nausea, sensitivity to light or sound) |
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What differentiates migraine and sinus headaches?
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sinus headaches have fever/mucus present
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List some red flags for non-migrainous headaches:
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--age over 50
--hit me right away --mild pain --strenuous activity brought on headache --fever/chills |
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Explain the MIDAS scale:
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helps identify and stratify care
--number of migraines --amount of work missed --etc.. |
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List some triggers for migraines:
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skipping meals
tyramines red wines unbalanced diets caffeine analgesic overuse changes in sleep patterns weather changes lightning fragrance/odors estrogens stress (post stress) overexertion |
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When is the optimal treatment time for migraines?
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ASAP, first sign of migraine
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List some non-pharmacological treatments for migraines
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--biofeedback (mind over matter)
--relaxation training --cold compress --sleep --rest in a cool, dark, quiet environment --headache diary --acupuncture (not for prevention) magnesium, riboflavin |
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When are specific agents appropriate for migraine treatment?
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more than half of headaches result in disability
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Why do we try to avoid opiates in the treatment of migraines?
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dependency
avoid relapse HAs |
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List three antiemetics:
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chlorpromazine
metoclopramide prochlorperazine |
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What is the added benefit of using metoclopramide as an antiemetic?
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promotes GI motility, prevents stasis which often occurs with nausea/vomiting, improves bioavailability of other oral medications
--less drowsy than others |
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B/G: chlorpromazine
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Thorazine
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B/G: metoclopramide
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Reglan
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B/G: prochlorperazine
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Compazine
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How many serotonin receptors are there?
Which three are associated with migraines? |
--Seven
--5HT1B/D--treatment of migraines (agonists) --5HT2--prevention (antagonists) --5HT3--nausea/vomiting--antiemetics (antagonists) |
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Name two ergot derivatives:
Which receptors do they work on? When are these most effective? Which enzyme metabolizes Ergot derivatives? |
--ergotamine and dihydroergotamine (DHE; Migranal)
--Serotonin, alpha-adrenergic, beta-adrenergic, dopaminergic --first sign of migraine, not effective later on --CYP3A4; interacts with certain antibiotics, antivirals, and antifungals (3A4 inhibitors) |
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B/G: Sumatriptan
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Imitrex
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B/G: zolmitriptan
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Zomig
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B/G: naratriptan
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Amerge
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B/G: rizatriptan
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Maxalt
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B/G: almotriptan
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Axert
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B/G: frovatriptan
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Frova
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B/G: eletriptan
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Relpax
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Which triptans have the longest half-lives?
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naratriptan and frovatriptan
--takes longer to get in but stay longer --prevents headache reoccurence/longer lasting headaches |
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Why does a melt tab take longer?
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the drug must dissolve in your mouth, be swallowed, and then be absorbed
--helpful in patients with upset stomach |
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What is the difference between the oral and injection versions of sumatriptan?
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bioavailabliity
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What counseling pearl goes along with the new RT sumatriptan tablets?
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do not split tablets
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What is the effectiveness of a melt tab verse a regular tab?
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Melt tabs take longer and have a lower effect
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Rank the following in terms of bioavailability: injection, tablet, nasal spray
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injection, nasal spray, tablet
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What contraindications exist for triptans?
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--CV risk factors (uncontrolled HTN; very rare interaction; chest pain vs chest pressure)
--must separate triptans and ergot derivatives by 24 hours --Pregnancy category C (talk to Dr.) --hemiplegic/basilar migraines --MAOIs --SSRI precaution (serotonin syndrome; start low, go slow; happy drunk side effects) --liver and kidney dysfunction |
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What interactions do triptans have?
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--MAOIs
--Ergots --SSRIs --OCs increase triptan concentration --Propranolol and Rizatriptan (increased triptan levels) |
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What are common triptan side effects?
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--tingling
--warmth --flushing --check and neck pressure --dizziness, drowsiness --abnormal taste --injection site burning with injection --make sure patients report chest pain! |
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What is the difference between chest pressure and chest pain?
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pressure--two telephone books stacked on top of you
pain--shooting, sharp, does not go away |
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What is the combination triptan product?
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Treximet (sumatriptan 85 mg and naproxen 500 mg)
--recommend taking naproxen in patients with menstrual migraines |
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Triptan choices: max efficacy and speed
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sumatriptan injection
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Triptan choices: speed and non-oral
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sumatriptan and zolmitriptan nasal sprays
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Triptan choices: convenience and flexibility
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sumatriptan
zolmitriptan rizatriptan almotriptan eletriptan (tablets) |
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Triptan choices: tolerability and duration
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Naratriptan, frovratriptan
(tablets) |
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Which triptan is the best?
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The one that works!
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When can you repeat a triptan dose?
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After specified amount of time if first dose was somewhat effective
(typically two hours, except for sumatriptan injection (1 hour) and naratriptan (4 hours)) |
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Which drugs have the lowest rate of headache recurrence?
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longest half-lives
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What are the guidelines for medication overuse/rebound headaches?
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simple analgesics > 5 days a week
triptans > 3 days a week opioids > 2 days a week |
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When is prophylactic therapy appropriate?
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Rule of 2's
--established HA frequency >2 days per week or 2-4 times per month --use of acute treatment meds (including OTCs) >2 days per week --use of rescue medications >2 times per month also, failure of acute therapy, contraindications to acute therapy, complex migraines, patient preferences |
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What is the key for migraine prophylaxis?
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start low, go slow
be patient (may take 2-3 months) |
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What are some FDA approved medications for migraine prophylaxis?
What are some non-FDA approved meds? |
VPA, TPM
propranolol, timolol amitriptyline TCAs Beta blockers Ca channel blockers (verapamil for cluster headaches) gabapentin Botox |
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Explain the effectiveness of VPA for migraine prophylaxis:
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--efficacy is well established
--reduces frequency, not necessarily the severity --adverse effects include: nausea, weakness, somnolence, weight gain, hair loss, tremor, hepatotoxicity, thrombocytopenia |
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What are the three most commonly used meds for migraine prophylaxis?
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topiramate
propranolol amitriptyline |
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What is important to remember about topiramate in migraine prophylaxis?
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--lower doses used for prophylaxis than for seizures
--risk of kidney stones, decreased sweating --drowsiness, weight loss, psychomotor slowing, tingling, difficulty concentrating |
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What is important to remember about beta blockers in migraine prophylaxis?
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--contraindications include asthma, COPD, Raynaud's, PVD
--exercise intolerance, fatigue, vivid dreams (can add to depression) |
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What is important to remember about TCAs in migraine prophylaxis?
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--start low, go slow
--make you tired, take at night --anticholinergic effects --weight gain |
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What is important to remember about Ca antagonists in migraine prophylaxis?
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verapamil used for cluster headaches
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