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109 Cards in this Set
- Front
- Back
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Types of primary HA disorders
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tension, migraine, cluster
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Symptoms of organic disease can cause what type of HA?
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secondary
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Definition of migraine
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common, recurrent, severe HA that interferes with normal functioning and is usually associated with autonomic sx
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What are the 4 phases of a migraine attack?
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1. prodrome
2. aura 3. pain 4. postdrome |
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Prodrome usually last ___ to ____.
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hours to days
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Aura
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positive and negative visual sx that precedes or accompanies an attack
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T/F. You always have pain with aura.
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False - some may have an aura w/o pain
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How long is the aura phase?
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typically evolves 5-20 minutes and lasts <60 min; HA occurs at the end of 60 min
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____ aura is the most common neurological event.
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visual - can occur w/o HA
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Scintillating scotoma
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dazzling zigzag lines in visual aura
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Negative vision
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blurred, shimmering, or cloudy vision
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Tunnel vision
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loss of peripheral vision
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Hemianopsia
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loss of half of visual sight
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What is the most common sx associated with migraine?
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nausea
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Pain from a migraine can last __ to __ hours if left untreated.
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4 to 72 hrs
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Some people feel refreshed/euphoric or depressed/malaise after which phase?
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postdrome
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What is the usual onset of age for migraine HA?
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10 and 29
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Foods containing ___ and ___ can cause migraine HA.
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tyramine & MSG
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What are the drugs that might trigger a migraine?
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estrogen
nitrates sildenafil nifedipine theophylline cardiac glycosides |
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What are the 3 migraine hypothesis?
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1. vascular
2. neuronal dysfunction 3. neurobiologic disorder |
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In vascular hypothesis, where does the aura phase develop?
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vasoconstriction - reduction in blood flow starting at occipital and moving across cortex; explains visual disturbances
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In neuronal dysfunction hypothesis, what characterizes the aura phase?
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not ischemia!
-depressed elec. activity that advances across the cortex at a similar rate of spread of aura. -neurons not fxn correctly -- similiar to depression |
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Explain the neurobiologic disorder.
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trigeminovascular
-ganglion innervates pain-sensitive intracranial anatomy -fibers project and terminate in brain stem and upper cervical spinal cord providing nociceptive transmission |
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Migraine is a _________ dz.
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neurovascular
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What causes hypersensitivity and hyperreponsiveness?
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abnormality in Ca channel that regulate excitability via release of 5-HT
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What is the main neurotransmitter associated with migraines?
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5-HT
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What are the s/sx of aura-resolution?
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N/V, photophobia, phonophobia, sleepy yawning
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What causes rebound HA?
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excessive use of migraine meds
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To prevent rebound HA in acute migraine, how long should you use migraine meds?
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limit acute migraine meds to 2-3 days/wk
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What drug classes are use for prophylaxis of migraine?
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BB, NSAIDs, anticonvulsants, TCA, physical activity
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For acute migraines, what do you use to treat non-specific tx? specific tx?
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non: NSAIDs & antiemetics
spec: triptans & ergot alkaloids |
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Analgesics & NSAIDs can be used to treat ___ to ___ attacks.
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mild to moderate
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T/F. APAP can be used as monotherapy for migraines.
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False - combo products with APAP/ASA/Caffeine is recommended
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Which drugs are used to treat N/V in migraines?
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DA antagonists - metoclopramide and prochlorperazine
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When should you administer antiemetics?
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15-30 minutes before anti-migraine meds given
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Migramax
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metoclopramide/ASA
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Piramax
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metoclopramide/APAP
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Opiate analgesics are used to treat ___ to ___ attacks.
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moderate to severe
rescue medication |
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Name an opiate analgesic used for migraine tx. What occurs in frequent use?
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butorphanol (stadol)
-dependence & rebound HA -intranasal and more effective in F>>M |
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5-HT and it's receptors has what kind of actions in the periphery?
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-regulates SM in GI and CV
-enhances platelet aggregation |
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Which 5-HT receptor causes vasoconstriction? vasodilation?
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c: 1B/D & 2A
d: 2B --> releases NO |
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What is the most useful drugs for severe migraines?
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5-HT1 receptor antagonists
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Ergot alkaloids are used for ___ to ___ attacks.
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moderate to severe
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Which receptors do ergot alkaloids work on?
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-nonselective: 5-HT1 & 5-HT2 receptors
-strong vasoconstrictors |
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Side effects of ergot alkaloids.
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HTN, ischemia, hallucinations, nausea
-high affinity for alpha and dopa receptors |
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Ergotamine and DHE is effective when given during which phase of migraine?
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aura
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What are the CI of ergotamine & DHE?
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coronary heart dz, peripheral hypoperfusion, pregnancy
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T/F. Ergotamine should be given IV.
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False - poor PO, given rectally & SL
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T/F. Ergotamine has emetic properties.
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True
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Triptans are agonist of what receptors?
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5-HT1B & 5-HT1D
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MOA of triptans
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-vasoconstriction in cerebral arteries via 5-HT1B
-inhibition of CGRP from trigem nerve via 5-HT1D |
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Triptans are effective during which migraine phase?
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during migraine attack
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Which migraine med should you not use in Raynaud's dz?
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triptans - vasoconstriction could worsen primary condition
-coronary heart dz too |
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T/F. CGRP is a vasodilator.
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True
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In trigeminal nerve endings, what does presynap 5HT1D cause? postsynap 5HT1B?
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d: inhibition of CGRP release
b: vasoconstriction |
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How do triptans work to relieve pain and associated sx?
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vasoconstriction occurs --> trigeminal inhibited (5HT recep) --> dec pain transmiss from brain stem to cortex --> relief
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The triptans have an ___ moiety
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indole
"trippin' on indo" |
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T/F. Each triptan has a particular max dose & frequency for proper therapeutic use.
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True
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Sumatriptan: brand, ROA, metabolism, half life
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-imitrex
-inj, tab, NS -MAO-A -2 hrs (quick onset) |
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Zolmitriptan: brand, ROA, metabolism, half life
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-zomig, rapimelt
-tab, ODT, NS -MAO-A and CYP1A2 -3 hrs |
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Eletriptan: brand, metabolism, half life
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-relpax
-CYP3A4 -5 hrs |
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Which triptans have higher PO bioavailability?
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zomig 40%, relpax 70%, amerge 70%, frova 30%
-more lipophilic & brain permeable = inc PO bioavail |
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Naratriptan: brand, metabolism, half life
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-amerge
-50% urine and 30% P450 -6 hrs; longer duration of action |
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Frovatriptan: metabolism
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CYP1A2
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T/F. All triptans will be equally efficacious of all patients.
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False - patient variability; 1 tx may not work the same for another pt
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DD interactions with triptans
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-MAOI w/i 2 wks
-ergotamine derivative w/i 24h -concurrently w/ SSRIs or NESRIs |
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Why should you not administer triptan + SSRIs or NE/SRIs?
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serotonin syndrome --> too much 5HT
-life threatening |
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Which migraine drugs can have a pin & needle side effect?
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triptans - parethesis
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Prophylaxis of migraines is treated for how long?
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3-6 months after severity and frequency diminishes --> slowly d/c
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How effective in pt pop. is BB for migraine prophylaxis?
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effective in 80% of pts to reduce 50% of attacks
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BB are useful for patients with what other co-conditions?
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anxiety, HTN, and angina
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Names of BB use for prophylaxis tx
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propranolol
timolol metoprolol nadolol atenolol |
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T/F. NSAIDs can be used for long term migraine prophylaxis.
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False - increase GI bleeding risk
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Which NSAIDs are used for migraine prophylaxis? What are their advantages?
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ASA, ketoprofen, naproxen
-OTC (micromedex RX?) |
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How can you limit N/V when using anti-epileptics in migraine prophylaxis?
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titrate dose
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Anti-epileptic prophylaxis drugs: B/G, MOA, side effects
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-Depakote (divalproex), Na channel blocker, hepatotoxicity, teratogen
-Topamax (topiramate), blocks AMPA/kainate receptors, anorexia, somnolence, memory issues |
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Migraine prophylaxis: TCA - MOA, drug names, side effects
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-down reg of 5HT2 & adrenergic recep
-amitriptyline, doxepin, nortriptyline, imipramine -serotonin syndrome |
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T/F. SSRIs and MAOIs show benefit in migraine prophylaxis.
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False - nothing definitive; caution use SSRI + triptans for 5HT syndrome
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Which CCB can be used for migraine prophylaxis?
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verapamil - effects seen in 8 wks
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Methysergide is used for which patient pop.? MOA?
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-reserved for pt w/ refractory HA that doesn't respond to other tx
-5HT receptor antag |
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Lisinopril, candasartan, riboflavin (B2), and bot toxin A is useful for prophylaxis or tx?
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prophylaxis
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Per IHS, what qualifies as a migraine w/o aura?
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-5+ attacks
-lasts 4-72 hrs untreated -2 crit: unilat, pulsating, mod-sev intensity -aggrav by phys activity -1 cit: GI sx, photo- or phono- |
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Per IHS, what qualifies as a migraine with aura?
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2+ attacks and fulfills typical criteria of aura
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T/F. Most migraines occur in the morning.
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True
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What is the benefit of using longer acting anal/nsaid vs. fast acting IBU or naproxen?
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less frequent dosing but onset of action takes longer
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Midrin
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APAP/isometheptene/dichloraphenazone
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What is the goal for ergotamine use?
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use enough to alleviate HA but not so much to cause GI effects
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DHE is better than ergotamine in what ways? vs. triptans?
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-DHE has less rebound and N/V
-less recurrence |
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T/F. Ergot alkaloids are safe to use in pregnancy.
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False - contraindicated; uterine vasospams can occur
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Patient presents to ER with migraine HA and currently treated with sumatriptan. Her sx are not resolving and the doctor wants to know if he can give the patient ergotamine in the same day. What do you recommend?
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Do not give ergotamine within 24 hours of sumatriptan
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Which migraine treatments are metabolized by P450?
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ergot alkaloids and 5HT agonist (-triptans)
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Patient presents with a severe migraine. What are the treatment options?
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ergot alkaloids, 5HT agonists, opioids
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GG received a prescription for zomig tablets. How do you counsel her on the correct administration?
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Give 1 dose, if HA is still present after 2-4 hours then may repeat dose x1. NMT 2 doses/24hr period.
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Which drug class is more specific for 5HT receptors: ergot or triptans?
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triptans; ergots are nonselective hence increased side effects
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JW received a medication last week in your pharmacy for migraine treatment. She reports feeling flushed and having warm sensations when taking the medication. She is on multiple medications and doesn't remember what the drug was called and would like your help in identifying which one of her pills is causing her sx.
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-triptans cause flushing/warm sensation --> important to counsel
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2010 american HA society wrote a paper about triptan + antidepressant use. What was their conclusion?
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the risk is low and patients should not be excluded from triptan use - monitor closely for 5HT syndrome
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30-40% of imitrex users experience ____ with use.
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higher recurrence (w/i 24h)
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PS experiences moderate migraine HA and would like to have a -triptan treatment with long duration. What would you recommend?
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naratriptan (amerge) or
frovatriptan (frova) or eletriptan (relpax) |
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NJ presents to clinic with severe HA and is currently on Amerge (naratriptan). She has a CrCl <30. Is this appropriate? If so, why? If not, what would you recommend?
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-inappropriate bc amerge is 50% unchanged in urine
-probably switch to another triptan (suma, riza, zolmi, ele, and possibly frova) |
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WB recently started having severe migraines. Her friend told her stadol is the best medicine for HA and should try to get a prescription for it. What do you advise the patient?
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-opioids are 3rd line tx
-Try 5HT agonists then ergot derivatives if no CI exists |
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KK is a 9 yo girl that experiences occasional HA. Her mom would like a recommendation on what she should give her to treat the HA. What's your recommendation?
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IBU is 1st line for children
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T/F. APAP can be considered in adolescents as monotherapy of HA.
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True - for acute tx
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Which triptan has the quickest onset of action?
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sumatriptans
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BW is taking Frova for HA but would like something to work faster. What would you recommend?
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suma >zolmi >riza >almo >ele >nara
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What are some justifications for using prophylaxis migraine tx?
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-HA causing disability
->2x/wk -desire to limit freq of attacks -acute tx don't work |
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BW suffers from tension HA and has been taking IBU. He reports that he still experiences pain. What do you recommend?
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NSAIDs and APAP are first line.. if it doesn't work then try butalbital or codeine
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MP is a 3rd yr pharmacy student and has chronic tension headaches from staring at her computer too long. What would you recommend for prophylaxis?
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TCA
-some studies support bot toxin inj |
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How long do cluster HA last?
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2 wks to 3 mos followed by longer period of time w/o HA
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RR has been experiencing HA pain that lasts from 15 mins to 3 hrs. He states no aura but experiences lacrimation and nasal stuffiness. What kind of HA does he have? What's your recommendation for treatment?
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cluster HA
-O2 100% by mask or -SC or NS triptan for fast onset |
