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PHRM 845 > (3.12) Pharmacotherapy of migraines > Flashcards

(3.12) Pharmacotherapy of migraines Flashcards

1
Q

What is migraine w/o aura?

A
  • Common
  • At least 5 attacks
  • Headache lasting 4-72 hrs
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2
Q

What are characteristics of migraine w/o aura?

A

Unilateral location, pulsating quality, moderate/severe pain, aggravation by routine activity

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3
Q

What are sxs of migraine w/o aura?

A

Nausea and/or vomiting, photophobia, phonophobia

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4
Q

What is migraine w aura?

A
  • Classic
  • At least 2 attacks
  • At least one fully reversible aura
  • No aura lasting more than 60 min
  • Headache follows aura within 60 min
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5
Q

What are sxs of migraine w aura?

A

Visual, sensory, speech/language, motor, brainstem, retinal

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6
Q

What are the phases of migraine headache?

A

1) Prodrome
2) Aura
3) Migraine Headache
4) Postdromal

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7
Q

What characterizes prodrome phase?

A
  • Hrs or days before onset of headache
  • May experience euphoria, depression, irritability, food cravings, constipation, neck stiffness, yawning
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8
Q

What characterizes aura phase?

A
  • Commonly visual, may be sensory, verbal, motor
  • Before or during migraine, lasts <60 min
  • Photopsia, scotoma, zigzag lines, numbness
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9
Q

What characterizes migraine headache phase?

A
  • Dull ache that intensifies
  • Unilateral and throbbing
  • Phonophobia, photophobia
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10
Q

What characterizes postdromal phase?

A
  • May last several days after headache has ended
  • Tiredness, head pain, GI distress, mood changes, weakness, cognitive difficulties
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11
Q

What meds are associated w med overuse headache (migraine triggers)?

A

Associated w analgesics, ergots, triptans

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12
Q

What meds can be a migraine trigger?

A

OC, hydralazine, NTG, nifedipine, cocaine

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13
Q

What foods can be a migraine trigger?

A

Chocolate, oranges, tomatoes, onions, aged cheese, processed foods, alcohol, caffeine

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14
Q

What additives/preservatives can be a migraine trigger?

A

Aspartame and monosodium glutamate

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15
Q

What environment factors can be a migraine trigger?

A

Altitude/weather changes, perfume, tobacco smoke, loud noises, flickering lights

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16
Q

What misc factors can be a migraine trigger?

A

Too little or too much sleep, skipping meals, stress, hormone changes

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17
Q

Pts w migraines should avoid overuse of what drug class?

A

Analgesics

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18
Q

What characterizes abortive tx?

A
  • Education to avoid med overuse
  • Mild-moderate: NSAIDs, acetaminophen
  • Moderate-severe: triptans/ergots
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19
Q

What characterizes preventive tx?

A
  • Four or more attacks/month w disability at least 3 days/month
  • Use of abortive meds more than twice per week
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20
Q

What is first line in abortive tx?

A

Triptans, NSAIDs

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21
Q

What is second line in abortive tx?

A

NSAIDs

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22
Q

What is first line in prevention tx?

A

Monotherapy:
- Valproate, topiramate, metoprolol, propranolol, frovatriptan

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23
Q

What is second line in prevention tx?

A

Amitriptyline

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24
Q

What is biofeedback and relaxation therapy?

A
  • Non pharm option
  • Decreases muscle tension and modifies blood flow
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25
Q

What is cognitive behavioral therapy (CBT)?

A
  • Non pharm option
  • Reduces emotional arousal associated w pain
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26
Q

How can diet be a non pharm therapy?

A

Elimination of food triggers and avoidance of hypoglycemia

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27
Q

How can sleep be a non pharm therapy?

A

Consistent duration and time of day to minimize variation in bedtime and wake time

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28
Q

What is transcutaneous electrical nerve stimulation (TENS) device?

A
  • Non pharm therapy
  • Prevention of episodic migraine pain, may stimulate release of endorphins to decrease pain
29
Q

How can a headache diary be a non pharm therapy?

A

Identify triggers to be avoided

30
Q

What are other non pharm therapies?

A

Exercise, massage, acupuncture, thermal biofeedback, heat/cold applications

31
Q

What are CI of triptans?

A
  • Recent use (within 24h) of an ergot or other triptan, MAO-A inhibitor use in past 2 weeks (frovatriptan, rizatriptan)
  • IHD, angina, hx of stroke/TIA, hemiplegic/basilar migraine, arrhythmias, PVD, uncontrolled HTN, ischemic bowel disease, severe hepatic impairment
32
Q

What are the warnings/precautions of triptans?

A
  • MI, pain/pressure/tightness in chest/throat/neck/jaw
  • CVA, HTN, GI ischemic rxns or peripheral vasospasms, med overuse headache, serotonin syndrome, sulfa allergy (almotriptan), corneal opacities (almotriptan), seizures
33
Q

What are the SEs of oral triptans?

A

Tingling, dizziness, drowsiness, fatigue, chest tightness/pressure, flushing

34
Q

What is drug interaction between triptans and SSRIs/SNRIs?

A
  • Use of triptan w SSRI/SNRI can increase risk of serotonin syndrome
  • However, clinically, both get prescribed together all the time
35
Q

What is a specific drug interaction w eletriptan?

A

Avoid strong 3A4 inhibitors w eletriptan

36
Q

What is MOA of ergot alkaloids?

A

Stimulate alpha adrenergic receptor and decrease vascular tone w vasoconstriction

37
Q

What are CIs to ergot alkaloids?

A

Risk for coronary heart disease, avoid administration w strong 3A4 inhibitors, uncontrolled HTN, hepatic/renal impairment, peripheral vascular disease

38
Q

What are warnings/precautions w ergot alkaloids?

A
  • Boxed warning for serious/life threatening peripheral ischemia
  • Warnings for cardiac valvular fibrosis, vasospasms, or vasoconstriction, cerebrovascular events, ergotism
39
Q

What are SEs of ergots?

A
  • Retroperitoneal, pleuropulmonary, and valvular fibrosis
  • Ergotism, vasoconstrictive complications
40
Q

What is a drug interaction w ergots?

A

3A4 inhibitors - ergot toxicity can result

41
Q

What drugs are in the calcitonin gene-related peptide (CGRP) receptor antagonist class?

A

Rimegepant, ubrogepant, zavegepant

42
Q

What are CGRP receptor antagonists used for?

A

FDA approved for abortive tx

43
Q

What are CGRP receptor antagonists CI w?

A

CI w strong 3A4 inhibitors

44
Q

What drugs can cause interactions w CGRP receptor antagonists?

A

Moderate/strong 3A4 inducers and inhibitors, p-glycoprotein inhibitors

45
Q

What is lasmiditan used for?

A

a 5-HT1F receptor agonist in abortive therapy

46
Q

What are warnings/precautions of lasmiditan?

A

Med overuse headaches, sedation, dizziness, serotonin syndrome, driving impairment (avoid for at least 8 hrs after dose)

47
Q

What are SEs of lasmiditan?

A

Dizziness, fatigue, paresthesia, sedation

48
Q

What are drug interactions of lasmiditan?

A

Use w caution w other CNS depressants and serotonergic meds; avoid use w p-gp or BCRP substrates, other meds that can decrease HR

49
Q

What are monitoring parameters of lasmiditan?

A

LFTs, BP, HR (esp in pts w CV disease)

50
Q

What other drug is an abortive therapy that can be used as a rescue med?

A

Butophanol nasal spray

51
Q

What are the doses of the BBs used in preventive migraine drug therapy?

A
  • Propranolol 80-240 mg/day
  • Metoprolol 100-200 mg/day
52
Q

What are BBs CI in?

A

Asthma and Raynaud’s syndrome

53
Q

What is the dose of the tricyclic antidepressant used in preventive drug therapy?

A
  • Not FDA approved
  • Amitriptyline 25-150 mg/day (for mixed migraine/tension-type)
54
Q

What are the SEs of atogepant?

A

Nausea, constipation, fatigue

55
Q

What are the SEs of rimogepant?

A

Nausea, rash, dyspnea

56
Q

What is the dose of valproate?

A

500-1500 mg/day

57
Q

What is the dose of topiramate?

A

50-100 mg/day

58
Q

What is the recommendation for valproate and topiramate?

A

Not recommended in ppl of child bearing age unless using contraception

59
Q

What is a natural product for migraine preventive therapy w good evidence for its efficacy?

A

Butterbur/petasites 150 mg/day

60
Q

Dihydroergotamine/ergotamine in pregnancy.

A

CI in pregnancy, use of contraception is recommended

61
Q

Triptans in pregnancy.

A

Recommended for use only if the benefit outweighs the risk to the fetus

62
Q

Valproate in pregnancy.

A

CI in pregnancy when used for tx of migraines, contraception is recommended

63
Q

Topiramate in pregnancy.

A
  • May cause fetal harm if used during pregnancy
  • If used during pregnancy, monitor for development of metabolic acidosis during and after pregnancy
64
Q

What is almotriptan FDA approved for in terms of migraine therapy in children?

A

FDA approved for children 12 yo and older as abortive therapy

65
Q

What is rizatriptan FDA approved for in terms of migraine therapy in children?

A

FDA approved for children 6 yo and older as abortive therapy

66
Q

What is zolmitriptan nasal spray FDA approved for in terms of migraine therapy in children?

A

FDA approved for children 12 yo and older as abortive therapy

67
Q

Explain use of sumatriptan nasal spray in terms of migraine therapy in children.

A

Sumatriptan nasal spray is not FDA approved in children, but clinical trials have shown effectiveness in children at least 6 yo for abortive therapy

68
Q

Explain use of sumatriptan/naproxen combo in terms of migraine therapy in children.

A

FDA approved for children aged 12 and older for abortive therapy

69
Q

Explain use of topiramate in terms of migraine therapy in children.

A

FDA approved for children 12 yo and older for migraine prophylaxis

PHRM 845 (48 decks)

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