(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
2
Q
What are characteristics of migraine w/o aura?
A
Unilateral location, pulsating quality, moderate/severe pain, aggravation by routine activity
3
Q
What are sxs of migraine w/o aura?
A
Nausea and/or vomiting, photophobia, phonophobia
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
5
Q
What are sxs of migraine w aura?
A
Visual, sensory, speech/language, motor, brainstem, retinal
6
Q
What are the phases of migraine headache?
A
1) Prodrome
2) Aura
3) Migraine Headache
4) Postdromal
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
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
9
Q
What characterizes migraine headache phase?
A
- Dull ache that intensifies
- Unilateral and throbbing
- Phonophobia, photophobia
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
11
Q
What meds are associated w med overuse headache (migraine triggers)?
A
Associated w analgesics, ergots, triptans
12
Q
What meds can be a migraine trigger?
A
OC, hydralazine, NTG, nifedipine, cocaine
13
Q
What foods can be a migraine trigger?
A
Chocolate, oranges, tomatoes, onions, aged cheese, processed foods, alcohol, caffeine
14
Q
What additives/preservatives can be a migraine trigger?
A
Aspartame and monosodium glutamate
15
Q
What environment factors can be a migraine trigger?
A
Altitude/weather changes, perfume, tobacco smoke, loud noises, flickering lights
16
Q
What misc factors can be a migraine trigger?
A
Too little or too much sleep, skipping meals, stress, hormone changes
17
Q
Pts w migraines should avoid overuse of what drug class?
A
Analgesics
18
Q
What characterizes abortive tx?
A
- Education to avoid med overuse
- Mild-moderate: NSAIDs, acetaminophen
- Moderate-severe: triptans/ergots
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
20
Q
What is first line in abortive tx?
A
Triptans, NSAIDs
21
Q
What is second line in abortive tx?
A
NSAIDs
22
Q
What is first line in prevention tx?
A
Monotherapy:
- Valproate, topiramate, metoprolol, propranolol, frovatriptan
23
Q
What is second line in prevention tx?
A
Amitriptyline
24
Q
What is biofeedback and relaxation therapy?
A
- Non pharm option
- Decreases muscle tension and modifies blood flow
25
What is cognitive behavioral therapy (CBT)?
- Non pharm option
- Reduces emotional arousal associated w pain
26
How can diet be a non pharm therapy?
Elimination of food triggers and avoidance of hypoglycemia
27
How can sleep be a non pharm therapy?
Consistent duration and time of day to minimize variation in bedtime and wake time
28
What is transcutaneous electrical nerve stimulation (TENS) device?
- Non pharm therapy
- Prevention of episodic migraine pain, may stimulate release of endorphins to decrease pain
29
How can a headache diary be a non pharm therapy?
Identify triggers to be avoided
30
What are other non pharm therapies?
Exercise, massage, acupuncture, thermal biofeedback, heat/cold applications
31
What are CI of triptans?
- 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
What are the warnings/precautions of triptans?
- 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
What are the SEs of oral triptans?
Tingling, dizziness, drowsiness, fatigue, chest tightness/pressure, flushing
34
What is drug interaction between triptans and SSRIs/SNRIs?
- Use of triptan w SSRI/SNRI can increase risk of serotonin syndrome
- However, clinically, both get prescribed together all the time
35
What is a specific drug interaction w eletriptan?
Avoid strong 3A4 inhibitors w eletriptan
36
What is MOA of ergot alkaloids?
Stimulate alpha adrenergic receptor and decrease vascular tone w vasoconstriction
37
What are CIs to ergot alkaloids?
Risk for coronary heart disease, avoid administration w strong 3A4 inhibitors, uncontrolled HTN, hepatic/renal impairment, peripheral vascular disease
38
What are warnings/precautions w ergot alkaloids?
- Boxed warning for serious/life threatening peripheral ischemia
- Warnings for cardiac valvular fibrosis, vasospasms, or vasoconstriction, cerebrovascular events, ergotism
39
What are SEs of ergots?
- Retroperitoneal, pleuropulmonary, and valvular fibrosis
- Ergotism, vasoconstrictive complications
40
What is a drug interaction w ergots?
3A4 inhibitors - ergot toxicity can result
41
What drugs are in the calcitonin gene-related peptide (CGRP) receptor antagonist class?
Rimegepant, ubrogepant, zavegepant
42
What are CGRP receptor antagonists used for?
FDA approved for abortive tx
43
What are CGRP receptor antagonists CI w?
CI w strong 3A4 inhibitors
44
What drugs can cause interactions w CGRP receptor antagonists?
Moderate/strong 3A4 inducers and inhibitors, p-glycoprotein inhibitors
45
What is lasmiditan used for?
a 5-HT1F receptor agonist in abortive therapy
46
What are warnings/precautions of lasmiditan?
Med overuse headaches, sedation, dizziness, serotonin syndrome, driving impairment (avoid for at least 8 hrs after dose)
47
What are SEs of lasmiditan?
Dizziness, fatigue, paresthesia, sedation
48
What are drug interactions of lasmiditan?
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
What are monitoring parameters of lasmiditan?
LFTs, BP, HR (esp in pts w CV disease)
50
What other drug is an abortive therapy that can be used as a rescue med?
Butophanol nasal spray
51
What are the doses of the BBs used in preventive migraine drug therapy?
- Propranolol 80-240 mg/day
- Metoprolol 100-200 mg/day
52
What are BBs CI in?
Asthma and Raynaud's syndrome
53
What is the dose of the tricyclic antidepressant used in preventive drug therapy?
- Not FDA approved
- Amitriptyline 25-150 mg/day (for mixed migraine/tension-type)
54
What are the SEs of atogepant?
Nausea, constipation, fatigue
55
What are the SEs of rimogepant?
Nausea, rash, dyspnea
56
What is the dose of valproate?
500-1500 mg/day
57
What is the dose of topiramate?
50-100 mg/day
58
What is the recommendation for valproate and topiramate?
Not recommended in ppl of child bearing age unless using contraception
59
What is a natural product for migraine preventive therapy w good evidence for its efficacy?
Butterbur/petasites 150 mg/day
60
Dihydroergotamine/ergotamine in pregnancy.
CI in pregnancy, use of contraception is recommended
61
Triptans in pregnancy.
Recommended for use only if the benefit outweighs the risk to the fetus
62
Valproate in pregnancy.
CI in pregnancy when used for tx of migraines, contraception is recommended
63
Topiramate in pregnancy.
- May cause fetal harm if used during pregnancy
- If used during pregnancy, monitor for development of metabolic acidosis during and after pregnancy
64
What is almotriptan FDA approved for in terms of migraine therapy in children?
FDA approved for children 12 yo and older as abortive therapy
65
What is rizatriptan FDA approved for in terms of migraine therapy in children?
FDA approved for children 6 yo and older as abortive therapy
66
What is zolmitriptan nasal spray FDA approved for in terms of migraine therapy in children?
FDA approved for children 12 yo and older as abortive therapy
67
Explain use of sumatriptan nasal spray in terms of migraine therapy in children.
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
Explain use of sumatriptan/naproxen combo in terms of migraine therapy in children.
FDA approved for children aged 12 and older for abortive therapy
69
Explain use of topiramate in terms of migraine therapy in children.
FDA approved for children 12 yo and older for migraine prophylaxis
