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NAPLEX 2024 > 59. Migraine > Flashcards

59. Migraine Flashcards

1
Q

Most migraines cause ____

A

N/V and sensitivity to light and sound

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2
Q

~1/3 of pts, migraines are preceded or accompanied by ____

A

senosory warning symptoms or signs (auras)

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3
Q

A headache accommpanied by ______ could indicate a serious cardiovascular, cerebrovascular, or infectious event and pts should seek immediate medical attention

A

Fever, stiff neck, rash, confusion seizures, double vision, weakness, numbness, chest pain, SOB, or aphasia (trouble speaking)

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4
Q

The cause of migraines is not well understood. They may be caused by increased neuronal activity, which results in an imbalance of NT (including ____) and/or activation of the trigeminal nerve (with release of _____)
These NT and neuropeptide changes ultimately lead to neurogenic inflammation and vasodilation in cranial blood vessels

A

serotonin
calcitonin gene-related peptide (CGRP)

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5
Q

A common type of migraine is ____ in women

A

Menstrual-associated migraine (MAM)

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6
Q

Menstrual-associated migraine (MAM) can be treated with ___

A

oral contraceptives, estradiol patch or creams to decrease frequency

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7
Q

Women who has migraine with aura have higher risk for ___ and should not use ___-containing contraceptives

A

Stroke
Estrogen-containing contraceptives

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8
Q

Common migraine triggers

A

Hormonal changes in women
Foods - alcohol (esp beer, red wine), aged cheese, chocolate, aspartame, overuse of caffeine, MSG, salty foods, processed foods
Stress
Sensory stimuli - bright lights, sun glare, loud sounds, certain scents
Changes in environment (weather or pressure)

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9
Q

Migraines can be dx when an adult has at least ___ attacks (not attributed to another disorder) fulfilling the following criteria:
1. headaches last ____ and recur sporadically
2. Headaches have ≥2 of the following characteristics: _____
3. One of the following occurs during the headache: _____

A

5 attacks
1. 4-72 hrs
2. unilateral location, pulsating, mod-severe pain, and aggravated (or causing avoidance of) routine physical activity
3. Nausea and/or vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound)

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10
Q

Natural products used for migraines

A

Riboflavin (Vit B12), Magnesium, butterbur, feverfew
Others: peppermint (topical) and coenzyme Q10

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11
Q

Medication overuse headaches (“rebound”) can result from the overuse of most acute headache medications. To prevent MOH, limit acute treatment meds to ___ times per week.

A

2-3x/week

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12
Q

OTC options for migraines

A

Acetaminophen, aspirin, Advil Migraine (contains only ibuprofen), naproxen, and combo products such as Excedrin Migraine (aspirin, APAP, caffeine)

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13
Q

Rx options for migraines

A

Serotonin receptor agonists (triptans), selec=ct CGRP receptor antagonists, ergotamine drugs, NSAIDs (high dose, and lasmiditan

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14
Q

What medications are not recommended in migraines d/t decreased efficacy, abuse/dependence potential, and risk of rebound headache?

A

Butalbital-containing products, opioid, tramadol, and tapentadol

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15
Q

Triptans MOA

A

Selective agonists for the 5-HT1 receptor (vasoconstrict cranial blood vessels)

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16
Q

What medication is first line for acute treatment for migraines?

A

Triptans

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17
Q

Rizatriptan formulations

A

Tablet, ODT

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18
Q

sumatriptan formulations

A

Tablet, SC (autoinjector, prefilled syringe and solution), nasal spray

Imitrex - tablet, nasal spray, SC injection

Imitrex STATdose system, Zembrace SymTouch - SC autoinjector

Onzetra Xsail - nasal powder

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19
Q

Sumatriptan PO dose frequency

A

can repeat x1 after 2 hrs

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20
Q

Sumatriptan SC Imitrex, Imitrex STATdoes System vs Zembrace SymTouch dose frequency

A

Imitrex, Imitrex STATdoes System = repeat x1 after 1 hr
Zembrace SymTouch = can repeat up to 4x/day, wait a minimum of 1 hr between doses

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21
Q

Sumatriptan intranasal spray vs powder dose frequency

A

Spray (Imitrex) = 1 nostril, can repeat x1 after 2 hrs
Powder (Onzetra Xsail) = each nostril, can repeat x1 after 2 hrs

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22
Q

zolmitriptan (Zomig ZMT) formulations

A

Tablet, ODT, nasal spray

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23
Q

Zomitriptan intranasal dosing frequency

A

1 nostril, can repeat x1 after 2 hrs

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24
Q

Contraindications of triptans

A

Cerebrovascular disease (stroke/TIA), uncontrolled HTN, ischemic heart disease, use within 24 hrs of another triptan or ergotamine-type medication

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25
Q

Warnings for triptans

A

Risk of increased BP, serotonin syndrome

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26
Q

Side effects for triptans

A

Paresthesia (tingling/numbness)
Others: dizziness, hot/cold sensations, chest pain/tightness, dry mouth, somnolence, nausea

Triptan sensations (pressure or heaviness in chest or neck region) usually dissipate after administration

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27
Q

ODTs, nasal sprays, and injection formulations of triptans are useful if ___ is present. Nasal sprays and injections work faster

A

Nausea

28
Q

Triptan nasal sprays contain __ dose

A

1 dose (do not prime)

29
Q

T/F: Triptan nasal sprays require priming before use

A

False - they only contain 1 dose

30
Q

Sumatriptan/naproxen (Treximet) dispensing requirements

A

Protect from moisture, dispense in original container

31
Q

Rixatriptan (Maxalt-MLT), Zolmitriptan (Zomig ZMT) ODTs contain phenylalanine and should not be used in pts with ___

A

phenylketonuria

32
Q

Which triptans are approved for children and adolescents ≥12 yo? 6-17yo?

A

≥ 12 yo: Almotriptan tablets, zolmitriptan nasal spray, and sumatriptan/naproxen (Treximent)
6-17yo: Rizatriptan

33
Q

Which triptan has the longest half-life?

A

Frovatriptan (26 hrs) - considered long-acting but onset is slower

34
Q

Which triptans are considered long-acting but onset is slower? Typically used if headache recurs after dosing, lasts a long time or can be anticipated (e.g. MAM)

A

Frovatriptan and naratriptan

35
Q

All sumatriptan injections are injected (IV/IM/SC). Preferred site is _____

A

SC
Lateral thigh or upper arm

36
Q

Which triptans come as PO tablets?

A

All

37
Q

Which triptans come as ODT?

A

Rizatriptan (Maxalt-MLT)
Zolmitriptan (Zomig ZMT)

38
Q

Which triptans come as nasal sprays?

A

Sumatriptan (Imitrex)
Zolmitriptan (Zomig)

39
Q

Which triptans come as nasal powders?

A

Sumatriptan (Onzetra Xsail)

40
Q

Which triptans come as SC injection?

A

Prefilled syringe - sumatriptan

Autoinjector - sumatriptan (Imitrex STATdose system, Zembrace SymTouch)

41
Q

Which triptans are contraindicated with MAO inhibitors or within 2 weeks of stopping?

A

Sumatriptan, rizatriptan, zolmitriptan

42
Q

Ergotamine MOA

A

Nonselective antagonist of serotonin receptors&raquo_space; causes cerebral vasoconstriction

43
Q

Dihydroergotamine (D.H.E. 45, Migranal) formulations

A

Injection (IM/SC/IV)
Nasal spray

44
Q

Boxed warning for ergotamine drugs

A

Contraindicated with potent CYP3A4 inhibitors d/t life-threatening peripheral ischemia

45
Q

Contraindications for ergotamine drugs

A

Uncontrolled HTN, ischemic heart disease, pregnancy
Others: angina, MI, peripheral vascular disease, hemiplegic or basilar migraine, renal/hepatic impairment, sepsis, use with pressors/vasoconstrictive drugs, use within 24 hrs of serotonin agonists (triptans) or other ergotamine-type drugs

Dihydroergotamine: avoid use during or within 2 weeks of d/c MAOi

46
Q

Warnings for ergotamine drugs

A

CV effects (avoid in any pt with baseline risk
Cerebrovascular events
Potentially serious drug interactions
Others: ergotism (intense vasoconstriction resulting in peripheral vascular ischemia and possible gangrene), cardiac valvular fibrosis

47
Q

T/F: Dihydroergotamine nasal spray requires priming before use

A

True - prime by pumping 4 times (do not inhale deeply (to let drug absorb into skin in nose)

48
Q

___ and ___ are oral CGRP receptor antagonists used for acute treatment. CGRP contributes to vasodilation and neurogenic inflammation in the pathogenesis of migraines; blocking the CGRP receptor helps reduce or eliminate migraine pain

A

Rimegepant (Nurtec) - ODT
Ubrogepant (Ubrelvy) - PO

49
Q

___ is an oral CGRP receptor antagonist approved to treat migraine attacks and ___ is approved to prevent AND treat acute migraine attacks

A

Treat only = Ubrogepant (Ubrelvy)
Treat + prevent = rimegepant (Nurtec)

50
Q

____ is a first-in-class serotonin agonist that is selective for 5-HT1F receptor subtype. Unlike triptans and ergotamine drugs, this drug does not cause vasoconstriction.

A

Lasmiditan (Reyvow) - C-V

51
Q

___ is a barbiturate found in Fioricet and Fiorinal. Butalbital-containing products are not recommended for treating acute migraines d/t abuse/dependence issues and lower efficacy. Taper when d/c.

A

Butalbital

52
Q

Preventative treatment should be considered who use acute migraine treatments ≥ ___ days/week or ≥ ____ times per month, have migraines that decrease QOL, if acute treatments are ineffective or contraindicated, or requested by pt

A

≥2 days/week
≥3 times per month

53
Q

Which antihypertensives can be used as ppx therapy for migraines?

A

Beta-blockers, best evidence with propranolol (Inderal)

54
Q

Which antiepileptic drugs can be used as ppx therapy for migraines?

A

Topiramate (Topamax) and valproic acid

55
Q

___ causes weight loss in many pts, making it a popular choice for migraine ppx

A

Topiramate

56
Q

2 oral CGRP receptor antagonists approved for ppx of migraines

A

Rimegepant (Nurtec and atogepant (Qulipta)
(Note: other CGRP antagonists used for migraine prevention are injectable monoclonal antibodies)

57
Q

Side effects of valproic acid, divalproex (Depakote)

A

Weight gain, thrombocytopenia, increased ammonia, alopecia
Others: N/V, somnolence, tremor, PCOS

58
Q

Side effects of topiramate (Topamax)

A

Weight loss (6-13%), somnolence, cognitive impairment
Others: paresthesia, reduced efficacy of oral contraceptives

59
Q

Warnings of valproic acid, divalproex (Depakote)

A

Fetal harm, hepatic failure, pancreatitis

60
Q

Warnings of topiramate (Topamax)

A

Fetal harm, metabolic acidosis, nephrolithiasis, increased ammonia, open angle glaucoma, and visual field defects, oligohirosis

61
Q

CGRP receptor antagonist for migraine ppx: Vyepti dosing frequency

A

IV every 3 months

62
Q

CGRP receptor antagonist for migraine ppx: Aimovig dosing frequency

A

SC once monthly

63
Q

CGRP receptor antagonist for migraine ppx: Ajovy dosing frequency

A

SC monthly or higher dose SC every 3 months

64
Q

CGRP receptor antagonist for migraine ppx: Emgality dosing frequency

A

Once monthly

65
Q

Botox is from chronic migraines only (≥ ___ headache days per month)

A

15

66
Q

Onzetra Xsail nasal powder administration notes

A

Insert nosepiece deeply into nose and rotate device to place the mouthpiece into your mouth
Blow into device with your mouth for 2-3 seconds to deliver medication into your nose
Repeat for second nostril

NAPLEX 2024 (74 decks)

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