Ch 25 highlights Flashcards
for mild to moderate migraine symptoms
NSAIDS (ASA, Naproxin)
For moderate to severe migraine symptoms
Serotonin Agonist (Triptans) - 1st line Ergot alkaloid second line opioid analgesic (butorphanol) if these fail
what 2 antiemetic meds are approved for migraine
Reglan and Prochlorperazine (formally known as compazine)
what is the recommended drug for opioid analgesics used for migraine treatment
Butorphanol nasal spray
what is first line for terminating migraine attack
Serotonin Receptor Agonist (Triptans)
-Sumatriptan (Imitrex)
What is the biggest concern when taking Sumatriptan (imitrex)
Coronary Vasospasm
Pt is taking Sumatriptan and is experiencing Heavy arms and chest pressure. Denies pain.
symptoms are transient and not related to ischemic heart disease. Not dangerous
What pt population should not take Sumatriptan
CAD
Angina
Rule out CAD if they are postmenopausal women, men older than 40, smokers, History of HTN, Hypercholesterolemia, diabetes or a family history of CAD
can you take sumatriptan while pregnant
no
sumatriptan should not be used within ____ hours of another triptan or a ergo alkaloid
24 hours
can you take Sumatriptan with an MAOI
No, and should not be used within 2 weeks of stopping an MAOI
signs of serotonin syndrome
ams incoordination myoclonus hyperreflexia excessive sweating tremor fever
can you take sumatriptan with SSRI/SNRI
no, may cause serotonin syndrome
prozac is in what drug class
SSRI
cymbalta is in what drug class
SNRI
what drug class Isocarboxazid (marplan) Phenelzine (Nardil) Selegiline (Emsam) Tranycypromine (Parnate)
MAOI
what drug class is second line for migraine abortion if the triptans did not work
Ergot Alkaloids
- Ergotamine
- Dihydroergotamine
what medication can you add to Ergotamine to help reduce nausea/vomiting
metoclopramide
prochlorperazine
ischemia secondary to constriction of peripheral arteries and arterioles: the extremities become cold, pale and numb. muscle pain develops and gangrene may eventually result
ergotism (toxicity from ergotamine) highest risk in sepsis, peripheral vascular disease and renal/hepatic impairment
pt on ergotamine prn for migraine abortion develops headache nausea, vomiting and restlessness
withdrawal due to physical dependence - resembles a migraine attack so the pt is likely to resume taking the drug perpetuating the cycle of dependence.
hospitalization may be required to break the physical dependence
what patient populations should not take ERgotamine
hepatic/renal impairment CAD peripheral vascular disease uncontrolled HTN taking potent inhibitors of CYP3A4 pregnant women
What is a intranasal spray that is a second line drug for migraines
Dihydroergotamine
associated with a lower rate of migraine recurrence
first line drug for migraine prevention
B Blockers
- propanolol
- metoprolol
pt is taking propanolol for 4 days and calls because it does not seem to be preventing his migraines
benefits take a few weeks to develop
antiepileptic drugs used in migraine prevention
Depakote ER
Topamax
Gabapentin
Gabitril
side effects for Depakote
nausea fatigue weight gain tremor bone loss reversible hair loss
fatal pancreatitis and hepatitis can occur
can Depakote be used in pregancy
no
Tricyclic antidepressant used in migraine prevention
Elavil
side effects of Elavil (Tricyclic antidepressant)
hypotension
anticholinergic effects
-dry mouth, constipation, urinary retention, blurred vision, tachycardia)
a migraine that routinely occurs 2 days of the onset of menses
menstrually associated migraine (triggered by decline in estrogen levels that precede menstruation)
medications for menstrually associated migraines
estrogen
estrogen gel and patches (Divigel, climara)
perimenstrual triptans - frovatriptan, naratriptan, zolmitriptan - dosing is done for 6 days each month beginning 2 days before expected onset of menses
Naproxen sodium BID given 6 days before to 7 days after menses
what are the 2 other drugs for migraine prevention
Erenumab (Aimovig) - human immunoglobulin G2 monoclonal antibody
Botulinum toxin (Botox)
a migraine that occur in a cluster of attacks each lasting 15 min to 2 hours and characterized by severe throbbing, unilateral pain in the orbital temporal area.
cluster headaches
how are cluster different from migraine
cluster headaches are not preceded by an aura
they do not cause n/v
they can be more debilitating
occur mostly in males
not associated with a family history of attacks
migraine headaches occur more often in what gender
females
what meds are used to prevent cluster headaches
glucocorticoids (prednisone, dexamethasone)
verapamil - first line
lithium - second line - serum levels require monitoring
suboccipital steroid injections are the only established effective treatment in the prophylaxis of cluster headaches
the only treatment for Medication overuse headache is
to stop taking all headache medicines
what measures can be taken to decrease the risk of developing MOH
limit use of abortive medicines
take abortive meds no more than 2-3 times per week
doses should be no higher than actually needed
what triptan has effects that persist longer than other triptans and helps the 24 hour recurrence rate to be decreased
naratriptan
ASA has a shorter or longer half life
shorter
Are Ergotamine and Zolmitriptan short acting or long acting
they do not have long durations
Beta Blockers cannot be used in what pt population
Asthmatics
COPD
what effects does Reglan have on oral anti-migraine meds
improves absorption
what is the first step in managing headaches for prevention
keep a headache diary to help identify triggers
what is meds to rescue for cluster headaches
Sumatriptan or Oxygen
Inhaling oxygen 100% for 15-20 min
abortive max use per week
1-2
Sumatriptan and ASA
when combined with reglan, ASA may work as well as sumatriptan which is a highly effective migraine
recommended opioid analgesic for migraine
butorphanol nasal spray
Sumitriptan (imitrex) is approved for
migraines
cluster h/a
contraindications for Sumitriptan (imitrex) - health conditions and why
coronary vasospasm is a big risk
NO cardiac history or risk of CAD
no in pregnancy
must r/o CAD if have following postmenopausal men older than 40 smokers HTN Hypercholesterolemia DM family history of CAD
adverse effect for Sumitriptan (imitrex) that is not concerning
chest pressure or heavy arms
pulmonary vasoconstriction
esophageal spasm
not dangerous
forewarn pt
drug interactions for Sumitriptan (imitrex)
Ergo alkaloids - also cause vasoconstriction so dont combine within 24 hours of each other (ergotamine, dihydroergotamine)
MAOI - toxicity - not within 2 weeks
SSRI/SNRI - risk of serotonin syndrome
(SSRI- fluoxetine - Prozac)
(SNRI- duloxetine - Cymbalta)
s/s serotonin syndrome
AMS anxiety hallucinations incoordination myoclonus hyperreflexia excessive sweating tremor fever
antiemetic meds for migraine
metoclopramide (Reglan)
prochlorperazine (Compazine)
Ergotamine is metabolized by
CYP3A4
adverse effect of Ergotamine that is common and what can be given with it to help
n/v
metoclopramide or prochlorperazine
other weakness in legs myalgias numbness and tingling in fingers and toes angina like pain tachycardia bradycardia
overdose of Ergotamine
symptoms
ergotism
ischemia secondary to constriction of peripheral arteries and arterioles
the extremities become cold, pale and numb, muscle pain develops and gangrene may eventually result
what should not be combined with ERgotamine
triptans (sumatriptan, zolmitriptan)
prolonged vasospastic reaction
separate by 24 hours
physical dependence and ergotamine
if used daily, you can develop physical dependence
s/s h/a n.v restlessness resembles a migraine attack which perpetuates the dependence cycle - hospitalization may be needed to break this cycle
who is Ergotamine contraindicated for
hepatic/renal impairment
sepsis (can cause gangrene)
CAD
Peripheral vascular disease
uncontrolled HTN
taking a CYP3A4 inhibitor
pregnancy
Dihydroergotamine (DHE) IM, IV or sub q
second line migraine abortive
also available intranasal
what b blockers are approved for migraine preventative
propanolol
metoprolol
timolol
atenolol
nadolol
can take a few weeks to develop benefits
antiepileptic drugs for migraine prevention
Divalproex (Depakote ER)
Topiramate (Topamax)
Gabapentin (Neurontin)
Tiagabine (Gabitril)
1st line for migraine prevention
B Blockers
Black box for Divalproex (Depakote)
fatal pancreatitis and hepatitis
teratogenic in pregnancy
adverse effects Topiramate (Topamax)
paresthesias
fatigue
cognitive dysfunction (psychomotor slowing, word finding difficulty, impairment of concentration and memory)
metabolic acidosis
moderate weight loss
TCA for migraine prevention
amitriptyline (elavil)
side effect of amitriptyline (elevil)
hypotension anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision, tachycardia)
migraine that routinely occurs within 2 days of menses
menstrually associated migraine
what meds for menstrually associated migraine
estrogen
topical estrogen gel or patches Divigel, climara)
perimenstrual triptans also help frovatriptan naratriptan zolmitriptan 6 days a month beginning 2 days before expected onset
other meds for migraine
botox erenumab (Aimovig) - sub q
series of headaches lasting 15 min to 2 hours characterized by severe, throbbing, unilateral pain in the orbital temporal area
cluster headaches
rules of cluster headaches
not preceded by aura do not cause n/v can be more debilitating less common more common in males not associated with familial history
drugs prophylaxis cluster
glucocorticoids (prednisone, dexamethasone)
verapamil - 1 st line
lithium
abortive for cluster
sumatriptan - 1st line or oxygen
