Chapter 29 Headache Disorders

Question 1

Valproate (Depakote)

Answer 1

• anticonvulsant for migraine prophylaxis
• onset of efficacy 2-3 weeks
• ADE: sedation, tremor, weight gain

Question 2

Fluoxetine (Prozac)

Answer 2

• SSRI for migraine prophylaxis

- ADE: anxiety, tremors, anorexia, sexual dysfunction

Question 3

Amitriptyline (Elavil) > Desipramine (Norpramin)

Answer 3

• TCAs for migraine prophylaxis
• tertiary are considered more effective than secondary due to more potent inhibition of 5-HT reuptake
• ADE: drowsiness, tremor, anti-ACh effects

Question 4

Phenelzine (Nardil)

Answer 4

• MAOIs for migraine prophylaxis
• inhibit 5-HT degradation and may be used after failure of other antidepressants
• ADE: HTN crisis with tyramine and sympathomimetics

Question 5

Naproxen (Aleve)

Answer 5

• NSAIDS for migraine prophylaxis
• block synthesis of TXA2 and platelet aggregation
• reduce 5-HT release from platelets
• used continuously or intermittently

Question 6

Propranolol (Inderal) / Timolol (Timolide)

Answer 6

• beta blockers for migraine prophylaxis
• only those without ISA
• may attenuate 2nd phase by blocking B2 mediated vasodilation
• propranolol may cause more CNS effects than timolol

Question 7

Verapamil (Calan)

Answer 7

• Ca channel blocker for migraine prophylaxis
• may be less effective than alternatives
• antagonize the vasoconstrictive phase

Question 8

Gabapentin (Neurontin)

Answer 8

• migraine prevention

- MAO unclear for migraine prevention

Question 9

Botulinum Toxin A (Botox)

Answer 9

• migraine prophylactic

- limited use as alternative therapy

Question 10

Ergotamine (Ergomar)

Answer 10

• Ergot Alkaloids
• Migraine termination with most effect given early
• ADE: N/V, diarrhea, muscle cramp, cold skin. paresthesia, vertigo
• caution in CAD or PVD due to vasoconstrictive properties
• excessive dose can cause severe vasoconstriction/ischemia and cause rebound vasodilation requiring hospitalization
• daily dosing avoided to cumulative toxicity
• avoid use with beta blockers

Question 11

Dihydroergotamine (DHE, Migranol)

Answer 11

• Ergot Alkaloids
• Migraine termination with most effect given early
• ADE: N/V, diarrhea, muscle cramp, cold skin. paresthesia, vertigo
• caution in CAD or PVD due to vasoconstrictive properties
• excessive dose can cause severe vasoconstriction/ischemia and cause rebound vasodilation requiring hospitalization
• daily dosing avoided to cumulative toxicity
• avoid use with beta blockers

Question 12

Sumatriptan (Imitrex)

Answer 12

• triptans class for migraine termination
• ADE: chest tightness, weakness, somnolence, dizziness, paresthesias
• coronary vasospasm so avoid in angina, MI, CAD
• can increase BP so avoid in uncontrolled HTN
• avoid use with MAOI or within 24 hr of Ergot
• use with SSRIs increases risk of serotonin syndrome

Question 13

rizatriptan (maxalt)

Answer 13

• triptans class for migraine termination
• newer agent 10-20% more effective and lower recurrence
• ADE: chest tightness, weakness, somnolence, dizziness, paresthesia
• coronary vasospasm so avoid in angina, MI, CAD
• can increase BP so avoid in uncontrolled HTN
• avoid use with MAOI or within 24 hr of Ergot
• use with SSRIs increases risk of serotonin syndrome

Question 14

zolmitriptan (zomig)

Answer 14

• triptans class for migraine termination
• newer agent 10-20% more effective and lower recurrence
• ADE: chest tightness, weakness, somnolence, dizziness, paresthesia
• coronary vasospasm so avoid in angina, MI, CAD
• can increase BP so avoid in uncontrolled HTN
• avoid use with MAOI or within 24 hr of Ergot
• use with SSRIs increases risk of serotonin syndrome

Question 15

isometheptene (midrid)

Answer 15

• migraine termination

- reserved for when other agents contraindicated or ineffective

Question 16

tramadol (ultram)

Answer 16

• migraine termination

- opioid mu agonist that also inhibits reuptake of NE and serotonin in CNS