Exam 1 - HA/Migraine Flashcards
Migraine with aura usually presents in what order?
visual, then sensory, then language
Migraine distinction symptoms? (7)
positive visual symptoms, gradual onset, sequential progression, repetitive identical attacks, flurry of attacks midlife, duration < 60 min, headache follows ~50%
TIA distinction symptoms? (5)
visual loss, abrupt, simultaneous occurrence, duration < 15 min, headache accompaniment uncommon
Recommended treatment options for mild to moderate migraine attacks? (3)
NSAIDs, acetaminophen, caffeinated analgesic combinations
Recommended treatment options for moderate to severe migraine attacks? (4)
triptans, DHE, gepants, ditans
Recommended treatment options for refractory moderate to severe migraine attacks? (5)
triptans + NSAIDs, gepants, ditans, analgesics + codeine or tramadol, opioids
Recommended treatment options for migraines with N/V, etc.? (2)
non-oral formulations, antiemetics (e.g., prochlorperazine)
What are the oral NSAID solutions for acute treatment of migraines? (2)
diclofenac potassium (Cambia) and celecoxib (Elyxyb)
What are the brands of butalbital/APAP/caffeine combinations? (4)
Fioricet, Bac, Esgic, Zebutal
How long can you use barbiturate combinations drugs to avoid MOH?
< / = 3 days/mo
Which butalbital combination can cause MOH and is a controlled substance (CIII)?
Fiorinal
What is the MOA for triptans?
5-HT selective agonists
Are triptans for acute or prohpylactic treatment?
acute
What are adverse effects of triptans?
flushing, chest pain, palpitations, dizziness, fatigue, serotonin syndrome
How long can you use triptans to avoid MOH?
< 10 days/mo
What are contraindications for triptans?
ischemic heart disease, cerebrovascular syndromes, uncontrolled HTN, MAOIs
Which triptans are PO only? (4)
almotriptan, eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge)
Order of half-life for triptans that are PO only?
longest is frova, nara, almo, ele
Which triptans are not PO-only? (3)
rizatriptan (Maxalt), sumatriptan (Imitrex), zolmitriptan (Zomig)
What is the onset of action in minutes for sumatriptan’s PO, intranasal, and SQ formulations?
PO = 30, intranasal = 15-30, SQ = 10
What is the MOA for lasmitidan (Reyvow)?
5-HT receptor agonist
Are ditans for acute or prophylactic treatment?
acute
What are adverse effects of ditans?
MUST WAIT 8HRS, CNS depression, serotonin syndrome, decreased HR, increased BP, N/V
What is the MOA for gepants?
CGRP receptor antagonists
Is rimegepant (Nurtec) for acute or preventive treatment?
BOTH
What is the dosing for acute rimegepant (Nurtec)? Prevention dosing?
acute = 75mg PO once; 75mg PO every other day
When should rimegepant (Nurtec) be avoided?
CrCL < 15 mL/min, severe hepatic impairment
What are adverse effects of rimegepant (Nurtec)? (3)
abdominal pain, dyspepsia, nausea
Is ubrogepant (Ubrelvy) for acute or preventive treatment?
acute
What is the dosing for ubrogepant (Ubrelvy)?
50-100mg PO once, may repeat dose after 2 hours (max 200mg/day)
What is the MOA for ergots?
5-HT receptor agonists
What are the BBWs for ergots?
CYP3A4 inhibitors (protease inhibitors, macrolides, azoles)
What are adverse effects for ergots? (2)
cardiac valvular fibrosis, ergotism
What are contraindications for ergots?
pregnancy/breastfeeding, older adults
What should be avoided in acute or preventive migraine treatment?
opioids and barbiturates
What is the MOA of topiramate? (4)
blocks voltage-dependent sodium channels, enhances GABA activity, antagonizes AMPA receptors, weakly inhibits carbonic anhydrase
What are adverse effects of topiramate?
cognitive dysfunction, CNS effects, nephrolithiasis, metabolic acidosis, angle-closure glaucoma, oligohydrosis/hyperthermia, suicidal ideation, weight loss, paresthesia
What are important counseling points for topiramate? (3)
stay hydrated, avoid in pregnancy, may take up to 2-3 months
What are BBWs for valproic acid? (4)
hepatotoxicity, patients with mitochondrial disease, fetal risk, pancreatitis
What is a contraindication for valproic acid?
pregnancy and childbearing potential without effective contraception
Which beta blockers are preferred for migraine?(2)
propranolol, timolol
What are adverse effects of TCAs?
anticholinergic effects, cardiac conduction abnormalities
Is atogepant (Qulipta) for acute or preventive treatment?
preventive
What is the dosing for atogepant (Qulipta)?
10, 30, 60mg po once daily
Which mab targets the CGRP receptor? (1)
erenumab (Aimovig)
Which mab is also indicated for prevention of cluster headache? (1)
galcanezumab (Emgality)
Which mab is dosed IV every 3 months?
eptinezumab (Vyepti)
Which mabs are SQ every month? (3)
erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality)
Which mab can cause nasopharyngitis and nausea?
eptinezumab (Vyepti)
Which mab can cause constipation?
erenumab (Aimovig)
What is the most common peripheral nerve block, and what does it use?
greater occipital nerve block, lidocaine/bupivicaine/methylprednisolone
What is a good OTC for menstrual migraines?
PO magnesium
What are adverse effects of PO magnesium?
diarrhea, N/V
What is a good OTC for migraine prophylaxis?
vitamin B2 (riboflavin)
What are adverse effects of feverfew? Contraindications?
GI issues; pregnancy
What are adverse effects of butterbur? Contraindications?
GI, rash, fatigue; products not labeled as free from pyrrolizidine alkaloids (PA-free)
What is a BBW for Botox?
spread of toxin effect
What are adverse effects for Botox?
injection site pain, neck pain, myalgia, facial paresis
What is treatment for acute cluster headaches? (3)
oxygen, SQ (preferred) or intranasal sumatriptan, intranasal zolmitriptan
What is treatment for preventive cluster headache? (1)
verapamil
What is treatment for hemicrania continua?
indomethacin
What medications can cause pseudotumor cerebri? (3)
growth hormone, tetracyclines, retinoids
What are treatments for pseudotumor cerebri? (5)
withdraw offending agent, weight loss, carbonic anhydrase inhibitors, furosemide, migraine preventive meds
What is reversible cerebral vasoconstriction syndrome also known as?
thunderclap headache (subarachnoid hemorrhage)
What are the cutoffs for medication overuse headache? (5)
non-opioid analgesics = 15, ergots = 10, triptans = 10, opioids = 10, butalbital = 5
Explain headache red flags SNOOP acronym?
systemic symptoms/signs/disease, neurologic symptoms/signs, onset sudden and after age 40, pattern change