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701 > Exam 1: Migraine > Flashcards

Exam 1: Migraine Flashcards

1
Q

list the 4 primary headache disorders

A
  1. migraine
  2. tension
  3. cluster
  4. hemicrania
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2
Q

list the 7 secondary headache disorders

A
  1. traumatic brain injury
  2. pseudotumor cerebri
  3. brain tumor
  4. reversible cerebral vasoconstriction syndrome
  5. subarachnoid
  6. medication overuse
  7. substance withdrawal
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3
Q

Migraine, no aura dx

A

at least 5 attacks with:
- last 4-72 hours
- 2/4 characteristics:
1. unilateral
2. pulsating
3. moderate-severe pain
4. aggravation by routine activity

AT LEAST 1 of
- photophobia
- phonophobia

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4
Q

Migraine with aura dx

A

at least 2 attacks with:
- one or more reversible aura sx:
>visual, sensory, speech, motor, brainstem, retinal
- at least 3/6 characteristics
1. one aura sx spreads gradually over ≥5 min
2. two or more sx in succession
3. each sx lasts 5-60min
4. at least 1 sx is unilateral
5. at least 1 sx is positive
6. aura w/ headache within 60 min

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5
Q

Migraine Aura sx

A

visual sx
gradual onset, spread
sequential progression
repetitive attacks, identical nature
flurry of attacks midlife
lasts <60 min
50% chance headache

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6
Q

Transient ischemic attack sx

A

Visual LOSS
ABRUPT, stepwise evolution
Simultaneous occurence of symptoms
lasts < 15 minutes (shorter)
no headache usually

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7
Q

Principles of migraine pharmacotherapy

A

BIG dose better
The SOONER given the better
Don’t overuse - more headache

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8
Q

Mild migraine

A

NSAID, APAP, Caffeinated options

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9
Q

Mod-severe
or refractory to OTC

A

triptans>DHE
Gepants, ditans if triptans contraindicated

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10
Q

Refractory mod-severe

A

Triptans + NSAID
Gepants
Lasmiditan
Analgesic w/ codeine/tramadol if infrequent
Opioids if infrequent (butorphanol)

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11
Q

Nasal/injectable formulations

A

for severe N/V, swallowing difficulties
Sx reach max intensity rapidly
inadequate response to traditional oral therapies
+ antiemetics (prochlorperazine, metoclopramide)

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12
Q

NSAID oral solutions use

A

rapid absorption
try if tablet takes too long to kick in
Mix with water
- diclofenac
- celecoxib

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13
Q

When to use Butalbital + caffeine + APAP

A

tension type, or migraine

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14
Q

Risks of Butalbital + caffeine + APAP

A

APAP = BBW hepatotoxicity
Medication overuse headache

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15
Q

AE butalbital + caffeine + APAP

A

cns depression
stomach upset

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16
Q

controlled migraine medications

A

Fiorcet/Fiorinal+codeine CIII
Lasmitidan (reyvow) CV

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17
Q

Triptans use limit for MOH

A

<10 days/month
give early in course of attack
caution in older adults d/t CV risk
start low go slow

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18
Q

Triptans ADR

A

flushing
chest pains
palpitations
dizziness
fatigue
xerostomia
serotonin syndrome

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19
Q

Triptans contraindication

A

hx hemiplegic migraine or w/brainstem aura
Known/suspected heart disease
Arryhtmias/cardiac pathway conduction disorder
Cerebrovascular syndromes
PVD (ischemic bowel disease)
Uncontrolled HTN
use within 24 h ergotamine or other triptan

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20
Q

MAOIs C/I with which triptans?

A

RIZ
SUM
ZOL
(maoi ex: hydrazine)

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21
Q

Triptan CV risk study: Hall

A

only looked at patients w/ less CV risk - inconclusive

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22
Q

Triptan CV risk study: Velentgas

A

excluded pt with history of CV or cerebrovascular in year prior

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23
Q

Triptan CV risk study: Albieri

A

no info on non-migrainers
triptan increased risk for stroke
(migraines worsen CV, not the drug)

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24
Q

Longest half life triptan

A
  1. frovatriptan
  2. naratriptan
  3. eletriptan
  4. almotriptan
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25
Q

pro/con of long half-life triptan

A

Pro: prevents reoccurrence
con: slower onset

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26
Q

Renal adjust triptans

A

Almotriptan ≤30ml.min
Naratriptan ≤15 ml/min

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27
Q

hepatic adjust triptans

A

Almotriptan
Naratriptan

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28
Q

Almotriptan unique

A

lower chest pain/tightness
SULFA group
reduce for CYP inhibitor, renal, hepatic
better tolerated
shortest half life

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29
Q

Eletriptan unique

A

Contraindicated CYP 3A4 inhibitor
most lipophillic
avoid severe hepatic impairment

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30
Q

Naratriptan unique

A

better than suma, slower onset
Contraindicated severe hepatic
dose reduce hepatic/renal

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31
Q

SQ Triptans

A

only sumatriptan

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32
Q

ODT triptan

A

RIZ
ZOL

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33
Q

Intranasal triptans

A

SUM
ZOL

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34
Q

Rizatriptan unique

A

dose reduce if propanolol

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35
Q

Sumatriptan unique

A

SQ 10 min
Nasal 15-30 min
lowest PO bioavailability

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36
Q

Zolmitriptan unique

A

Dose reduce/d/c if hepatic

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37
Q

Lasmitidan unique

A

give once. repeat dose not helpful
AVOID if severe hepatic….
WAIT 8 H between dosing and driving

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38
Q

Lasmitidan ADR

A

CNS depression
Serotonin syndrome
decreased HR, increased BP, palpitation, dizziness, N/V

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39
Q

Lasmitdan onset

A

30-60 min

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40
Q

Gepants

A

small molecule CGRP antagonist

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41
Q

Nurtec (rimegepant) use

A

Acute: 75 QD
Prevent: 75mg every other day

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42
Q

Nurtec AVOID

A

severe hepatic impairment
renal ≤15 (not studied)

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43
Q

Nurtec benefit

A

acute and prevention
ODT onset ≤2 hrs for acute

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44
Q

Nurtec ADR

A

abdominal pain
dyspepsia
nausea

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45
Q

Ubrogepant (ubrelv) use

A

ACUTE only: 50-100mg x1
may repeat dose after ≥2 hrs
MDD 200mg
Affected by high fat meal

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46
Q

Ubrelvy contraindication

A

strong CYP3A4 inhibitors
renal <15

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47
Q

Ubrelvy ADR

A

nausea
drowsiness
xerostomia

48
Q

Quilipta (Atogepant) use

A

prevention only of episodic
10/30/60mg x 1

49
Q

Atogepant hepatic/renal

A

severe hepatic avoid
renal <30 reduce

50
Q

Atogepant ADR

A

constipation
nausea
drowsiness/fatigue
weight loss

51
Q

CGPR Mabs pro/con

A

Pro: long half life, not many DDI
con: caution CV

52
Q

Drug interaction CGRP mab

A

Efgartigimod (vygart)
monitor closely

53
Q

CGRP mab for cluster prevention

A

Galcanezumab (emaglity)

54
Q

CGRP with constipation ADR

A

Aimovig (erenumab)

55
Q

CGRP with nasopharyngitis, nausea

A

Eptinezumab (Vyepti)

56
Q

targets ligand

A

Epitinezumab (Vyepti)
Fremanezumab (Ajovy)
Galcanezumab (Emaglity)

57
Q

targets receptor

A

Erenumab (Aimovig)

58
Q

CGRP ab IV

A

Eptinezumab (Vyepti)
Every 3 months

59
Q

CGRP SQ

A

Erenumab (Q month)
Fremanezumab (Q month/3month)
Galcanezumab (Q month)

60
Q

Greater occipital nerve block drugs

A

lidocaine
bupivacaine
Methylprednisolone (avoid in pregnancy)

61
Q

Nonpharm migraine

A

Stress reduce, Diet, avoid trigger

62
Q

alt migraine tx

A

magnesium
B2
feverfew
Butterbur
neuromod device

63
Q

PO magnesium use

A

prophylaxis, esp aura
menstrual migraine
400mg BID
citrate>oxide
start low go slow

64
Q

PO magnesium ADR

A

diarrhea
n/v

65
Q

B2 riboflavin use

A

well tolerated
prophylaxis
good for menstration
400mg QD for 3 months reduce duration/pain

66
Q

Feverfew use

A

prophyalxis
AVOID PREGNANCY - contractions
50-150mg QD for 4 months

67
Q

Feverfew ADR

A

GI

68
Q

Butterbur (petasites) use

A

prophylaxis
avoid products not labeled “PA free”
d/t toxic alkaloid formation

69
Q

Butterbur ADR

A

GI (belch,n/v/d)
drowsiness
fatigue
pruritis, rash
hepatotoxicity (RARE)

70
Q

Ergot BBW

A

contraindicated with potent CYP3A4 inhibitors
- protease
- macrolide antibiotics
- azole antifungals
Causes vasospasm and ischemia

71
Q

ERGOT class serious ADR

A

cardiac valvular fibrosis
ergotism (vasoconstriction/gangrene)
Serotonin syndrome

72
Q

Contraindication Ergot

A

pregnancy/breastfeeding
24 hr or triptans, other serotonin agents, ergot-like agents

73
Q

Ergotamine use

A

acute mod-severe migraine
not for older adults
Sublingual tablet

74
Q

Ergotamine ADR

A

N/V
ecg change, HTN, ischemia, vasospasm
numbness, paresthesia, gangrene, etc

75
Q

Ergotamine d/c

A

even after limited use – withdrawal rebound headache

76
Q

Dihydroergotamine use

A

SQ/IM/IV: acute cluster headache, migraine
nasal spray: acute migraine

77
Q

DHE off label use

A

medication overuse headache
status migrainosus

78
Q

DHE contraindication

A

CV history
post vasular surgery
use of other periphera/central vasoconstrictors
nasal spray: hemiplegic migraine/brainstem

79
Q

DO NOT USE in Hemiplegic migraine/brainstem headache

A

Triptans
DHE

80
Q

Severe migraine treatment in the ED

A

IV/IM dexamethasone (decrease recurrence)
SQ sumatriptan (fast onset)
IV prochlorperazine + diphenhydramine (VERY GOOD)
IV DHE + antiemetic
IV valproate
IV/IM ketorolac
IV magnesium

81
Q

Purpose of diphenhydramine

A

prevent dystonia

82
Q

Topiramate use

A

Prevention for ≥12 y.o

83
Q

Topiramate ADR

A

cognitive dysfunction, CNS
nephrolithiasis
metabolic acidosis
angle closure glaucoma
oligohidrosis/hyperthermia
suicidal ideation
weight loss
paresthesias
AVOID in pregnancy

83
Q

Topiramate off label

A

cluster headache prevention

84
Q

Topiramate counseling

A

DRINK WATER - stay hydrated

85
Q

Topiramate MOA

A

block na channel
enhance GABA
antagonize AMPA glutamate R
weak CA inhibition (acidosis..)

86
Q

Valproic acid use

A

migraine prevention

87
Q

Valproic acid BBW

A

hepatotoxicity
mitochondrial disease
fetal risk
pancreatitis

88
Q

Valproic acid ADR

A

CNS
hematologic
hepatotoxicity
pancreatitis
suicidal ideation
encephalopathy
TEN/SJS/DRESS

89
Q

Valproic acid contraindications

A

pregnant/childbearing (lack contraception)
severe hepatic impairment
mitochondrial disorder (increase acute LF)

90
Q

Beta blocker use

A

prevention
timolol, propanolol

91
Q

TCA use

A

prevention (-triptyline)
start low go slow
takes 2-3 month for effect

92
Q

TCA BBW

A

suicide risk

93
Q

TCA ADR

A

anticholinergic
CNS depression
cardiac conduction abnormalities
SS
orthostatic hypotension

94
Q

Venlafaxine use (SNRI)

A

prevention
neuropathic pain

95
Q

Venlafaxine ADR

A

CNS depression
weight loss, anorexia
HTN
hepatotoxicity
hyponatremia
acute angle closure glaucoma
serotonin syndrome

96
Q

drugs that cause acute angle closure glaucoma

A

topiramate
venlafaxine

97
Q

Menstural migraine treatment

A

occurs day 1-2
fovatriptan
naratriptan
zolmitriptan
magnesium (if plan to conceive)
estrogen contraception

98
Q

AVOID estrogen contraception for menstural headache if

A

AURA = stroke risk
estrogen = risk for ischemic stroke

99
Q

Frovatriptan dose

A

2.5mg po qd or BID 2 days prior to menses
continue 6 days total

100
Q

Naratriptan dose

A

1mg po BID 2-3 days prior to menses
continue 5-6 days total

101
Q

Zolmitriptan

A

take 2.5mg po BID or TID 2 days prior to menses
continue until 5 days after menses (7 days total)

102
Q

Patients with CV disease, what to use for acute migraine?

A

Gepants
Lasmitidan (reyvow)
CGRP mab (caution if recent event)

103
Q

Pregnant patient acute migraine

A

APAP
Avoid NSAID if 3rd trimester
pregnancy progression helps

104
Q

Cluster headache prevention

A
  1. verapamil
  2. glucocorticoids
  3. CGRP mab Galcanezumab
  4. lithium
  5. Topiramate
  6. greater occipital nerve block
105
Q

Cluster headache acute tx

A

oxygen
SQ/nasal sumatriptan
nasal zolmitriptan

106
Q

Hemicrania continua treatment

A
  1. Indomethacin
  • botoxA
  • occipital stimulation
  • vagus stimulation
  • peripheral block
107
Q

Subarachnoid headache

A

thunderclap - max pain in seconds
life threatening emergency (hemorrhage)
photophobia, neck stiffness, n/v
brief loss of consciousness

108
Q

overuse ≥10 days/month

A

Triptans
opioids
ergots

109
Q

overuse ≥5 days/month

A

butalbital

110
Q

≥15 days/month

A

non opioid pain meds
nsaid/apap/asa/etc

111
Q

headache red flags

A

SNOOP

112
Q

S in SNOOP

HA red flags

A

Systemic s/s
- fever
- myalgias
- weight loss
systemic disease
- malignancy/acquired immune deficiency

113
Q

N in SNOOP

HA red flags

A

neurologic s/s

114
Q

First O in SNOOP

headache red flags

A

Onset sudden “thunderclap”

115
Q

Second O in SNOOP

headache red flgs

A

Onset after age 40

116
Q

P in SNOOP

headache red flags

A

pattern change
progressive headache with loss of headache-free periods
change in type of headache

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