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CDM 2 > Exam 2: Migraines > Flashcards

Exam 2: Migraines Flashcards

1
Q

____ is a common, recurrent, severe headache that interferes with normal function

A

Migraine

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2
Q

Episodic migraine is ___ monthly migraine days (MMDs) or monthly headaches days (MHDs)

A

<15

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3
Q

Chronic migraine is ____ MHDs for ≥3 months (≥8 days are MMDs)

A

≥15

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4
Q

____ is a complex of positive and negative focal neurologic symptoms that precedes or accompanies an attack

A

Aura

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5
Q

Aura: scintillations def

A

Vision with a shimmering, twinkling or wavy effect; vision in the area of the shimmer is impaired

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6
Q

Aura: Photopsia def

A

Flashing lights

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7
Q

Aura: Telchopsia def

A

A transient visual sensation of bright shimmering colors

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8
Q

Aura: Fortification spectrum def

A

Flashing, brightly colored lights in a zigzag pattern that typically start in the middle of the visual field move outward

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9
Q

Aura: Scotoma def

A

a blind spot in the field of vision

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10
Q

Aura: Hemianopsia def

A

blindness or reduction in vision in one half of the visual field

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11
Q

____ self-sustaining cycle of headache sin which the headache returns when the medication wares off, leading to use more meds which perpetuates the cycle – increased headache freq and med consumption

A

Medication overuse headache

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12
Q

Primary headache types (classifications)

A

Sinus
Cluster
Tension
Migraine

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13
Q

Secondary headache types (classification)

A 
Head trauma
Stroke
Infections 
Substance abuse/withdrawal
Craniofacial structure disorders
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14
Q

____ headaches occur usually behind the forehead and/or cheekbones

A

Sinus

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15
Q

____ headaches occur in and around one eye

A

Cluster

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16
Q

____ headache occurs like a band squeezing the head

A

Tension

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17
Q

____ headache usually has pain, nausea, and visual changes

A

Migraine

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18
Q

Tension type headache characteristics

A

Over the top of the head, extending to the base of the skull

Varies from diffuse ache to tight, pressing, constricting pain

Gradual

Duration: Min to days

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19
Q

Migraine Headache characteristics

A

Usually unilateral

Throbbing pain, maby be preceded by an aura

Sudden onset

Duration: Hours to 2 days

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20
Q

Sinus headache characteristics

A

Face, forehead or periorbital area

Pressure behind eyes or face, dull bilateral pain – worse in the morning

Simultaneous with sinus symptoms including purulent nasal discharge

Duration: Days (resolves with sinus symptoms)

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21
Q

Risk factors for migraines

A 
F > M 
Age 30s-40s
Lower socioeconomic status 
FHx 
Diet (red wine, cured meats) 
Co-morbidities (neurologica disorders, psychiatric disorders, CV disorders)
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22
Q

Acute Migraine Pathophysiology

A

External trigger > neuronal dysfuncton > vasodilation > activation of trigeminal nerves > neuropeptide release > inflammation

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23
Q

Lifestyle triggers for migraines

A 
Stress 
Lack of sleep or oversleeping
Fasting/skipping meals
Overexertion
Travel
Caffeine (>200mg/day) or withrdrawal 
Sexual activity.
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24
Q

Food triggers for migraines

A 
Chocolate
Processed meats
Fermented and pickled foods
MSG
Tyramine containing foods
ASpartame containing foods
Alcohol
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25
Q

Environmental triggers of migraines

A 
Weather or seasonal changes
Bright or flickering lights
Strong odors
Change in altitude 
Loud noises
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26
Q

Physical triggers of migraines

A

Menstruation or other hormonal changes

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27
Q

Headache usually begins within ___ min of aura

A

60

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28
Q

Acute migraine s/sx

A

Absence of daily headache
Normal neurologic examination
FHx migraine
Trigger association

Throbbing head pain
Unilateral (often)
Gradual in onset but peaks after minutes to hours
Begins most often in early morning hours
May last 4-72hrs
N/V
Sensitivity to light, sound, and/or movement

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29
Q

T/F: Migraines usually occur at night

A

False - usually in early morning hours

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30
Q

Migraine: POUND mnemonic

A 
Pulsatile quality
One day duration (4-72hrs)
Unilateral
N/V
Disabling
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31
Q

aura positive symptoms

A

Scintillation
Photopsia
Teichopsia
Fortification spectrum

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32
Q

Aura negative symptoms

A

Scotoma

Hemianopsia

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33
Q

Diagnosis of migraine without aura

A

At least 5 attacks

Headache lasted 4-72hrs
At least 2 of the following:
-unilateral location, pulsing quality, moderate or severe intensity, aggravation by or avoidance of routine physical activity

And 1 of the following
-N/V, photophobia, phonophobia, not attributable to another disorder

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34
Q

Diagnosis of migraine with aura

A

at least 2 attacks

Migraine aura fulfills criteria for typical, hemiphlegic, or basilar-type

Not attributable to another disorder

Typical aura

  • fully reversible visual, sensory, or speech symptoms but no motor weakness
  • homonymous or bilateral visual symptoms or unilateral sensory symptoms including positive or negative features or any combination
  • at least 2 of the following: at least one symptom that develops gradually over at least 5min or diff symptoms occur in succession in both, each symptom lasts for at least 5 min and for no longer than 60 min, headache that meets criteria for migraine without aura begins during the aura or follows the aura within 60 min
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35
Q

Migraine non-pharmacologic therapy

A 
Cold compresses
Rest or sleep
Quiet, dark environment
Devices
Identification and avoidance of triggers
Behavioral interventions (relaxation techniques, acupuncture, wellness programs)
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36
Q

Trigger avoidance tips

A

Migraine logs.

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37
Q

Non-pharmacological devices for migraines age limits

A

≥12yo : Nerivio, Spring TMs, gammaCore

≥18yo: Relivion, Cefaly

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38
Q

Which non-pharmacological devices for migraines are for treatment only

A

Nerivio and Relivion MG

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39
Q

Which non-pharmacological devices for migraines are for treatment and prevention/

A

Spring TMS, gammaCore, Cefaly

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40
Q

Goals of Therapy for Acute Migraines

A 
Restore ability to function
Treat attacks rapidly and consistently
Minimize the use of backup/rescue medications 
Optimize self-care
Utilize cost-effective management 
Cause minimal to no side effects
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41
Q

Who are NOT candidates for self care of migraines

A 
Recent trauma 
Complaints of confusion, drowsiness, cognitive impairment, peripheral numbness/weakness
Fever
Onset at >50 yo
Under age 18
Hx of liver disease or alc abuse
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42
Q

Acute migraines: 2 treatment approaches

A

STEP-UP: Use of NSAIDs and combination products first, reserving other therapies

STRATIFIED CARE: initial migraine treatment is based on symptom severity and headache-related disability

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43
Q

According to the DISC study, of the 2 treatment approaches of acute migraines, ____ produced better results than ____

A

Stratified > step care

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44
Q

5-HT Agonists (Triptans) MOA

A

Vasoconstriction via activation of postsynaptic 5-HT1B receptors of the smooth muscle of blood vessels

Presynaptic 5-HT1D receptors activity leading to blockade of release of vasoactive peptides from the trigeminal neurons

Presynaptic 5-HT1D receptors activity leading to blockade of NT and activation of second-order neurons – may facilitate descending pain inhibitory systems

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45
Q

Sumatriptan brand name tab

A

Imitrex

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46
Q

Sumatriptan brand name nasal spray

A

Imitrex, Tosymra

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47
Q

Sumatriptan brand name nasal powder

A

Onzetra Xsail

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48
Q

Sumatriptan Brand name SQ injection

A

Alsuma, Imitrex, Sumavel, Zenbrace Smytouch

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49
Q

Sumatriptan DDIs

A

Avoid use w/in 2 weeks of MAOi like isocarboxaid, phenlzine, selegilline, tranylcyp-romine

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50
Q

Sumatriptan clinical considerations

A

Max PO dose 50mg with mild-mod hepatic impairment (NOT recommended for severe hepatic impairment)

SQ sumatriptan has fastest onset of action (~10min) and has best efficacy data

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51
Q

Sumatriptan-Naproxen sodium brand name tab

A

Treximet

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52
Q

Zolmitriptan brand name

A

Zomig

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53
Q

Zolmitriptan dosage forms

A

Tab, oral dissolving wafer, nasal spray

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54
Q

Zolmitriptan DDIs

A

Avoid use w/in 2 weeks MAOis

Max single dose 2.5mg and Max total dose 5mg when used with cimetidine

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55
Q

Zolmitriptan clinical considerations

A

No renal adj

CYP1A2

Max PO dose of 1.25mg (max total dose 5mg) with mod-severe hepatic impairment
Avoid ODT and nasal spray in mod-severe hepatic impairment

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56
Q

Almotriptan brand name

A

Axert

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57
Q

Almotriptan dosage form

A

Tab

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58
Q

Almotriptan DDI

A

Reduce dose to 6.25mg when used with potent CYP3A4 inhibitor (like ketoconazole)

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59
Q

Almotriptan Clinical Considerations

A

Contains sulfa group (Allergy!)

Dose adj for renal/hepatic impairment: start dose 6.25mg max of 12.5mg/24h

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60
Q

Eletriptan brand name

A

Replax

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61
Q

Eletriptab dosage form

A

Tab

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62
Q

Eletriptan DDIs

A

Should not be used within 3 days of potent CYP3A4 inhibitors

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63
Q

Eletriptan should not be used within ___ days of potent CYP___ inhibitors

A

3 days of 3A4 inhibitors

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64
Q

Eletriptan clinical considerations

A

Avoid use in severe hepatic impairment

CYP3A4

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65
Q

Rizatriptan brand name

A

Maxalt

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66
Q

Rizatriptan dosage forms

A

Tab, oral dissolving wafer

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67
Q

Rizatriptan DDIs

A

5mg/dose and max 3 doses/24hrs when used with propranolol

Do not use w/in 2 weeks of MAOi

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68
Q

Which triptan is contraindicated in pts with a sulfa allergy?

A

Almotriptan

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69
Q

Which triptans come as oral dissolving wafer?

A

Zolmitriptan

Rizatriptan

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70
Q

Frovatriptan brand name

A

Frova

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71
Q

Naratriptan brand name

A

Amarge

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72
Q

___ is considered less effective than other triptans

A

Frovatriptan

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73
Q

Frovatriptan clinical considerations

A

Considered less effective than other triptans

Slower onset and longer duration of action

CYP1A2

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74
Q

Naratriptan clinical considerations

A

Similar to frovatriptan (Less efficacious and slower onset)

Mild-moderate renal impairment start lower dose

CI for CrCl <15

Child-Pugh dosing adj

Various CYP enzymes

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75
Q

Triptans contraindication

A

Hx CAD, angina, vasopastic angina, uncontrolled HTN, cerebrovascular disease, peripheral vascular disease, hemiplegic/basilar migraine, hepatic disease (sumatriptan, zolmitiptan, eletriptan, and naratriptan)

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76
Q

Triptan ADEs

A

Fatigue, dizziness, flushing, warm sensations, somnolence, paresthesias, chest/neck symptoms (may go away if you switch triptans or meds)

Medication overuse headache

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77
Q

Triptan DDIs

A

Within 24 hrs ergot alkaloids
within 2 weeks of MAOi
Potential for serotonin syndrome (fluoxetine, sertraline, venlafaxine)

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78
Q

Meds with Serotonin Syndrome

A

MAOis, trazodone, SSRIs, SNRIs, TCAs, Triptans, Ditans, valproate
Tramadol, meperidine
5-HT3 antagonists (ondansetron), metoclopramide
Linezolid

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79
Q

Triptan place in thearpy

A

Mod-severe mirgaine with no contraindications

Severe migraines which responded poorly to NSAIDs or combo analgesics

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80
Q

Triptans clinical considerations

A

Start at low doses for geriatric pts, many have renal/hepatic dose adj
1/3 of pts do not respond to triptan monotherapy

If ineffective: increase dose, try another triptan, try another formulation, combo, try diff therapy

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81
Q

Oral triptan patient education

A

Onset of action: 20-60min
May repeat a dose after a certain amt of time
Max dosing

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82
Q

Ergot-Alkaloids MOA

A

Non-selective 5-HT1 receptor agonists, α1/2 receptors, DA2 receptors (ergotamine has more peripheral vasoconstriction than dihydroergotamine so there may be more ADEs)

83
Q

Ergot-Alkaloids medications

A

Ergotamine/caffeine
Ergotamine
Dihydroergotamine

84
Q

Ergotamine/caffeine brand

A

Cafergot

Migergot

85
Q

Ergotamine brand name

A

Ergomar

86
Q

Dihydroergotamine brand name

A

Migranal, Trudhesa, D.H.E 45

87
Q

Ergot Alkaloid injection and nasal spray options

A

Dihydroergotamine

88
Q

Which ergot-alkaloids are contraindicated with strong CYP3A4 inhibitors?

A

Dihydroergotamine

89
Q

Ergot-alkalids contraindications

A

Renal/hepatic failure, coronary, cerebral, or peripheral vascular disease, uncontrolled HTN, sepsis, women who are pregnant or nursing (CATEGORY X)

90
Q

Ergot-Alkaloids ADEs

A 
N/V/D  (consider pretreatment with antiemetics) 
Abdominal pain 
Weakness
Fatigue 
Parasthesias 
Muscle pain
Nasal/throat irritation 
Chest tightness
Peripheral ischemia
91
Q

Ergot-alkaloids DDI

A

Do not use within 24hrs of triptans

92
Q

Erogt-Alkaloids place in therapy

A

Moderate-severe headache pain

93
Q

Ditans MOA

A

Selective 5-HT1F Agonist

  • Block neurogenic inflammation in the trigeminal pathway
  • Doesn’t cause vasoconstriction like Triptans
94
Q

Ditan examples

A

Lasmiditan

95
Q

Lasmiditan brand name

A

Reyvow

96
Q

Lasmiditan max dosing

A

Do not exceed 1 dose in 24hrs

97
Q

Lasmiditan DDI

A

Serotonergic agents

PGP substrates

98
Q

Lasmiditan contraindication

A

None listed

99
Q

Ditans place in therapy

A

Mod-severe migraines with no CIs
Severe migraine with poor response to NSAIDs or combo
CI or did not tolerate triptans or who have failed 2+ triptans

100
Q

Gepants MOA

A

CGRP receptors antagonists

101
Q

CGRP Antagonists examples

A

Ubrogepant (Ubrelyy)

rimegepant (Nurtec)

102
Q

CGRP antagonists option good for pts with nausea

A

Rimegepant (Nurtec) because it is ODT

103
Q

Ubrogepant brand name and dosage form

A

Ubrely Tablet

104
Q

Rimegepant brand name and dosage form

A

Nurtec

ODT

105
Q

Ubrogepant DDI

A

CI with concomitant strong CYP3A4 inhibitors (ketoconazole, clarithromycin, ritonavir)

106
Q

Rimegepant DDIs

A

Avoid concomitant administration w/strong CYP3A4 inhibitors

Avoid concomitant administration w/moderate to strong CYP3A4 inducers

Avoid administration w/in 48h of moderate CYP3A inducers

Avoid concomitant administration with PGP or BCRP inhibitors

107
Q

Gepand ADEs

A

N/V

Somnolence

108
Q

Match gepant with pt education points:

  1. Avoid grapefruit juice, may take a second dose at least 2h after initial dose
  2. Keep medication blister in the outer aluminum pouch until time to use; allow medication to disintegrate on or under the tongue
A
  1. ubrogepant

2. rimegepant

109
Q

Gepant place in therapy

A

Mod-severe migraine with no contraindications
Severe migraine which responded poorly to NSAIDs or combination analgesics
Patients who are contraindicated to or unable to tolerate triptans, or who have failed 2+ triptans

110
Q

NSAIDs and Non-opioid analgesic options

A

APAP/ASA/Caffeine (Excedrin Migraine)
ASA
Ibuprofen (Motrin)
Naproxen (Aleve)

111
Q

NSAID DDIs

A

AntiHTN
Tacrolimus
ACEi/ARB

112
Q

Barbiturate hypnotics MOA

A

Sedative-hypnotic by enhancing effects of GABA

113
Q

Barbiturate hypnotics examples

A

Fiorinal (ASA/butalbital/caffeine)

Fioricet (APAP/butalbital/caffeine)

114
Q

Friends dont give friends ___ for migraines

A

Fiorinal/Fioricet

115
Q

Barbiturate hypnotics ADE

A

Sedation, nausea, dizziness, confusion

116
Q

Barbiturate hypnotics DDI

A

other CNS depressants

117
Q

Barbiturate hypnotics place in therapy

A

Moderate headache

Due to risk of overuse and withdrawal, use should be limited

118
Q

Opioid analgesics MOA

A

Activity on mu, kappa, and delta opioid receptors

119
Q

Opioid analgesics examples and dosage form

A

Butorphanol (Stadol) - nasal spray

120
Q

Butorphanol place in therapy

A

IN, IV, IM as rescue therapy or when other medication options cannot be used; PO may be considered in acute migraine

121
Q

Antiemetic Agents examples

A

Metoclopramide (Reglan)
Prochlorperazine (Compazine)
Promethazine (Pehenergan)
Ondansetron (Zofran)

122
Q

Metoclopramide (Reglan) MOA

A

Dopamine antagonists

123
Q

Prochlorperazine (Compazine) MOA

A

Dopamine antagonist

124
Q

Promethazine (Phenergan) MOA

A

Dopamine antagonists

125
Q

Ondansetron (Zofran) MOA

A

5-HT3 antagonism

126
Q

Metoclopramide (Reglan) dosage forms

A

Inj

ODT

127
Q

Prochlorperazine (Compazine) Dosage forms

A

Tab

Supp

128
Q

PRomethazine (Phenergan) Dosage form

A

Tab

Supp

129
Q

Ondansetron (Zofran) Dosage forms

A

Tab
ODT
Inj

130
Q

Dopamine antagonists DDI

A 
QTc prolonging agents
Atypical antipsychotics
SSRi
SNRI
TCA
131
Q

Ondansetrone(Zofran) DDI

A

Serotonergic agents, QTc prolonging agents

132
Q

Which antiemetic agents can be used as monotherapy for intractable headaches?

A

Metoclopramide (Reglan)

Prochlorperazine (Compazine)

133
Q

Which antiemetic agents are less preferred as cannot treat migraine, only N/V ?

A

Ondansetron (Zofran)

134
Q

Antiemetics ADE

A

Drowsiness, sedation, dysto

135
Q

Antiemetics place in therapy

A

Adjunct in the treatment of N/V associated with migraine
Pre-treatment to prevent ergot alkaloid induced N/V
Metoclopramide may improve absorption of oral medications by reducing gastroparesis
Dopamine antagonists also may be used as monotherapy in intractable headaches (prochlorperazine, metoclopramide)

136
Q

Dexamethasone MOA

A

Anti-inflammatory

137
Q

Dexamethasone place in therapy

A

Rescue therapy for status migrainous

Adjunct to abortive therapy

138
Q

Miscellaneous migraine treatment options

A

Dexamethasone (anti inflammatory)
Lidocaine (solution dripped into nostril)
Magnesium (IV)

139
Q

Established efficacy for acute migraine specific

A

Triptans
Ergotamine derivatives
Gepants
Lasmiditan

140
Q

Established efficacy for acute non-migraine specific

A

NSAIDs

Combo analgesics

141
Q

Probably efficacy for acute migraine specific agents

A

Ergotamine

Other forms of dihydroergotamine

142
Q

Probable efficacy for acute non-migraine specific agents

A

NSAIDs (flurbiprofen, keoprofen, IV and IM ketorolac)
IV magnesium
Antiemetics

143
Q

Acute migraine special pop: Pregnancy

A

Increases risk of pre-eclampsia and gestational hypertension
Management:
- Acetaminophen (pregnancy category C)
- NSAIDs in 1st/2nd trimester (pregnancy category C); avoid in 3rd trimester (pregnancy category D)
- Metoclopramide IV (pregnancy category B)
- AVOID triptans and ergot alkaloids

144
Q

Acute migraine special pop: Pediatrics

A

Limited evidence

Management:

  • APA
  • Ibuprofen
  • Rizatriptan
  • Zolmitriptan nasal spray
145
Q

Migraine prophylaxis indications

A

Pt preference

Frequent (>2x/week, ≥10 days/mo triptans, ergots, opioids, combo// ≥15 days/mo nonopioid analgesics)

Predictable patterns

Sig disability

risk of neurologic injury

Acute migraine meds not effective, CI, or severe ADE

146
Q

For migraine ppx, start with a low dose, titrate up, and try for at least ____ to see full effect (and then determine to maintain or d/c)

A

2-6 months

147
Q

Beta blockers for migraine PPx

A

Propranolol

Timolol

148
Q

Propranolol and timolol ADEs

A

Drowsiness, fatigue, sleep disturbances, bradycardia, impotence, masking SSX of hypoglycemia

149
Q

Propranolol and timolol DDIs

A

Non-DHP CCB

150
Q

Propranolol and timolol clinical considerations: Caution

A

CHF, PVD, asthma, DM

151
Q

Propranolol and timolol clinical considerations: Useful for

A

Concurrent HTN, angina, anxiety

152
Q

Migraine PPX Anti-epileptic drugs

A

Valproic acid, divalproex sodium

Topiramate

153
Q

Migraine PPx: Valproic acid, divalproex sodium: ADEs

A

Nausea, vomiting, alopecia, tremor, somnolence, weight gain, hepatotoxicity

154
Q

Migraine PPx: Valproic acid, divalproex sodium: DDIs

A

Lamotrigine, estrogen containing hormonal contraceptives, warfarin

155
Q

Migraine PPx: Valproic acid, divalproex sodium: Clinical considerations: Cuation

A

Contraindicated for chronic liver disease and hx of pancreatitis

Pregnancy

156
Q

Migraine PPx: Valproic acid, divalproex sodium: Clinical Considerations usefl for

A

seizure or bipolar disorder

157
Q

Migraine PPx: topiramate: ADEs

A

Fatigue, anorexia, diarrhea, weight loss, difficulty with memory, paresthesia

158
Q

Migraine PPx: topiramate: DDIs

A

Other sedating meds

159
Q

Migraine PPx: topiramate: Clinical considerations: Caution

A

Hx of nephrolithiasis, renal/hepatic dysfunction, concurrent oral contraceptives

160
Q

Migraine PPx: topiramate: Clinical considerations: Useful for

A

Concurrent seizure or bipolar disorder

161
Q

Which meds would you use for migraine ppx when pt has concurrent seizure or bipolar disorder?

A

Valproic acid, divalproex sodium

Topiramte

162
Q

Which meds would you use for migraine ppx when pt has concurrent HTN, angina, anxiety?

A

Propranolol

Timolol

163
Q

Triptans used for migraine ppx

A

Frovatriptan, naratriptan, zolmitriptan

164
Q

Triptans for migraine PPx useful for

A

Migraine associated with menses

165
Q

Which meds used for migraine ppx are useful for migraine associated with menses?

A

NSAIDS (naproxen, IBU) and triptans

166
Q

Which meds used for migrain ppx are useful for concurrent depression, neuropathy?

A

Amitriptyline, nortriptyline, venlafaxine, fluoxetine

167
Q

Which TCAs are used for migraine ppx

A

Amitriptyline

Nortriptyline

168
Q

Which SNRI are used for migraine ppx

A

Venlafaxine

169
Q

Which SSRI are used for migraine ppx

A

Fluoxetine

170
Q

Which antidepressants for migraine ppx have a DDI with triptans?

A

SNRI/SSRI (Venlafaxine and fluoxetine)

171
Q

Which CCB is used for migraine ppx?

A

Verapamil (Non-DHP CCB)

172
Q

Verapamil DDI

A

BB

CYP interactions

173
Q

Verapamil for migraine ppx useful for

A

Prolonged aura

174
Q

Verapamil for migraine ppx clinical consideration caution for

A

CHF

175
Q

Are Gepants used for migraine ppx?

A

Yes - rimegepant (ODT) and Atogepant (Tab)

176
Q

Anti-CGRP antibodies for migraine ppx: MOA

A

Monoclonal antibodies that bind to CGRP receptor (erenumab) or CGRP ligand (others) to antagonize CGRP activity

177
Q

Migraine PPX: Anti-CGRP Antibodies Medication options

A

Erenumab-aooe (Aimovig)
Fremanezumab-vfrm (Ajovy)
Galcanezumab-gnlm (Emgality)
Epitnezumab-jjmr (Vyepti)

178
Q

Which Anti-CGRP antibodies for migraine ppx has issues with LATEX ALLERGY?

A

Erenumab-aooe (Aimovig)

179
Q

Which Anti-CGRP antibodies is an IV solution?

A

Vyepti

180
Q

Anti-CGRP antibodies ADEs

A

Injection site reactions (SQ agents), constipation (erenumab), nasopharyngitis (epitnezumab), hypersensitivity (epitnezumab), HTN (erenumab)

181
Q

Anti-CGRP Antibodies DDIs

A

None listed

182
Q

Anti-CGRP antibodies: Clinical considerations

A

More expensive than other options

Reserve use for patients who are unable to tolerate or who have failed ≥2 oral medications with strong evidence

183
Q

OnabotulinumtoxinA MOA

A

blocks neuromuscular transmission by inhibiting release of acetylcholine

184
Q

OnabotulinumtoxinA has ___ units in __ injection sides divided across __ specific head/neck muscle areas

A

155 units
31 injections
7 areas

185
Q

OnabotulinumtoxinA: Clinical Considerations ADE

A

Neck pain, headache

186
Q

OnabotulinumtoxinA: Clinical Considerations DDI

A

Aminoglycosides or other agents impacting neuromuscular transmission, muscle relaxants

187
Q

OnabotulinumtoxinA: Clinical Considerations pt education

A

Avoid operating machinery if the have muscle weakness

188
Q

OnabotulinumtoxinA: Clinical Considerations

A

Indicated for prophylaxis of headaches in adult patients with chronic migraine ≥ 15 days/month with headache lasting ≥4 hours/day)
Expensive, and requires in-office administration which is less convenient for patients
Reserve use for patients who are unable to tolerate or who have failed ≥2 oral medications with strong evidence (e.g., topiramate, divalproex, BB, TCA, or SNRI)

189
Q

Other agents used for migraine ppx

A

Melatonin

Magnesium

190
Q

Melatonin Clinical Considerations for migraine ppx

A

ADE: Fatigue

Clinical considerations: lack of sleep = tigger? , well tolerated (evidence is promising but still lacking)

191
Q

Magnesium Clinical Considerations for migraine ppx

A

ADE: diarrhea

probably efficacy
May have benefits of prevention of menstrual related migraine

192
Q

Migraine Prophylaxis: Evidence of Efficacy: Established efficacy: Oral options

A 
Candesartan
Divalproex sodium
Frovatriptanf
Propranolol
Timolol
Topirimate
Valproate sodium
193
Q

Migraine Prophylaxis: Evidence of Efficacy: Established efficacy: Parenteral options

A 
Eptinezumab
Erenumab
Fremanezumab
Galcanezumab
OnabotulinumtoxinAd
194
Q

Migraine Prophylaxis: Evidence of Efficacy: Probable efficacy: Oral options

A 
Amitriptyline
Atenolol
Lisinopril
Memantine
Nadolol
Venlafaxine
195
Q

Migraine Prophylaxis: Evidence of Efficacy: Probable efficacy: Parenteral options

A

OnabotulinumtoxinA + CGRP mAbd,e

196
Q

Migraine PPX: menstrual related migraine

A

Frovatriptan, naratriptan, zolmitriptan

197
Q

Migraine PPX: co-morbid obesity/overweight

A

Topiramte

198
Q

Migraine PPX: Headache recurring in predictable pattern

A

NSAID or triptan at time of vulnerability

199
Q

____ are migraines that occur on day -2 to +3 of menstruation at least 2 of three menstrual cycles and at no other time of the cycle

A

Pure menstrual migraine

200
Q

____ migraines that occur on day -2 to +3 of menstruation at least 2 of three menstrual cycles and additionally at other times of the cycle

A

Menstrual related migraine

201
Q

Triptans for menstrual related migraines clinical considerations: Begin ____ PIROR to menstruation and continue for ____

A

Begin 6 days prior

Continue 5-7 days

202
Q

Migraine PPX: If there is not a response after an appropriate trial (≥ ___ weeks on an effective dose) change to another effective medication

A

8 weeks

203
Q

Pharmacological therapy options for migraine ppx

A 
Treatment option based on DDI, comorbid conditions, etc
NSAIDs
Triptans
AEDs
Antidepressants
Magnesium
Melatonin
CGRP Antagonists (gepants)
Anti-CGRP Antibodies
OnabotulinumtoxinA

CDM 2 (8 decks)

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