Exam 2: Migraines Flashcards
1
Q
____ is a common, recurrent, severe headache that interferes with normal function
A
Migraine
2
Q
Episodic migraine is ___ monthly migraine days (MMDs) or monthly headaches days (MHDs)
A
<15
3
Q
Chronic migraine is ____ MHDs for ≥3 months (≥8 days are MMDs)
A
≥15
4
Q
____ is a complex of positive and negative focal neurologic symptoms that precedes or accompanies an attack
A
Aura
5
Q
Aura: scintillations def
A
Vision with a shimmering, twinkling or wavy effect; vision in the area of the shimmer is impaired
6
Q
Aura: Photopsia def
A
Flashing lights
7
Q
Aura: Telchopsia def
A
A transient visual sensation of bright shimmering colors
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
9
Q
Aura: Scotoma def
A
a blind spot in the field of vision
10
Q
Aura: Hemianopsia def
A
blindness or reduction in vision in one half of the visual field
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
12
Q
Primary headache types (classifications)
A
Sinus
Cluster
Tension
Migraine
13
Q
Secondary headache types (classification)
A
Head trauma Stroke Infections Substance abuse/withdrawal Craniofacial structure disorders
14
Q
____ headaches occur usually behind the forehead and/or cheekbones
A
Sinus
15
Q
____ headaches occur in and around one eye
A
Cluster
16
Q
____ headache occurs like a band squeezing the head
A
Tension
17
Q
____ headache usually has pain, nausea, and visual changes
A
Migraine
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
19
Q
Migraine Headache characteristics
A
Usually unilateral
Throbbing pain, maby be preceded by an aura
Sudden onset
Duration: Hours to 2 days
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)
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)
22
Q
Acute Migraine Pathophysiology
A
External trigger > neuronal dysfuncton > vasodilation > activation of trigeminal nerves > neuropeptide release > inflammation
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.
24
Q
Food triggers for migraines
A
Chocolate Processed meats Fermented and pickled foods MSG Tyramine containing foods ASpartame containing foods Alcohol
25
Environmental triggers of migraines
```
Weather or seasonal changes
Bright or flickering lights
Strong odors
Change in altitude
Loud noises
```
26
Physical triggers of migraines
Menstruation or other hormonal changes
27
Headache usually begins within ___ min of aura
60
28
Acute migraine s/sx
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
29
T/F: Migraines usually occur at night
False - usually in early morning hours
30
Migraine: POUND mnemonic
```
Pulsatile quality
One day duration (4-72hrs)
Unilateral
N/V
Disabling
```
31
aura positive symptoms
Scintillation
Photopsia
Teichopsia
Fortification spectrum
32
Aura negative symptoms
Scotoma
| Hemianopsia
33
Diagnosis of migraine without aura
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
34
Diagnosis of migraine with aura
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
35
Migraine non-pharmacologic therapy
```
Cold compresses
Rest or sleep
Quiet, dark environment
Devices
Identification and avoidance of triggers
Behavioral interventions (relaxation techniques, acupuncture, wellness programs)
```
36
Trigger avoidance tips
Migraine logs.
37
Non-pharmacological devices for migraines age limits
≥12yo : Nerivio, Spring TMs, gammaCore
| ≥18yo: Relivion, Cefaly
38
Which non-pharmacological devices for migraines are for treatment only
Nerivio and Relivion MG
39
Which non-pharmacological devices for migraines are for treatment and prevention/
Spring TMS, gammaCore, Cefaly
40
Goals of Therapy for Acute Migraines
```
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
```
41
Who are NOT candidates for self care of migraines
```
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
```
42
Acute migraines: 2 treatment approaches
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
43
According to the DISC study, of the 2 treatment approaches of acute migraines, ____ produced better results than ____
Stratified > step care
44
5-HT Agonists (Triptans) MOA
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
45
Sumatriptan brand name tab
Imitrex
46
Sumatriptan brand name nasal spray
Imitrex, Tosymra
47
Sumatriptan brand name nasal powder
Onzetra Xsail
48
Sumatriptan Brand name SQ injection
Alsuma, Imitrex, Sumavel, Zenbrace Smytouch
49
Sumatriptan DDIs
Avoid use w/in 2 weeks of MAOi like isocarboxaid, phenlzine, selegilline, tranylcyp-romine
50
Sumatriptan clinical considerations
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
51
Sumatriptan-Naproxen sodium brand name tab
Treximet
52
Zolmitriptan brand name
Zomig
53
Zolmitriptan dosage forms
Tab, oral dissolving wafer, nasal spray
54
Zolmitriptan DDIs
Avoid use w/in 2 weeks MAOis
Max single dose 2.5mg and Max total dose 5mg when used with cimetidine
55
Zolmitriptan clinical considerations
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
56
Almotriptan brand name
Axert
57
Almotriptan dosage form
Tab
58
Almotriptan DDI
Reduce dose to 6.25mg when used with potent CYP3A4 inhibitor (like ketoconazole)
59
Almotriptan Clinical Considerations
Contains sulfa group (Allergy!)
Dose adj for renal/hepatic impairment: start dose 6.25mg max of 12.5mg/24h
60
Eletriptan brand name
Replax
61
Eletriptab dosage form
Tab
62
Eletriptan DDIs
Should not be used within 3 days of potent CYP3A4 inhibitors
63
Eletriptan should not be used within ___ days of potent CYP___ inhibitors
3 days of 3A4 inhibitors
64
Eletriptan clinical considerations
Avoid use in severe hepatic impairment
CYP3A4
65
Rizatriptan brand name
Maxalt
66
Rizatriptan dosage forms
Tab, oral dissolving wafer
67
Rizatriptan DDIs
5mg/dose and max 3 doses/24hrs when used with propranolol
Do not use w/in 2 weeks of MAOi
68
Which triptan is contraindicated in pts with a sulfa allergy?
Almotriptan
69
Which triptans come as oral dissolving wafer?
Zolmitriptan
| Rizatriptan
70
Frovatriptan brand name
Frova
71
Naratriptan brand name
Amarge
72
___ is considered less effective than other triptans
Frovatriptan
73
Frovatriptan clinical considerations
Considered less effective than other triptans
Slower onset and longer duration of action
CYP1A2
74
Naratriptan clinical considerations
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
75
Triptans contraindication
Hx CAD, angina, vasopastic angina, uncontrolled HTN, cerebrovascular disease, peripheral vascular disease, hemiplegic/basilar migraine, hepatic disease (sumatriptan, zolmitiptan, eletriptan, and naratriptan)
76
Triptan ADEs
Fatigue, dizziness, flushing, warm sensations, somnolence, paresthesias, chest/neck symptoms (may go away if you switch triptans or meds)
Medication overuse headache
77
Triptan DDIs
Within 24 hrs ergot alkaloids
within 2 weeks of MAOi
Potential for serotonin syndrome (fluoxetine, sertraline, venlafaxine)
78
Meds with Serotonin Syndrome
MAOis, trazodone, SSRIs, SNRIs, TCAs, Triptans, Ditans, valproate
Tramadol, meperidine
5-HT3 antagonists (ondansetron), metoclopramide
Linezolid
79
Triptan place in thearpy
Mod-severe mirgaine with no contraindications
| Severe migraines which responded poorly to NSAIDs or combo analgesics
80
Triptans clinical considerations
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
81
Oral triptan patient education
Onset of action: 20-60min
May repeat a dose after a certain amt of time
Max dosing
82
Ergot-Alkaloids MOA
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
Ergot-Alkaloids medications
Ergotamine/caffeine
Ergotamine
Dihydroergotamine
84
Ergotamine/caffeine brand
Cafergot
| Migergot
85
Ergotamine brand name
Ergomar
86
Dihydroergotamine brand name
Migranal, Trudhesa, D.H.E 45
87
Ergot Alkaloid injection and nasal spray options
Dihydroergotamine
88
Which ergot-alkaloids are contraindicated with strong CYP3A4 inhibitors?
Dihydroergotamine
89
Ergot-alkalids contraindications
Renal/hepatic failure, coronary, cerebral, or peripheral vascular disease, uncontrolled HTN, sepsis, women who are pregnant or nursing (CATEGORY X)
90
Ergot-Alkaloids ADEs
```
N/V/D (consider pretreatment with antiemetics)
Abdominal pain
Weakness
Fatigue
Parasthesias
Muscle pain
Nasal/throat irritation
Chest tightness
Peripheral ischemia
```
91
Ergot-alkaloids DDI
Do not use within 24hrs of triptans
92
Erogt-Alkaloids place in therapy
Moderate-severe headache pain
93
Ditans MOA
Selective 5-HT1F Agonist
- Block neurogenic inflammation in the trigeminal pathway
- Doesn’t cause vasoconstriction like Triptans
94
Ditan examples
Lasmiditan
95
Lasmiditan brand name
Reyvow
96
Lasmiditan max dosing
Do not exceed 1 dose in 24hrs
97
Lasmiditan DDI
Serotonergic agents
| PGP substrates
98
Lasmiditan contraindication
None listed
99
Ditans place in therapy
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
Gepants MOA
CGRP receptors antagonists
101
CGRP Antagonists examples
Ubrogepant (Ubrelyy)
| rimegepant (Nurtec)
102
CGRP antagonists option good for pts with nausea
Rimegepant (Nurtec) because it is ODT
103
Ubrogepant brand name and dosage form
Ubrely Tablet
104
Rimegepant brand name and dosage form
Nurtec
| ODT
105
Ubrogepant DDI
CI with concomitant strong CYP3A4 inhibitors (ketoconazole, clarithromycin, ritonavir)
106
Rimegepant DDIs
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
Gepand ADEs
N/V
| Somnolence
108
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
1. ubrogepant
| 2. rimegepant
109
Gepant place in therapy
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
NSAIDs and Non-opioid analgesic options
APAP/ASA/Caffeine (Excedrin Migraine)
ASA
Ibuprofen (Motrin)
Naproxen (Aleve)
111
NSAID DDIs
AntiHTN
Tacrolimus
ACEi/ARB
112
Barbiturate hypnotics MOA
Sedative-hypnotic by enhancing effects of GABA
113
Barbiturate hypnotics examples
Fiorinal (ASA/butalbital/caffeine)
Fioricet (APAP/butalbital/caffeine)
114
Friends dont give friends ___ for migraines
Fiorinal/Fioricet
115
Barbiturate hypnotics ADE
Sedation, nausea, dizziness, confusion
116
Barbiturate hypnotics DDI
other CNS depressants
117
Barbiturate hypnotics place in therapy
Moderate headache
| Due to risk of overuse and withdrawal, use should be limited
118
Opioid analgesics MOA
Activity on mu, kappa, and delta opioid receptors
119
Opioid analgesics examples and dosage form
Butorphanol (Stadol) - nasal spray
120
Butorphanol place in therapy
IN, IV, IM as rescue therapy or when other medication options cannot be used; PO may be considered in acute migraine
121
Antiemetic Agents examples
Metoclopramide (Reglan)
Prochlorperazine (Compazine)
Promethazine (Pehenergan)
Ondansetron (Zofran)
122
Metoclopramide (Reglan) MOA
Dopamine antagonists
123
Prochlorperazine (Compazine) MOA
Dopamine antagonist
124
Promethazine (Phenergan) MOA
Dopamine antagonists
125
Ondansetron (Zofran) MOA
5-HT3 antagonism
126
Metoclopramide (Reglan) dosage forms
Inj
| ODT
127
Prochlorperazine (Compazine) Dosage forms
Tab
| Supp
128
PRomethazine (Phenergan) Dosage form
Tab
| Supp
129
Ondansetron (Zofran) Dosage forms
Tab
ODT
Inj
130
Dopamine antagonists DDI
```
QTc prolonging agents
Atypical antipsychotics
SSRi
SNRI
TCA
```
131
Ondansetrone(Zofran) DDI
Serotonergic agents, QTc prolonging agents
132
Which antiemetic agents can be used as monotherapy for intractable headaches?
Metoclopramide (Reglan)
| Prochlorperazine (Compazine)
133
Which antiemetic agents are less preferred as cannot treat migraine, only N/V ?
Ondansetron (Zofran)
134
Antiemetics ADE
Drowsiness, sedation, dysto
135
Antiemetics place in therapy
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
Dexamethasone MOA
Anti-inflammatory
137
Dexamethasone place in therapy
Rescue therapy for status migrainous
| Adjunct to abortive therapy
138
Miscellaneous migraine treatment options
Dexamethasone (anti inflammatory)
Lidocaine (solution dripped into nostril)
Magnesium (IV)
139
Established efficacy for acute migraine specific
Triptans
Ergotamine derivatives
Gepants
Lasmiditan
140
Established efficacy for acute non-migraine specific
NSAIDs
| Combo analgesics
141
Probably efficacy for acute migraine specific agents
Ergotamine
| Other forms of dihydroergotamine
142
Probable efficacy for acute non-migraine specific agents
NSAIDs (flurbiprofen, keoprofen, IV and IM ketorolac)
IV magnesium
Antiemetics
143
Acute migraine special pop: Pregnancy
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
Acute migraine special pop: Pediatrics
Limited evidence
Management:
- APA
- Ibuprofen
- Rizatriptan
- Zolmitriptan nasal spray
145
Migraine prophylaxis indications
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
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)
2-6 months
147
Beta blockers for migraine PPx
Propranolol
| Timolol
148
Propranolol and timolol ADEs
Drowsiness, fatigue, sleep disturbances, bradycardia, impotence, masking SSX of hypoglycemia
149
Propranolol and timolol DDIs
Non-DHP CCB
150
Propranolol and timolol clinical considerations: Caution
CHF, PVD, asthma, DM
151
Propranolol and timolol clinical considerations: Useful for
Concurrent HTN, angina, anxiety
152
Migraine PPX Anti-epileptic drugs
Valproic acid, divalproex sodium
| Topiramate
153
Migraine PPx: Valproic acid, divalproex sodium: ADEs
Nausea, vomiting, alopecia, tremor, somnolence, weight gain, hepatotoxicity
154
Migraine PPx: Valproic acid, divalproex sodium: DDIs
Lamotrigine, estrogen containing hormonal contraceptives, warfarin
155
Migraine PPx: Valproic acid, divalproex sodium: Clinical considerations: Cuation
Contraindicated for chronic liver disease and hx of pancreatitis
Pregnancy
156
Migraine PPx: Valproic acid, divalproex sodium: Clinical Considerations usefl for
seizure or bipolar disorder
157
Migraine PPx: topiramate: ADEs
Fatigue, anorexia, diarrhea, weight loss, difficulty with memory, paresthesia
158
Migraine PPx: topiramate: DDIs
Other sedating meds
159
Migraine PPx: topiramate: Clinical considerations: Caution
Hx of nephrolithiasis, renal/hepatic dysfunction, concurrent oral contraceptives
160
Migraine PPx: topiramate: Clinical considerations: Useful for
Concurrent seizure or bipolar disorder
161
Which meds would you use for migraine ppx when pt has concurrent seizure or bipolar disorder?
Valproic acid, divalproex sodium
| Topiramte
162
Which meds would you use for migraine ppx when pt has concurrent HTN, angina, anxiety?
Propranolol
| Timolol
163
Triptans used for migraine ppx
Frovatriptan, naratriptan, zolmitriptan
164
Triptans for migraine PPx useful for
Migraine associated with menses
165
Which meds used for migraine ppx are useful for migraine associated with menses?
NSAIDS (naproxen, IBU) and triptans
166
Which meds used for migrain ppx are useful for concurrent depression, neuropathy?
Amitriptyline, nortriptyline, venlafaxine, fluoxetine
167
Which TCAs are used for migraine ppx
Amitriptyline
| Nortriptyline
168
Which SNRI are used for migraine ppx
Venlafaxine
169
Which SSRI are used for migraine ppx
Fluoxetine
170
Which antidepressants for migraine ppx have a DDI with triptans?
SNRI/SSRI (Venlafaxine and fluoxetine)
171
Which CCB is used for migraine ppx?
Verapamil (Non-DHP CCB)
172
Verapamil DDI
BB
| CYP interactions
173
Verapamil for migraine ppx useful for
Prolonged aura
174
Verapamil for migraine ppx clinical consideration caution for
CHF
175
Are Gepants used for migraine ppx?
Yes - rimegepant (ODT) and Atogepant (Tab)
176
Anti-CGRP antibodies for migraine ppx: MOA
Monoclonal antibodies that bind to CGRP receptor (erenumab) or CGRP ligand (others) to antagonize CGRP activity
177
Migraine PPX: Anti-CGRP Antibodies Medication options
Erenumab-aooe (Aimovig)
Fremanezumab-vfrm (Ajovy)
Galcanezumab-gnlm (Emgality)
Epitnezumab-jjmr (Vyepti)
178
Which Anti-CGRP antibodies for migraine ppx has issues with LATEX ALLERGY?
Erenumab-aooe (Aimovig)
179
Which Anti-CGRP antibodies is an IV solution?
Vyepti
180
Anti-CGRP antibodies ADEs
Injection site reactions (SQ agents), constipation (erenumab), nasopharyngitis (epitnezumab), hypersensitivity (epitnezumab), HTN (erenumab)
181
Anti-CGRP Antibodies DDIs
None listed
182
Anti-CGRP antibodies: Clinical considerations
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
OnabotulinumtoxinA MOA
blocks neuromuscular transmission by inhibiting release of acetylcholine
184
OnabotulinumtoxinA has ___ units in __ injection sides divided across __ specific head/neck muscle areas
155 units
31 injections
7 areas
185
OnabotulinumtoxinA: Clinical Considerations ADE
Neck pain, headache
186
OnabotulinumtoxinA: Clinical Considerations DDI
Aminoglycosides or other agents impacting neuromuscular transmission, muscle relaxants
187
OnabotulinumtoxinA: Clinical Considerations pt education
Avoid operating machinery if the have muscle weakness
188
OnabotulinumtoxinA: Clinical Considerations
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
Other agents used for migraine ppx
Melatonin
| Magnesium
190
Melatonin Clinical Considerations for migraine ppx
ADE: Fatigue
| Clinical considerations: lack of sleep = tigger? , well tolerated (evidence is promising but still lacking)
191
Magnesium Clinical Considerations for migraine ppx
ADE: diarrhea
probably efficacy
May have benefits of prevention of menstrual related migraine
192
Migraine Prophylaxis: Evidence of Efficacy: Established efficacy: Oral options
```
Candesartan
Divalproex sodium
Frovatriptanf
Propranolol
Timolol
Topirimate
Valproate sodium
```
193
Migraine Prophylaxis: Evidence of Efficacy: Established efficacy: Parenteral options
```
Eptinezumab
Erenumab
Fremanezumab
Galcanezumab
OnabotulinumtoxinAd
```
194
Migraine Prophylaxis: Evidence of Efficacy: Probable efficacy: Oral options
```
Amitriptyline
Atenolol
Lisinopril
Memantine
Nadolol
Venlafaxine
```
195
Migraine Prophylaxis: Evidence of Efficacy: Probable efficacy: Parenteral options
OnabotulinumtoxinA + CGRP mAbd,e
196
Migraine PPX: menstrual related migraine
Frovatriptan, naratriptan, zolmitriptan
197
Migraine PPX: co-morbid obesity/overweight
Topiramte
198
Migraine PPX: Headache recurring in predictable pattern
NSAID or triptan at time of vulnerability
199
____ 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
Pure menstrual migraine
200
____ 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
Menstrual related migraine
201
Triptans for menstrual related migraines clinical considerations: Begin ____ PIROR to menstruation and continue for ____
Begin 6 days prior
| Continue 5-7 days
202
Migraine PPX: If there is not a response after an appropriate trial (≥ ___ weeks on an effective dose) change to another effective medication
8 weeks
203
Pharmacological therapy options for migraine ppx
```
Treatment option based on DDI, comorbid conditions, etc
NSAIDs
Triptans
AEDs
Antidepressants
Magnesium
Melatonin
CGRP Antagonists (gepants)
Anti-CGRP Antibodies
OnabotulinumtoxinA
```
