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Neurologic & Psych > Exam 2 Pharmacotherapy Headache Dr. Brown (resident) > Flashcards

Exam 2 Pharmacotherapy Headache Dr. Brown (resident) Flashcards

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1
Q

Which headache type has a throbbing presentation?

A

Migraines

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2
Q

Which type of headache causes a stabbing and burning pain around the eye?

A

Cluster headace

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3
Q

Which type of headache causes a squeezing or tight sensation around the head?

A

Tension-type headache
(most common)

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4
Q

Comorbidities that may present with headache

A

-depression/anxiety
-epilepsy
-stroke
-TBI (traumatic brain injury)
-sleep apnea
-obesity, tobacco use

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5
Q

Modifiable risk factors

A

Stress
-depression
-dietray triggers
-hormone levels (due to menstrual cycle -> may be treated with OC preventing periods)
-poor sleep habits

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6
Q

Medication that can cause headache

A

Vasodilation causing drugs -> affecting cranial blood vessels -> causing headache

-PDE-5 inhibitor
-Nitrates
-hydralazine (peripheral vasodialtor)

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7
Q

When is migraine considered episodic?

A

1-14 days per month

> 15 or more days per month -> chronic

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8
Q

How is migraine with aura classified?

A

-1+ fully reversible aura symptoms lasting +4 minutes or 2+ symptoms occurring in sequence

-the symptoms should not last more than 60 minutes

-headache onset is within 60 minutes of aura

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9
Q

How is migraine without aura classified?

A

-<2 characteristics:
Pain: unilateral/pulsating
Intensity: moderate-severe

-<1 symptom:
N/V
Photo or Sonophobia

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10
Q

What are the prodrome symptoms that occur before the migraine?

A

increased parasympathetic tone
-> lacrimation (flow of tears), nasal congestion, rhinorrhea, irritability, food cravings, mood swings, sensory sensitivity

onset up to 3 days before migraine

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11
Q

Treatment for acute migraine

A

-Mild-moderate: analgesics (tylenol, ibuprofen) and supportive care

-Moderate-severe: CGRP receptor antagonists, triptans, ditans, ergotamine

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12
Q

When is it appropriate to treat migraine prophylacticly?

A

-no guidelines that direct that

-use it if the patient has significant disability despite acute therapy
-epidsodes >2 per week (risk for medication overuse headache)
-ineffective rescue therapies or intolerable ADEs
-risk of neurologic damage with uncommon migraine types

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13
Q

What are the recommended drug therapies for ACUTE migraine based on the guidelines?

A level evidence

A

-Triptans: all available options and doses

for milder migraines:
-APAP (Tylenol) 1000mg (max 4g/d and not longer than 15 days due to overuse)
-Aspirin 500-1000mg - not preferred bc Salicylate
-ibuprofen 200-400mg
naproxen 500mg, diclofenac 50-100mg

-Dihydroergotamine 2mg nasal spray or 1mg inhaler
-Butorphanol 1mg nasal spray

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14
Q

What are the recommended drug therapies for PREVENTION of EPISODIC migraine based on the guidelines?

A level evidence

A

-valproic acid 500-1000mg/d
-Topiramate 50-200mg/day

-Propranolol 80-160mg/day
-Metoprolol 200mg/day

-Frovatriptan 2.5mg once or twice daily (for menstrual migraine) -> has the slowest onset and longest half-life

-evaluate patient comorbidites and side effects of drug

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15
Q

Which migraine prevention drug may be used in a bipolar patient?

A

Valproic acid

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16
Q

Which migraine prevention drug may be used in a patient who suffers from seizures?

A

Topiramate

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17
Q

Which migraine prevention drug may be used in a patient with HTN or heart failure?

A

ß-blockers (propranolol)

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18
Q

Which migraine prevention drug may be used in a patient with menstrual migraine?

A

Frovatriptan

Naratriptan
Zolmitriptan (nasal spray for patients with N/V)

or oral contraceptives

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19
Q

How should Frovatriptan be taken?

A

once or twice daily for 6 days
start 2 days prior to the period

2.5 mg/day
max 7.5 mg/day

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20
Q

What type of migraines conflict with the use of oral contraceptives?

A

avoid combined oral contraceptives (COC) in patients with migraine with aura
-> absolute contraindication

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21
Q

What are the recommended drug therapies for PREVENTION of EPISODIC migraine based on the guidelines?

B level evidence

A

-Amitriptyline
-Venlafaxine XR 150mg daily
-Nadolol
-Naratriptan
-Zolmitriptan

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22
Q

Which durg might be used for migraine prevention in patients with depression?

A

Amitriptyline (TCA)
Venlafaxine (SSRI)

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23
Q

What is the preferred first line therapy based on the guidelines?

A

CGRP antagonists
-> but still not recognized by insurance
->patients might try triptans first

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24
Q

Which drugs may be used for predictable migraine episodes?

A

Prophylaxis: make sure the patient is eligible -> >2 episodes per week, ineffective rescue therapy or intolerable ADE

-Erenumab (Aimovig)
-Rimegepant (Nurtec)
-> both CGRP receptor antagonist

maybe Frovatriptan in menstrual cycle -> CAUTIOS with CV risk bc it causes some vasoconstriction

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25
Q

Which drugs can be used for pain syndrome (headache)?

A

-Ibuprofen

prophylactics
-TCA: Amitriptyline
-SSRI: Venlafaxine

26
Q

Treatment for mild migraine

A

Tylenol
NSAIDs

27
Q

Treatment for patients who are otherwise healthy

A

Lasmiditan
Triptans

28
Q

How is Lasmiditan different from Triptans?

A

it only blocks Serotonin-1F receptors

-> blocks neuropeptide release on the presynaptic receptor
-but does not cause vasoconstriction of the arteriole on the meninges

29
Q

Which migraine treatment should be avoided in HTN patients?

A

-Erenumab (contraindicated in recent CV events, it may worsen HTN)
-Triptans
-Venlafaxine (contraindicated in HTN if > 150 mg, note: > 150 mg is needed to get enough norepinephrine effect for pain control)

30
Q

Which migraine treatment should be avoided in patients with long QTc syndrome?

A

-Triptans (since causing vasoconstriction, more 1B, 1D receptor agonists???)

-TCA (side effect of cardiac conduction delay)

31
Q

Which migraine treatment should be avoided in patients with a history of CVD?

A

Triptans
Ibuprofen
Rimegepant (Nurtec) -> block CGRP on blood vessels -> vasoconstriction
dihydroergotamine

32
Q

Which migraine treatment should be avoided in patients with CKD or AKI?

A

CGRP antagonits

with CrCl < 15: ESRD patients (end-stage renal disease)
Ubrogepant
Rimegepant (Nurtec)

with CrCl < 30:
Atogepant
Zavegepant

-Naratriptan (contraindicated in CrCl < 15)
-Ibuprofen

33
Q

Which migraine treatment should be avoided in patients with Liver dysfunction?

A

CGRP antagonists:
Ubrogepant: dose adjust
Rimegepant (Nurtec) - Contraindicated

Triptans:
Sumatriptan
Naratriptan
Eletriptan

Serotonin agonist:
Lasmiditan

Ergot alkaloid:
Dihydroergotamine

34
Q

Which migraine treatment should be avoided in patients with low body weight?

A

Topiramate
-> weight loss is a side effect

35
Q

Which migraine treatment should be avoided to avoid DDI?

A

CGRP antagonists
Ubrogepant - CYP 3A4 inhibitor
Rimegepant (Nurtec) - CYP 3A4 inhibitor
Atogepant - CYP 3A4 inhibitor

Dihydroergotamine: strong CYP 3A4 inhibitor, space 2 weeks from MAOIs, space 24h from Triptans

Triptans: avoid within 24h with other serotonergic drugs

Butorphanol: check interaction checker
Amitriptyline, Venlafaxine, Topiramate: check interaction chekcer

36
Q

Which migraine treatment should be avoided to drug interactions with pregnant/lactation?

A

Valproic Acid
Topiramate
Venlafaxine

Lasmiditan!!!

Ibuprofen after 20 weeks

37
Q

Which migraine treatment should be avoided in patients with GI conditions?

A

-Ibuprofen -> risk for GI bleeds

-Erenumab (Aimovig) -> can cause severe constipation
-Atogepant (Qulipta) -> ADR for constipation

-Triptans are contraindicated in IBD (ischemic bowel disease)

38
Q

Which drug has a BBW for being a strong CYP 3A4 inhibitor?

A

Dihydroergotamine

39
Q

Classification Cluster Headache

A

multiple short, severe/very severe occurrences
lasting 15 minutes to 3 hours

location: unialteral -> orbital (cavity of the eye), suborbital, temporal

1+ symptoms
-eye irritation, pinpoint pupils, eyelid dropping, eyelid swelling

autonomic:
-lacrimation
-nasal congestion
-rhinorrhea
-face sweating

40
Q

How are episodic cluster headaches classified?

A

daily for weeks to months -> long pain-free intervals of about 2 years

41
Q

How are chronic cluster headaches classified?

A

recurrence (daily headache) for more than a year
or
remission (pain-free) for less than a month

42
Q

What are the treatment options for cluster headaches?

Guidelines Level A

A

-Sumatriptan 6mg SQ
-Zolmitriptan 5mg or 10mg nasal spray
-High flow oxygen (100% at 6-12 L/min)

Level B:
-other formulations
-Sphenopalatine ganglion stimulation

43
Q

What are the prophylactic treatment options for cluster headaches?

Level A

A

-Suboccipital steroid injection (single or series;
monotherapy or add-on

44
Q

What are the PROPHYLAXIS treatment options for cluster headaches?

Level B and C

A

-Civamide 50mcg nasal drops daily (not available in the US)

Level C: Possibly effective
-Lithium 900mg daily !!
-Verapamil 360mg daily !!
-Warfarin to INR 1.5-1.9
-Melatonin 10mg nightly

CGRP receptor antagonist:
-Galcanezumab (Emgality®) 300mg SQ for 3 months

45
Q

How is tension headache classified? Name the characterisitcs

A

10 more occurrences lasting 30 minutes to 7 days
-> pressing/thightening
-> bilateral, hatband
-> not aggravated by physical activity

46
Q

When is tension headache considered episodic?

A

1 or more occurences per month
frequent episodic: 1-14 days per month

47
Q

When is tension headache considered chronic?

A

15 or more days per month

48
Q

What is thought to cause tension headaches?
Pathopyhsiology

A

Peripheral Mediation
-> muscle contraction of the head -> activation of peripheral nociceptors

Central Sensitization
-> persistent peripheral activation -> sensitization of trigeminal nerve

49
Q

Acute Treatment for tension headache

A

-Trigger management
-APAP 1000 mg or NSAIDs
-Aspirin 500 mg

-Caffeine-containing combinations (Level B)

50
Q

Prophylaxis for tension headache

A

-Amitriptyline 25-75mg/day (Level A)
-Venlafaxine >150mg/day (Level B)
-Mirtazapine 30mg/day (Level B)

51
Q

Which drug is NOT recommended for acute treamtent of tension headache?

A

triptans
muscle relaxants
opioids

52
Q

Which drug is NOT recommended for prophylaxis treamtent of tension headaches?

A

botulinum toxin
SSRI

53
Q

When should prophylaxis treatment for tension headaches be reevaluated?

A

every 6-12 months

54
Q

How is Status Migrainosus classified?

A

continuous headache phase lasting >72 hours despite treatment

headache free phase is less than 4h (not including sleep)

55
Q

How is “frequent use” in Medication Overuse Headache classified?

A

average >3 days per week for 3 months

-simple analgesics: max of 15 days !!!
NSAIDs, Aspirin, APAP

-complex analgesics: max of 10 days !!!
opioids, ergotamines, triptans

56
Q

How long should the washout period last to get rid of the acute treatment dose from the system?

A

about 2 months
->may stay on prophylactic treatmentv (CGRP), doesn’t seem to contribute to overuse headache

57
Q

Status Migrainosus treatment

A
  1. IV fluids
  2. IV prochlorperazine or IV metoclopramide for nausea
  3. NSAID, Tylenol 1g
  4. SC sumatriptan (space 24h between ergots)
  5. magnesium sulfate
  6. consider DHE (ergot) or dexamethasone 4-16 mg IV
58
Q

When to refer Status Migrainosus patients

A

-Change in frequency, severity, intensity or associated symptoms of headache

-Systemic symptoms (ie, fever, weight loss, rash, chills, night sweats, and jaw claudication)
-Secondary risk factors (ie, pregnancy, cancer, HIV/AIDS, and immune-compromised state)
-Seizures or neurologic symptoms/signs
-New headache or change in headache in someone over age 50

-Thunderclap headache
-Positional component
-Pulsatile tinnitus
-Precipitated headache, specifically by cough, exercise, sexual activity or sleep

59
Q

Treatment for N/V

A

Nausea:
Ondanestron

Vomitting:
Metoclopramide IV
Prochlorperazine IM

60
Q

Non-pharmalogical headache treatment

A

Riboflavin
Magnesium
CBT, relaxing technique
TENS treatment
Herbals
Smoking cessation

61
Q

ADE for valproic acid

A

-liver toxicity
-pancreatitis
-weight gain
-sedation

Neurologic & Psych (37 decks)

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