Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

P&T Neuro/Psych > Final Exam (Migraines) > Flashcards

Final Exam (Migraines) Flashcards

You may prefer our related Brainscape-certified flashcards:
Psychology 101 flashcards GRE® Psychology flashcards
1
Q

Which of the following is/are involved in the pathophysiology of migraines:

I. Calcitonin gene-related peptide (CGRP)
II. Trigeminal nucleus caudalis
III. Prostaglandin

A. I only
B. I & II
C. III only
D. I, II, & III

A

D. I, II, & III

The pathophysiology of migraines is characterized by a dysfunction of the trigeminal nerve system and its central connections in the brain involving:

  1. VASODILATION
  2. Release of VASOACTIVE PEPTIDES (CGRP, neurokinin A, and substance P)
  3. PAIN NEUROTRANSMISSION

Migraines start in the brain stem (trigeminal ganglion). VASODILATION activates surrounding nerves which release vasoactive neuropeptides and cause PAIN, INFLAMMATION, and further VASODILATION. Pain signal is transmitted from trigeminal ganglion to trigeminal nucleus caudal and up to the higher CNS

SEROTONIN dysfunction plays a role in vasodilation and sensitization of trigeminal nerve fibers

PROSTAGLANDIN is activated in later stages of migraine attack and amplifies the pain signal resulting in a “full blown” migraine attack

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

All of the following statements about migraines are true, EXCEPT:

A. More common in women than men
B. Genetic predisposition
C. Any medication used for abortive therapy can cause rebound HA
D. Typically presents as bilateral
E. None of the above
A

D. Migraines typically present as UNILATERAL

C. Abortive medications can cause rebound HA and use should be limited to 2-3 days/week to avoid medication overuse and rebound HA. If patient is refractory to abortive med Tx, start prophylactic therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe typical characteristics of migraines?

A 
Migraines are:
Unilateral
Pain occurs in frontotemporal region
Often occurs in early AM 
Duration is 4-72 hours
N/V very common Sx
Photophobia, phonophobia, and osmophobia
Resolution phase: fatigue, irritability, listlessness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Premonitory Sx of migraine are characterized by neurological (sensitivity to light), psychological (anxiety), and constitutional (stiff neck, yawning) Sx. When do these Sx typically occur?

A

Premonitory symptoms occur several hours to 1-2 days BEFORE the aura and migraine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

All of the following statements about migraine aura are correct, EXCEPT:

A. Lasts 5-60 min
B. Precedes or accompanies migraine
C. Sx are most often visual such as blurred vision or flickering light
D. The majority of migraineurs experience aura
E. None of the above

A

D. Only 1/3 of ptns that get migraines experience aura

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Which of the following nonpharmacologic therapies is/are good recommendations for migraineurs?

A. Hot shower
B. Dark/quiet environment
C. Ice pack on head
D. A & B
E. B & C
A

E. Dark/quiet environment and ice pack on head would be good recommendations to anyone with a migraine.

Remember, migraines are characterized by vasodilation which you would want to avoid making worse. A hot shower may cause further vasodilation and increase pain transmission. An ice pack can help with vasoconstriction of the local area minimizing the migraine pathophysiology.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What (3) medications should be avoided by ptns susceptible to migraines as these can be triggers for some patients?

A
  1. Oral contraceptives (b/c estrogen component is a vasodilator - lower dose of estrogen or switch to progestin only OC if woman getting frequent migraines)
  2. Corticosteroid withdrawal
  3. Hydralazine (Apresoline®)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

T/F: Triggers for migraines can be medications, environmental, foods, and behavioral (too much/little sleep)?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Which of the following statements regarding migraines is/are correct?

A. “Triptans” are 1st line therapy for mild-moderate migraine
B. Triggers are different for all patients, but will be consistent with one individual
C. Ergotamine is DOC in severe migraines
D. Pharmacotherapy is MOST effective when administered at the onset of migraine
E. B & D

A

E. B &D - these statements are both true

B. Triggers are different for all patients, but will be consistent with one individual

D. Pharmacotherapy is MOST effective when administered at the onset of migraine

“Triptans” are 1st line therapy for MODERATE-SEVERE migraines and Ergotamine is NOT DOC due to issues with efficacy and SE profile

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Walk through the migraine treatment algorithm:

After diagnosis and patient education on avoidance of triggers, etc., assess patients HA severity. Is it impairing the patients functionality? If not, patient has mild to moderate symptoms

  1. How would you treat mild to moderate Sx?
  2. What if patient tried whatever you recommended in question 1 but had an inadequate response? What would you recommend for the patient?
  3. The patient took your recommendation, but still had an inadequate response. What now?
  4. What if a newly diagnosed patient with migraine has impaired functionality and therefore has “severe” Sx. What are the 1st line agents in the treatment of severe Sx?
  5. What 2nd line agents would be attempted in patients that failed 1st line agents?

6 What are the last line “rescue” medications used for migraines?

A
  1. Mild-moderate Sx can be treated with APAP or NSAIDs (ASA, Ibuprofen, naproxen)
  2. Recommend patient try combination analgesics:
    i) Excedrin Migraine: 250mg APAP + 250mg ASA + 65mg caffeine
    OR
    ii) Fioricet: 325mg APAP + 50mg butalbital + 40mg caffeine (new Fioricet = 300mg APAP instead of 325mg. The old formulation of Fioricet was allowed to be manufactured up to January 1, 2014)
  3. For patients with mild-moderate Sx having inadequate response from OTC products and combination analgesics, triptans are now indicated.
4.  Triptans are 1st line treatment for severe Sx
RAZES
Rizatriptan (Maxalt®)
Almotriptan (Axert®)
Zolmitriptan (Zomig®)
Eletriptan (Relpax®)
Sumatriptan (Imitrex®)
  1. Dihydroergotamine or Ergotamine
    No longer 1st line agents b/c of SE profile: severe N/V, 5-HT syndrome, HTN, Reynaud’s (excessively reduced blood flow causing discoloration in fingers and toes)
  2. Rescue medications: opioids or antiemetics
    OPIOIDS:
    meperidine (Demerol®)
    butorphanol (Stadol®) mixed agonist/antagonist
    oxycodone (Oxycontin®)
    hydromorphone (Dilaudid®)

ANTIEMETICS:
metoclopramide (Reglan®)
prochlorperazine (Compazine®)

Antiemetics can be used monotherapy as an alternative to narcotic analgesics for intractable, refractory migraine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Give the BRAND, DOSE, and MAX DAILY DOSE:

Rizatriptan
Almotriptan
Zolmitriptan
Eletriptan
Sumatriptan
A

Drug PO Dose Max Daily Dose
Rizatriptan (Maxalt®) 5mg or 10mg 30mg
Almotriptan (Axert®) 6.25mg or 12.5mg 25mg
Zolmitriptan (Zomig®) 2.5mg or 5mg 10mg
Eletriptan (Relpax®) 20mg or 40mg 80mg
Sumatriptan (Imitrex®) 25,50, 100mg 200mg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

When should migraine abortive medications be taken?

A

As soon as they have Sx of migraine or as soon as aura begins (if ptn experiences aura - only occurs in 1/3 of migraineurs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are patients at risk of getting from abortive medication over use (i.e. using > 2-3 days/week)?

A

rebound HA or “medication overuse” HA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

T/F - medrol dose pak can be used to try and “break the cycle” in patients refractory to abortive medications Tx?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Which of the following statements regarding Triptans is/are true?

I. Triptans are 5-HT agonists that help promote vasoconstriction
II. Triptans inhibit release of substance P and other vasoactive peptides
III. Patients that fail with one triptan should try another triptan

A. I only
B. I & II
C. III
D. I, II, & III

A

D. I, II, & III

Triptans are “migraine specific” agents. Migraines are characterized (partially) by serotonin dysfunction. Triptans specifically target 5-HT receptors

MOA: 5-HT1B and 5-HT1D receptor agonists

  1. Helps promote vasoconstriction
  2. Inhibits release of vasoactive peptides
  3. Blocks pain pathways in brain stem

The clinical response to triptans varies considerably among individual patients so if a patient fails one triptan, it’s ok to try a different one.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How often can doses of triptans be repeated?

A

Every 2 hours up to the max dose of individual agent.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Which triptan medication must use the lower dose if taken concomitant propranolol?

Name the agent, dose, and max daily dose

A

Rizatriptan (Maxalt®) 5mg; max daily dose 15mg if patient on propranolol.

Both rizatriptan (Maxalt®) and propranolol are metabolized by MAO-A to some extent resulting in competition for metabolism.

18
Q

Which triptan should be used with caution with CYP3A4 inhibitors such as verapamil, diltiazem, grapefruit juice, azoles, PIs, and amiodarone?

A

Eletriptan (Relpax®)

19
Q

Name the (7) CI with triptans?

A
  1. Ischemic heart disease (patients w/ Hx of MI, angina, cardiac cath w/ blockage)
  2. Uncontrolled HTN (>160/95)
  3. Cerebrovascular disease
    4 Hemiplegic (unilateral motor Sx) or Basilar migraine (very specific aura, unsteady gait)
  4. Severe hepatic impairment
  5. Use within 24 hrs of ergotamine derivatives
  6. Use within 2 weeks of an MAO-I

MAO-I lead to accumulation of triptan and increase toxicity:
phenelzine (Nardil®)
isocarboxazid (Marplan®)
tranylcypromine (Parnate®)

20
Q

Caution with triptans should be used in which of the following populations?

A. Pregnancy
B. Uncontrolled vascular risk factors
C. Men > 40 y/o
D. Postmenopausal women
E. All of the above
A

E. All of the above

Clinically, triptans are NOT used in pregnancy (even though they are category C)

Patients with uncontrolled HTN, DM, and hyperlipidemia should undergo CV testing before being prescribed triptans

21
Q

AE of triptans are related to their vasoconstrictive properties. Name (4) of the more common AE and (1) rare AE?

A

Common

  1. paresthesias (tingling)
  2. dizziness
  3. flushing
  4. transient chest pressure or heaviness

Rare
1. MI and coronary vasospasm - more likely in pts w/ cardiac/cerebrovascular disease

22
Q

What is Treximet®? Indication?

A

Treximet® is Sumatriptan (Imitrex®) 85mg + Naproxen 500mg

Indication: moderate-severe migraine partially relieved by triptan therapy. Sumaptriptan alleviates early migraine Sx while naproxen targets later migraine response from prostaglandins

23
Q

How does Ergotamine MOA differ from Triptan MOA?

A

Triptan MOA is 5-HT agonist

Ergotamine MOA is 5-HT agonist + α-adrenergic, β-adrenergic, and dopaminergic receptor agonist causing:

VASOCONSTRICTION and INHIBITION of neuronal INFLAMMATION

24
Q

Cafergot® is Ergotamine + Caffeine. What is the role of caffeine?

A

Caffeine is a vasoconstrictor, but also enhances the absorption of ergotamine.

25
Q

Name the brand and dosage form for each ergotamine derivative:

Ergotamine tartrate
Dihydroergotamine
Dihydroergotamine
Ergotamine w/ Caffeine

A

Ergotamine tartrate (Ergomar®) SL tablet
Dihydroergotamine (DHE-45®) IM injection
Dihydroergotamine (Migranal®) Nasal spray
Ergotamine w/ Caffeine (Cafergot®) Oral tablet

26
Q

Which of the following decrease adrenergic and sympathetic response?

A. DHE 45®
B. Migranal®
C. Relpax®
D. A & B
E. B & C
A

D. A & B

DHE 45® and Migranal® are both ergotamine derivatives causing vasoconstriction and agonists at α, β, and dopaminergic receptors decreasing adrenergic and sympathetic response

27
Q

Name the (4) CI with ergotamine derivatives?

A
  1. Renal or hepatic failure
  2. CAD, stroke, PVD
  3. Uncontrolled HTN (>160/95)
  4. Pregnancy or lactation - Category X
28
Q

T/F - similar to triptans, ergotamine derivatives are CYP3A4 substrates and should be used with caution with strong CYP3A4 inhibitors such as clarithromycin and azoles?

A

True

29
Q

What is the primary AE seen with ergotamine derivatives that make them 2nd line agents and not 1st line for tx of migraine?

A

NAUSEA/VOMITING

30
Q

What is ergotism?

A

Peripheral ischemia: painful numbness in extremities

31
Q

All of the following statements are true, EXCEPT?

I. Compazine® should be administered with IV diphenhydramine when used to treat migraine
II. Possible AE of metoclopramide is EPS
III. Reglan® and Compazine® are dopamine agonists

A. I only
B. I & II
C. III only
D. I, II, & III

A

C. III only

Antiemetics Reglan® and Compazine® are dopamine ANTAGONISTS, not agonists. As such, they have AE of EPS (and drowsiness and dizziness). IV diphenhydramine is administered with both Reglan® and Compazine® to prevent akathisia and dystonic reactions and also potentially beneficial in treating migraine as well.

32
Q

All of the following are indications that a patient should receive prophylactic therapy for migraines, EXCEPT:

A. Attack >2x/week
B. Frequent use of abortive tx leading to rebound HA
C. HA occuring in a non-predictable fashion with no recognizable pattern
D. Recurring migraines that produce significant disability
E. Abortive tx that is ineffective, CI, or produce serious SE

A

C. Prophylaxis is NOT indicated for patients with HA occuring in a non-predictable fashion with no recognizable pattern. Prophylaxis is only indicated if HA are occurring in a PREDICTABLE PATTERN (like after exercise or menstruation)

33
Q

Which of the following medications is the PREFERRED choice for prophylactic therapy in a patient with migraines and PMH significant for HTN?

A. Inderal®
B. Lopressor®
C. Calan®
D. Corgard®

A

A. propranolol (Inderal®)

All the choices listed here are acceptable to use as prophylaxis for patients with migraine and HTN, however B-blockers, specifically propranolol, are the preferred agents. If B-blockers were CI, verapamil (Calan®) would be the next best choice. Metoprolol (Lopressor®), Nadolol (Corgard®), and atenolol (Tenormin®) are also acceptable B-blockers

34
Q

What is the DOC for migraine prophylaxis in patients with migraine and depression?

A. Chlorpromazine
B. Imipramine
C. Topamax®
D. St. John's Wort
E. Elavil®
A

E. The TCA Amitriptyline (Elavil®) is the DOC for migraine prophylaxis in patients with comorbid depression. Amitriptyline is dosed HS

Imipramine (Tofranil®) is also a TCA, but is not the preferred drug in its class.

35
Q

List the correct DOC for migraine prophylaxis with each comorbidity:

  1. Healthy or HTN or angina
  2. Depression or insomnia
  3. Epilepsy or bipolar disorder
  4. Overweight/obese
A
  1. Healthy or HTN or angina: propranolol (Inderal®) or verapamil (Calan® or Isoptil®)
  2. Depression or insomnia: amitriptyline (Elavil®)
  3. Epilepsy or bipolar disorder: topiramate (Topamax®)
  4. Overweight/obese: topiramate (Topamax®)
36
Q

Which of the following statements is TRUE?

A. Migraine prophylaxis medications should be started at their highest doses to provide maximum protection
B. A notable AE of Topamax is weight gain
C. Migraine prophylaxis meds should be tried for 2-3 months before assessing efficacy
D. Migraine prophylaxis meds can be D/C as soon as the frequency and severity of HA improve
E. B & C

A

C. Migraine prophylaxis meds should be tried for 2-3 months before assessing efficacy. Start at LOW doses and titrate up to effective dose. Prophylaxis should be CONTINUED for 3-6 months after frequency and severity of HA improve.

A notable “AE” of topamax is weight LOSS

37
Q

Which class of migraine prophylaxis medication “calms” migraine response down by enhancing GABA mediated inhibition and decreasing excitatory glutamate

A

Antiepileptics

38
Q

What would you need to counsel on for a patient taking Trokendi XR?

A

Must avoid alcohol within 6 hrs of taking topiramate (Trokendi XR®) to prevent XR formulation changing into IR formulation.

39
Q

Which of the following are used for migraine prophylaxis?

A. Riboflavin
B. Botox®
C. Naproxen
D. Magnesium
E. All of the above
A

E. All of the above

40
Q

Match the following to the appropriate description:

  1. Botox® A. Good for ptn w/ aura, menstrual mig.
  2. Riboflavin B. AE of parasthesia and CNS effects
  3. Magnesium C. Good option in pregnancy
  4. Naproxen D. Inhibits prostaglandin synthesis
  5. Topamax® E. decreases NT release, last line agent
A
  1. Botox® E. decreases NT release, last line agent
  2. Riboflavin C. Good option in pregnancy
  3. Magnesium A. Good for ptn w/ aura, menstrual mig.
  4. Naproxen D. Inhibits prostaglandin synthesis
  5. Topamax® B. AE of parasthesia and CNS effects

P&T Neuro/Psych (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions