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Summer pharm 3 > HA > Flashcards

HA Flashcards

1
Q

What is a med overuse headache

A

Frequent or excess use of migraine medication causing a syndrome of self-sustaining HA-Medication cycle

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2
Q

How do you recognize a med overuse headache

A

gradual onset of an atypical daily or near daily headache with superimposed episodic migraine attacks

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3
Q

What meds are said to cause med overuse headaches more frequently

A

Simple and combo analgesics and opiates

Triptans (in men w/ high frequency of HA)

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4
Q

How often should you use Triptans

A

Max of 9 times per month!

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5
Q

What is a migraine headache

A

Recurring throbbing head pain
Unilateral
Lasts 4-72 hours
Associated N/V, photophobia, phonophobia, and sensitivity to movement

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6
Q

The pathogenesis of migraine headaches is related to

A

complex dysfunctions in neuronal and broad sensory processing
Pain and Sx are 2/2 neural suppression, and activation of subcortical structures

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7
Q

Migraine pain is 2/2

A

Activity within the trigeminovascular system (afferent fibers arising from trigeminal ganglia and projecting peripherally to innervate IC extracerebral blood vessels, dura, and large venous sinuses

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8
Q

What is the pathophys of a migraine

A
  • Afferent fibers of trigeminal ganglia project centrally and terminate in the brain stem and upper cervical spinal cord
  • Activating trigeminal sensory nerves= release of vasoactive neuropeptides (CGRP, neurokinin A, substance P)
  • Neuropeptides interact with dural blood vessels= vasodilation and dural plasma extravasation= Neurogenic inflammation
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9
Q

Continues afferent input can result in

A

sensitization of these central sensory neurons= hyperalgesic state that responds to previously innocuous stimuli and maintains HA

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10
Q

What is 5-HT

A

a mediator of migraine HA, involved in the pathophys and Tx of migraine HA

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11
Q

Long story short pathophys of migraines

A

Vasodilation of extra-cerebral vessels= activation of perivascular trigeminal nerves= vasoactive neuropeptide release= neurogenic inflammation
Central pain transmission activates other brain stem nuclei= associated Sx

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12
Q

Goals of migraine Tx include

A

Long term: Reduce migraine frequency, severity, and disability
Acute: Treat rapidly, restore functional ability

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13
Q

Analgesics that can be used to Tx migraines are

A 
Tylenol 
Excedrin migraine (APAP250/ASA250/caffeine65)
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14
Q

NSAIDs that can be used for migraine are

A

ASA
Ibuprofen
Naproxen sodium
Diclofenac

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15
Q

Serotonin Agonists that can be used to Tx migraines are

A

Triptans!
Sumatriptan: inject, PO, nasal spray
Zolmitriptan: PO, nasal spray
Adjunct: Metoclopramide (reglan), Prochlorperazine (compazine)

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16
Q

Other acute migraine meds include

A

Ergotamine Tartrate: oral w/ caffeine, sublingual, rectal suppository w/ caffeine
Dihydroergotamine: injection, nasal spray
(Ergo has more potent arterial effects)

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17
Q

What is Ergotamine/Dihydroergotamine

A

Non-selective 5-HT1 receptor AGONIST;
Constricts IC blood vessels and inhibits development of neurogenic inflammation in trigeminovascular system
Dopaminergic receptor agonist

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18
Q

How do Triptans work

A

Selective 5-HT1b/1d receptor AGONISTS

  • Enhance IC vasoconstriction
  • Inhibit vasoactive peptide release from trigeminal neurons
  • Inhibit transmission through second order neurons ascending to thalamus
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19
Q

How do you dose Sumatriptan

A

Injection: 6mg subQ at onset. repeat after 1 hour if needed. MAX 12mg
PO: 25-100mg at onset, repeat after 2 hours if needed. MAX 200mg
Nasal: 5-20mg at onset, repeat after 2 hours if needed. MAX 40mg

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20
Q

How do you dose Zolmitriptan

A

oral tab: 2.5-5mg, repeat after 2 hr if needed. MAX 10mg
*Do NOT divide ODT
Nasal: one 5mg spray at onset, repeat in 2 hr if needed. MAX 10mg

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21
Q

How do you dose the other Triptans

A

Naratriptan: 1-2.5mg, repeat in 4 hr. MAX 5mg
Rizatriptan (ODT): 5-10mg, repeat in 2 hr. MAX 30mg
Almotriptan: 6.25-12.5, repeat in 2 hr. MAX 25mg
Frovatriptan: 2.5-5mg, repeat in 2hr. MAX 7.5mg
Eletriptan: 20-40mg, repeat in 2hr. MAX 80mg

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22
Q

With ergotamine administration, consider

A

pre-treatment with antiemetic when dosing oral tablet or rectal suppository

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23
Q

What do you need to remember about Dihydroergotamine nasal spray

A

You start with ONE spray in each nostril, can repeat after 15 min. max dose is four sprays total
Discard open ampules after 8 hours of being opened
Prime sprayer 4 times before using
Do not tilt head back, just put up nose and inhale

24
Q

What is “Triptan Sensation”*

A

Tightness, Pressure, Heaviness, or Pain in chest, neck or throat
Usually at the nipple level and above

25
Q

Applications and ADE of Sumatriptan are

A

Good for Migraine and Cluster HA

ADE: paresthesias, dizziness, chest pain, coronary vasospasm, serotonin syndrome

26
Q

What is Serotonin syndrome

A

Hyperthermia, hyperreflexia, tremors, clonus, HTN, diarrhea, mydriasis, agitation, coma
Onset w/in hours of taking meds like SSRI, second gen antidepressants, tramadol, fentanyl, zofran, sumatriptan, MDMA, St. John’s wort, and ginseng

27
Q

How od you treat serotonin syndrome

A 
Sedation w/ benzos 
Paralysis 
intubation 
ventilation 
-Consider 5-HT2 block with cyproheptadine or chlorpromazine
28
Q

What is Neuroleptic malignant syndrome

A

Hyperthermia and acute severe parkinsoniam 2/2 taking D2 blocking antipsychotics and Sumatriptan

29
Q

How do you treat neuroleptic malignant syndrome

A

Diphenhydramine (parenteral)
Cooling
Sedation with benzos

30
Q

What is malignant hyperthermia

A

hyperthermia, muscle rigidity, HTN, tachycardia 2.2 taking volatile anesthetics, Succinylcholine, and sumatriptan

31
Q

How do you treat malignant hyperthermia

A

Dantrolene

cooling

32
Q

When should you consider preventive migraine therapy

A

In the setting of recurrign migraines that produce significant disability despite acute therapy
Frequent attacks (>2x wk)
Sx therapies ineffective or CI, or w/ serious ADE

33
Q

FDA approved migraine preventive meds are

A 
Propranolol 
Timolol
Divalproex sodium 
Topiramate 
*Need 2-3 months of therapy to assess efficacy! Noticeable in 1 month, best judgement after 6 months*
34
Q

Prophylactic Tx should be continued at least

A

6-12 months after frequency and severity of HA have diminished
Then gradually taper or d/c prophylaxis

35
Q

What are Erenumab, Fremanezumab, and Galcanezumab

A

CGRP MABs under review by FDA for use in migraine prevention by stopping CGRP’s vasodilatory and nociception effects
Log half lives mean you can take them once a month subQ

36
Q

Ibuprofen can be used to prevent

A

Menstrual migraine onset!

Daily prolonged use can lead to med overuse HA and has potential toxicity

37
Q

When should Frovitriptan be taken

A

in the perimenstrual period to prevent menstrual migraine

38
Q

Riboflavin is beneficial only

A

after 3 months of use

39
Q

Withdrawal of MIG99 is associated with

A

increased HA

40
Q

Magnesium is more helpful in

A

migraine with aura and menstrual migraine

41
Q

To be prophylactic, Frova Nara and Zolmitriptan should be taken

A

1-2 days before expected onset of HA and continued during the period of vulnerability

42
Q

What is the MC and least studied primary HA

A

Tension headache

1 year prevalence is rising 31 to 86%

43
Q

Pain in a tension headache is thought to arise from

A

myofascial factors and peripheral sensitization of nociceptors
Heightened sensitivity of pain pathways in the CNS

44
Q

CBT treatment options for tension headaches are

A

Stress management
Relaxation training
Biofeedback

45
Q

These treatment options offer inconsistent results, but are ok to use to treat tension HA

A 
heat or cold pack 
US 
electrical nerve stimulation 
stretching, exercise 
massage 
acupuncture 
manipulations 
ergonomic instruction 
trigger point injection 
occipital nerve block
46
Q

What are the recommended Tension HA meds

A

Acetaminophen (alone or with caffeine)
Acute mild-mod: NSAIDs (ASA, Diclofenac, Ibu, Naprozen, Ketoprofen, Ketorolac
High dose NSAID
(ASA or APAP) + (Butalbital or codeine)

47
Q

How long can you take acute medications for tension HA

A

Butalbital: no more than 3 days
Combo analgesics: no more than 9 days
NSAIDs: no more than 15 days

48
Q

There is no evidence to support these meds in treating tension HA

A

Skeletal muscle relaxers

49
Q

Preventive therapy for Tension HA is

A

TCA
SSRI IF also with depression
Chronic tension: Topiramate and Gabapentin
-Botox injection into pericranial muscles NOT recommended
-Limited studies on SNRI’s (Mirtazapine, Venlafaxine)

50
Q

What is the most severe primary HA disorder

A

Cluster HA
Excruciating, unilateral head pain occurs in a series lasting weeks-months (cluster periods), separated by remission periods lasting months-years

51
Q

What is generally the modulator of cluster headaches

A 
The hypothalamus (ipsilateral grey area is activated) 
Hypothalamus then activates trigeminal autonomic reflexes= ipsilateral pain and cranial autonomic features
52
Q

What is a hallmark of cluster HA

A

Circadian rhythm of painful attacks

MC episodic cluster HA (occur for 2 weeks-months, then LONG pain free period)

53
Q

Cluster HA is often accompanied by

A

Cranial autonomic Sx:
conjunctival injection, lacrimation, nasal stuffiness, rhinorrhea, eyelid edema, facial swelling, miosis or pitosis
(resolve with resolution of HA)

54
Q

Difference between migraine and cluster patients

A

Migraine retreat to a dark room

Cluster sit and rock or pace around the room clutching their head

55
Q

Abortive therapy for a cluster HA is

A

Oxygen! standard acute Tx is 12L 100% O2 for 15-30 min using nonbreather facial mask

  • Triptans injections (or sprays) > orals (except Zolmitriptan)
  • IV dihydroergotamine or Ergotamine tartrate
56
Q

Prophylactic therapy for cluster headaches is

A

Verapamil* (takes 2-3 weeks)
Lithium (can cause lethary, nausea, diarrhea, abd discomfort)
Corticosteroids (Prednisone 5 days, then taper)
Misc: Intranasal lidocaine, hyperbaric oxygen, subQ octreotide

Summer pharm 3 (13 decks)

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