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pharm 2 > Headache > Flashcards

Headache Flashcards

1
Q

classification of headaches

A

-Cluster
-Migraine
-Tension

-Secondary headache disorders
-Arise from other disorders
-hemorrhage
-infection
-neuropathy
-stroke
-tumor

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2
Q

pathogenesis of migraine headaches

A

-Neurovascular dysfunction
-1. imbalance of excitatory and inhibitory neurotransmitter activity in CNS - serotonin

-2. the imbalance may be triggered by:
-hormones
-stress
-lack of sleep
-food:
-alcohol (red wine)
-chocolate
-aspartame
-MSG
-coffee
-nitrites/nitrates
-cheese
-pickled meats
-nuts

-drugs:
-danazol (Danocrine) - anti-androtropic for endometriosis
-oral contraceptives
-H2 blockers

-sensorial
-bright or flickering lights
-odors

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3
Q

phases of migraine attack

A

-1st phase
-characterized by cerebral vasoconstriction and ischemia
-release of 5-HT from CNS neurons and circulating platelets contribute to this phase -> SSRI, antiplatelets can help

-2nd phase (longer than first phase)
-cerebral vasodilation and pain:
-trigeminal neurovascular system has central role
-neurons in trigeminal complex release peptides, including substance P and calcitonin gene-related peptide (CGRP).
-Peptides trigger vasodilation and inflammation of dural vessels -> stimulates nociceptive fibers of trigeminal nerve -> PAIN

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4
Q

migraine with and without aura

A

-AURA of migraine headaches
-occur in 15% of pts
-may be visual or sensory
-vasoconstriction and ischemia

-Migraine w/o aura – may be accompanied with premonitory symptoms such as photophobia and irritability as well N/V

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5
Q

general approach to tx of migraines

A

-Goals of long-term migraine treatment (prophylaxis)
-reduce frequency, severity and disability of migraine
-reduce reliance on poorly tolerated medications
-improve QOL
-avoid increased headache medication use
-educate pts to manage their disease
-select medication based on side-effect profile and pt’s underlying disease states. Medication should be used for at least 2-3 months to assess efficacy!!!!!!!!
 
-Goals of acute/abortive migraine tx
-treat migraine attacks rapidly and consistently without recurrence
-restore the patients ability to function
-minimize the use of backup and rescue medications
-optimize self-care for overall management
-be cost-effective in overall management
-cause minimal or no adverse effects

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6
Q

prophylactic drugs

A

-Anticonvulsants
-Antidepressants
-NSAIDS
-Beta blockers
-Calcium Channel blockers
-5-HT2 receptor blockers
-Miscellaneous agents

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7
Q

abortive (symptomatic drugs)

A

-Non-narcotic analgesics
-5-HT1D/1B receptor agonists (triptans)
-Dihydroergotamine and ergotamine
-Miscellaneous

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8
Q

prophylaxis: anticonvulsants

A

-Onset 2-3 wks
-ADRs – weight gain, sedation, tremor

-Ex:
-Divalproex Na (Depakote, Depakote ER) –
-Topiramate (Topamax)

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9
Q

prophylaxis: antidepressants

A

-Onset of efficacy is 3-4 weeks
-MOA for prevention of migraine not fully understood – may stabilize seroternergic neurotransmission by antagonizing or down regulating 5HT2 receptors
 
-Examples:

-Selective Serotonin Reuptake Inhibitors (SSRI) (Prozac and others)
-ADRS – anxiety, GI effects, sexual dysfunction, serotonin syndrome (hyperreflexia, fever, HTN)

-Tricyclic antidepressants (TCA)
-ADRs – drowsiness, tremor and anticholinergic side effects

-Monoamine oxidase inhibitors (MAO inhibitors)
-ADRs – hypertensive crisis with tyramine containing foods, sympathomimetic amine drugs

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10
Q

prophylaxis: NSAIDs

A

-MOA – inhibit thromboxane synthesis and platelet aggregation -> reduce release of serotonin
-can also be used for treatment of migraines

-Examples:
-Aspirin, naproxen, ibuprofen, diclofenac

-ADRs – GI effects, bleeding, Na and H20 retention, antagonize antihypertensive effects

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11
Q

prophylaxis: beta blockers

A

-must be without ISA activity (timolol, propranolol)
-MOA – may block beta 2 mediated vasodilation and reduce platelet aggregation (uncertain)

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12
Q

prophylaxis: CCB

A

-less effective that other prophylactic migraine drugs
-Verapamil primarily used –

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13
Q

prophylaxis: 5-HT2 receptor antagonists

A

-Methysergide (Sansert) (X) – ergot alkaloid
-MOA – blocks 5-HT2 receptor -> prevents vasoconstrictive phase of migraine

-ADRs - Associated with several potentially life-threatening ADRs like retroperitoneal, pleural and cardiac valve fibrosis. Rarely used, limit to 6 months of use, monitor serum creatinine and chest x ray

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14
Q

prophylaxis: miscellaneous agents

A

-Feverfew – herbal preparation -> Contraindicated in pregnancy
-Magnesium
-Riboflavin

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15
Q

prophylaxis: calcitonin gene-related peptide (CGRP) antagonist

A

-MOA – blocks or reverses CGRP-mediated dilation of intracranial vessels, thereby relieving the pain associated with acute migraine attacks

-galcanezumab-gnlm (Emgality) - SC Inj
-erenumab-aooe (Aimovig)- SC Inj
-Fremanezumab (Ajovy)- SC Inj
-ADRs - Most common side effects are injection site reactions and constipation (erenumab)

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16
Q

non-narcotic analgesics

A

-FIRST LINE FOR ABORTIVE TREATMENT OF MILD-MODERATE MIGRAINES
-NSAIDs

-Examples – aspirin, ibuprofen, naproxen, ketorolac
-Ketorolac IM (Toradol) - Very effective; Limit use < 5 days due to ADRs
-acetaminophen and aspirin combinations; also combined with caffeine in OTC products like Excederin

17
Q

5-HT receptor agonists (triptans)

A

-(C)
-structural analogs of 5-HT
-MOA: activate serotonin 5-HT1D/1B receptors in trigeminal neurovascular system -> produces vasoconstriction -> reverses vasodilation and reduces throbbing. Also inhibits release of peptides that cause vasodilation, inflammation and pain. Also prevents activation of trigeminal nerves involved in migraine
-CI: CAD, PVD, uncontrolled HTN, and in pts using MAO inhibitors, pregnancy
-All have specific dosing recommendations w/ maximum doses!!!!!!!!!!!!!!!!
-ADRs – chest tightness, weakness, dizziness, paresthesias, nausea. More serious – coronary vasospasm

-Examples:
-Sumatriptan – several formulations available
-Imitrex - SC, PO, nasal
-Sumavel DosePro – needless injection
-Treximet - PO combination of sumatriptan and naproxen (combo therapy is more effective and lasts longer than triptan alone, but can use any triptan and any NSAID combo

-Newer triptans:
-more lipophilic with incr bioavailability
-!May be! more effective than Imitrex with less recurrence of headaches

-Examples of newer triptans:
-Almotriptan (Axert)
-Eletriptan (Relpax)
-Frovatriptan (Frova)- rebound headache
-Naratriptan (Amerge)
-Rizatriptan (Maxalt, Maxalt MLT)
-Zolmitriptan (Zomig, Zomig- ZMT)

17
Q

dihydroergotamine (DHE) and ergotamine

A

-pregnancy category X
-used for migraine and cluster headaches
-Ergot alkaloids – derived form fungus that grows on rye
-MOA – Similar to “triptans” –

-CI: in CAD, PVD, uncontrolled HTN, and in pts using MAO inhibitors
-Must follow strict dosing guidelines and maximum dosing recommendations!!!!!!!!
-ADRs – N,V,D, muscle cramps. More serious - severe cerebral vasoconstriction, ischemia!!!, rebound vasodilation and headache

-Examples:
-Ergotamine
-Available PO, SC, PR
-Combined w/ caffeine (Cafergot)

-DHE:
-Available Intranasal (Migranal), INJ (DHE-45)
-INJ often combined w/ Metoclopramide to prevent N/V

18
Q

miscellaneous agents: narcotic analgesics

A

-opioids effective to relieve pain. Less commonly used
-Pregnancy C/D
-Good for acute migraine when sedation will not put patient at risk

-Examples
-Butorphanol nasal spray (Stadol NS)
-Hydrocodone/APAP (Vicodin)
-Meperidine (Demerol) – !Avoid in elderly!

19
Q

miscellaneous agents: barnituate hypnotics

A

-Pregnancy Category D
-Avoid due to overuse and misuse. Max daily dose = 6 doses per day

-Examples:
-butalbital/APAP/ caffeine (Fioricet)
-butalbital/ASA/caffeine (Fiorinal) – CIII

20
Q

miscellaneous drugs: antiemetics

A

-Rationale for use: Treat N/V
-Enhance absorption of migraine medication (metoclopramide – Reglan)
-Dopamine antagonists (PTZ, metoclopramide) have demonstrated efficacy in treating acute migraine when given as monotherapy

21
Q

miscellaneous: steroids

A

-good for status migrainosus
-MC is dexamethasone IM

22
Q

miscellaneous: isometheptene

A

-works like sympathomimetic to treat migraine
-available as combo product w/ APAP and mild sedative dichlorphenazone (Midrin)
-good for mild-moderate headaches

23
Q

miscellaneous: intranasal lidocaine

A

-Rapid acting
-Compounded product

24
Q

tx of tension headache

A

-prophylaxis: TCA antidepressants, Botox
-abortive: NSAIDs, APAP, opioids

25
Q

menstrual migraine- TEST

A

-triptans
-nonsteroidals (NSAIDs)

26
Q

tx of cluster headaches

A

-similar to migraine tx
-prophylaxis: CCBs (verapamil), ergotamine, steroids, lithium, topiramate
-Abortive: oxygen, triptans, injectable ergotamines, intranasal lidocaine

27
Q

medication overuse headache

A

-MCC of chronic daily headache (withdrawal from analgesic causes headache to recur – difficult cycle to break)
-Can occur if med is used > 15 days/month (> 10 days/month if on triptans)
-Management: d/c headache drugs for 3-12 weeks to reset

28
Q

summary

A

A. Headache disorders are classified as either cluster, migraine or tension.
B. The pathophysiology of Migraine headache is primarily neurovascular and involves an imbalance of the CNS neurotransmitters. Serotonin is the primary neurotransmitter to consider.
C. Management of migraine headaches varies for prophylaxis versus abortive treatment
D. Medications for the prophylaxis of migraine headaches include antidepressants, anticonvulsants, NSAIDs, beta-blockers, calcium channel blockers and 5-HT2 receptor blockers. The choice of prophylactic therapy depends on the patient’s past medical history. Beta blockers are considered the preferred treatment in healthy patients or patients with HTN, angina or anxiety.
E. The two main classes of medications for the abortive treatment of migraine headaches are the non-narcotic analgesics and the
5-HT1D/1B receptor agonists (triptans). Non-narcotic analgesics are considered first-line for the abortive treatment for mild-moderate migraines whereas triptans are considered first-line for the abortive treatment of moderate to severe migraines or after non-narcotic analgesics fail.
F. The triptans produce vasoconstriction to relieve the vasodilation, inflammation and pain associated with an acute migraine attack. Due to their MOA, they are contraindicated in CAD, PVD, uncontrolled hypertension, pregnancy and in patients using MAO inhibitors.
G. Other options for the abortive treatment of migraines include ergotamines, narcotic analgesics, barbiturate hypnotics, antiemetics, steroids, isometheptene and intranasal lidocaine.
H. The management of cluster headaches is slightly different than the management of migraines. The primary difference is the use of CCBs as the primary prophylactic drug and the use of oxygen as the first -line abortive drug.
I. The management of tension headaches is slightly different than the management of migraines. The primary difference is the use of TCAs as the primary prophylactic drug and the preferred use of non-narcotic analgesics instead of triptans for the abortive treatment. Also, the use of Botox injections is currently FDA-approved for the prophylaxis of tension headaches only.
J. Medication overuse headache is the most common cause of chronic daily headache and is very difficult to treat.

29
Q

Case 1: A 32-year-old female presents to your office complaining of headaches that are consistent with migraine headaches. She indicates that they occur more frequently during her menstrual cycle. She indicates that she has been utilizing acetaminophen PRN to treat these headaches.
1. What class of medication would you recommend at this point for the prophylaxis of her migraine headaches
2. What class of medication would you recommend at this point for the treatment of her acute migraine attacks?
3. Write the prescription.

A

-600-800 for ibuprofen

30
Q

The same patient returns to your office 3 months later for a follow-up visit. She reports that the medication you prescribed is reducing the frequency of her migraine headaches. However, when she does get a migraine attack, it is very painful and the medication does not work quickly or adequately.
1. What class of medication would you recommend at this point for the treatment of her migraine headaches.
2. Write the prescription.

A

nsaids

pharm 2 (10 decks)

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