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Spring 15 - Pharm Unit II > Headache > Flashcards

Headache Flashcards

1
Q

HA Pathophysiology

A
  • not well understood

- neuronal hypothesis: due to imbalance in modulation of nociception and blood vessel tone

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2
Q

Goals of Long-Term Migraine Therapy

A
  • reduce migraine frequency, severity, disability
  • reduce reliance on poorly tolerated/ineffective txs
  • improve QOL
  • prevent HA
  • avoid escalation of HA med use
  • educate pts on dz management
  • reduce HA-related distress and psych sxs
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3
Q

Goals of Acute Migraine Treatment

A
  • treat migraine attacks rapidly and consistently w/o recurrence
  • restore pt’s ability to function
  • minimize use of backup and rescue meds
  • optimize self-care for overall management
  • be cost-effective in overall management
  • cause minimal or no AEs
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4
Q

Nonpharm Migraine Tx

A
  • pt education: HA diary, identify and avoid triggers, establish therapy efficacy and need for prophylaxis, understand when/how to use meds
  • behavioral medicine: cognitive behavioral therapy, relaxation therapy, biofeedback
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5
Q

What is first line treatment for mild to moderate migraine?

A

NSAIDs: aspirin, ibuprofen (Motrin, Advil), naproxen

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6
Q

If NSAIDs don’t work for migraine tx, what is the next option?

A

combination analgesics

eg APAP/ASA/caffeine (Excedrin Migraine)

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7
Q

AEs of Excedrin Migraine (APAP/ASA/caffeine)

A

may cause MOH

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8
Q

What migraine tx option should be considered for pregnant patients?

A

simple analgesic: acetaminophen

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9
Q

AEs of the Triptans/5HT Receptor Agonists

A
  • dizziness
  • sensation of warmth
  • chest fullness
  • nausea
  • rare: angina, arrhythmia, cerebral and myocardial ischemia
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10
Q

CIs of the Triptans

A
  • CV dz: angina, hx MI, uncontrolled HTN, CVA, PVD, hemiplegic and basilar migraine
  • don’t use w/in 14 days of MAOI or 24hrs of ergotamine, DHE, methysergide
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11
Q

Ergotamine AEs

A
  • N/V frequent
  • possible vasospasm
  • muscle aches
  • tremor, tingling of extremities
  • rebound HA
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12
Q

Ergotamine CIs

A
  • CV dz
  • PVD
  • pregnancy
  • cerebrovascular dz
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13
Q

When should triptans be used?

A

for moderate to severe migraine (or mild unresponsive to simple analgesics and NSAIDs)

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14
Q

When should ergotamines be used?

A

moderate to severe migraine

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15
Q

Dihydroergotamine AEs

A
  • diarrhea

- muscle cramps

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16
Q

Dihydroergotamine CIs

A
  • CV dz
  • PVD
  • pregnancy
  • cerebrovascular dz
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17
Q

When should dihydroergotamine be used?

A

moderate to severe migraine

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18
Q

What drugs are considered rescue therapy for migraine treatment?

A
  • opioid combos (ASA/APAP with narcotics)

- corticosteroids

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19
Q

What can be given to treat N/V and decrease pain associated w/ migraines?

A
  • metoclopramide (Reglan)

- propchlorperazine (Compazine)

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20
Q

What type of patients require caution when using triptans?

A

unrecognized CAD in:

  • postmenopausal women (higher risk of CAD)
  • males > 40
  • patients w/ uncontrolled CAD risk factors (HTN, dyslipidemia, age, fam hx, smoking)
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21
Q

Rank triptan dosage routes in order of onset time.

A

SQ is fastest, then nasal, then PO

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22
Q

Rank triptan dosage routes in order of cost.

A

faster onset = greater cost so SQ is most expensive, PO least

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23
Q

When should PO triptans be avoided?

A

when pt has N/V

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24
Q

Mild HA

A

patient is aware of HA but able to continue daily routine with minimal alteration

25
Q

Moderate HA

A

HA inhibits daily activities but is not incapacitating

26
Q

Severe HA

A

incapacitating HA

27
Q

Status HA

A

severe HA that has lasted > 72 hours

28
Q

In what order should med categories be used in migraine tx?

A

simple analgesic (APAP) –> NSAIDs –> combo analgesics –> triptans/ergots/DHE –> combinations, rescue therapy

29
Q

Diagnostic Criteria for Medication Overuse HA

A
  • HA present 15+ days of month
  • shifts btw migraine and tension HA
  • regular overuse >3 months of HA tx
  • HA has developed or worsened during med use
  • HA resolves or reverts to previous pattern 2 months after stopping HA med
30
Q

Management of MOH

A
  • stop taking medications
  • or substitute another drug class
  • discontinuing may result in several days of HAs
31
Q

Prophylactic Migraine Tx Strategy

A
  • initiate meds w/ highest level efficacy
  • start w/ lowest effective dose and titrate up
  • may take 2-3 months to see benefit
  • use abortive meds for breakthrough HAs
32
Q

What is the DOC for migraine prophylaxis?

A

beta blockers

33
Q

Relative CIs for Beta Blocker Prophylaxis

A
  • asthma
  • depression
  • unstable CHF
  • Raynaud’s
  • DM
34
Q

AEs of Beta Blockers

A
  • fatigue
  • depression
  • N, dizziness
  • insomnia, exercise intolerance
35
Q

What 2 drug classes are POSSIBLY effective for migraine prophylaxis?

A

ARBs (candesartan) and ACEs (lisinopril)

36
Q

Relative CIs of ARBs and ACEs

A
  • 2nd/3rd trimester pregnancy

- bilateral renal artery stenosis

37
Q

What 2 classes of drugs are PROBABLY effective for migraine prophylaxis?

A

TCAs (amitriptyline, nortriptyline) and SNRIs (venlafaxine)

38
Q

Relative CIs of TCAs

A
  • urinary retention
  • heart block
  • also caution for serotonin syndrome with triptans
39
Q

AEs of TCAs

A
  • drowsiness
  • weight gain
  • anti-SLUD
40
Q

Relative CIs of SNRI

A

MAOI within 14 days

41
Q

Which AEDs can be used for migraine prophylaxis?

A

valproic acid (depakote) and topiramate (topamax)

42
Q

Relative CIs for Valproic Acid

A

liver dz

bleeding disorders

43
Q

AEs of Valproic Acid

A
  • weight gain
  • hair loss
  • tremor
44
Q

AEs of Topiramate

A
  • paresthesia
  • slowed thinking
  • weight loss
45
Q

What drug class should be used for prophylaxis of HAs that recur in a predictable pattern?

A

NSAID or triptan at time of vulnerability

46
Q

What drug class should be used for prophylaxis of HAs in pts who are healthy or have comorbid HTN or angina?

A

beta blockers (verapamil if BB contraindicated)

47
Q

What drug class should be used for prophylaxis of HAs in pts with comorbid depression or insomnia?

A

TCA

48
Q

What drug class should be used for prophylaxis of HAs in pts who have comorbid seizure disorder or bipolar disorder?

A

AED
if AED ineffective, BB
if BB ineffective, combination therapy

49
Q

What drug class should be used for prophylaxis of HAs in pts that do not get relief from NSAIDs, BBs, triptans, TCAs, or AEDs?

A

consider combination therapy

50
Q

When should valproic acid be used as abortive therapy for migraines?

A

can be used as rescue med for patients whose HA continues after DHE or triptan

51
Q

Evaluation of Migraine Therapy

A
  • monitor pt HAs with HA diary
  • watch for AEs
  • re-evaluate therapy: after 3-6 months, consider tapering or D/Cing tx if HAs are well-controlled
52
Q

Cluster HAs

A

-severe unilateral, supraorbital and/or temporal pain

53
Q

DOC and Dosage for Abortive Cluster HA Tx

A

100% oxygen by facial mask at 5-10L/min x15 min

54
Q

Besides O2, what other options are available for abortive cluster HA tx?

A
  • triptans: SQ or intranasal
  • DHE
  • ergotamine
  • corticosteroid
55
Q

Cluster HA Prophylactic Strategy

A
  • decreased frequency and severity and shorten duration of cluster attacks
  • start early in cluster
  • take qd until HA free >2 weeks
  • taper, but restart with next cluster
56
Q

What can be used as prophylactic therapy for cluster HAs?

A
  • verapamil
  • lithium
  • prednisone
  • ergotamine
57
Q

Non-pharm Tx of Tension HAs

A
  • psychophysiologic therapy: reassurance, counseling, stress management, relaxation training, biofeedback
  • physical therapy
58
Q

Pharm Tx of Tension HAs

A

-simple analgesics: ASA, APAP, NSAIDs

59
Q

Prophylactic Tx of Tension HAs

A

-consider if HA >2x/wk, duration >3-4 hours, severity results in med overuse

Spring 15 - Pharm Unit II (9 decks)

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