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Pharm I > Headache > Flashcards

Headache Flashcards

1
Q

Types of overall headaches

A

Primary
-Migraine
-Tension-type
Related to a disease (secondary)

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2
Q

Epidemiology of migraine

A

Occurs in 17.1% of women and 5.6% of men
After age 12, females 2-3x more likely to experience
Prevalence highest between ages 18-44
Pts that have less income and education are more likely to experience migraines

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3
Q

Pathophysiology of migraine

A

Genetic factors play an important role in susceptibility
Partially a neurovascular process
-Caused by changes in trigeminal nerve, decrease in 5-HT, and cranial vasodilation

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4
Q

Migraine without aura

A

At least 5 attacks
HA lasts 4-72 hrs and has 2 of the following characteristics
-Unilateral location, pulsating quality, moderate or severe intensity, and aggravation by or avoidance of routine physical activity
During HA at least 1 must be present and not attributed to another disorder
-N/V, photophobia, phonophobia
Increased risk for ischemic stroke

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5
Q

Migraine with aura

A

At least 2 attacks
Fulfills criteria for typical, hemiplegic, or basilar-type aura
Not attributed to another disorder

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6
Q

Aura

A

Evolves over 5-20 mins, lasts <60 mins
Most often visual, but can also be sensory and motor
Must have at least one of the following
-One symptom that develops gradually over at least 5 mins or different symptoms that occur in succession or both

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7
Q

Visual positive sx of aura

A

Flickering lights, spots or lines

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8
Q

Visual negative sx of aura

A

Loss of vision

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9
Q

Premonitory sx- neurologic

A

Phonophobia
Photophobia
Hypersomnia
Difficulty concentrating

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10
Q

Premonitory sx- psychological

A 
Anxiety
Depression
Irritability
Drowsiness
Fatigue
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11
Q

Premonitory sx- autonomic

A

Polyuria
Diarrhea
Constipation

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12
Q

Premonitory sx- constitutional

A 
Stiff neck
Yawning
Thirst
Food cravings
Anorexia
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13
Q

Resolution phase of migraine

A 
Once HA pain fades
Tiredness
Exhaustion
Irritability
Scalp tenderness
Mood changes
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14
Q

Assessment of migraines

A 
HA hx
HA triggers
Physical exam
Neuroimaging- not routine, only in atypical presentation
Identify HA diagnostic alarms
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15
Q

HA triggers

A 
Fatigue
Alcohol
Tobacco smoke
Weather changes
MSG
Caffeine
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16
Q

Acute tx goals- migraine

A

Treat migraine attacks rapidly and consistently without recurrence
Restore pt’s ability to function
Minimize use of backup and rescue medications
Minimize 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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17
Q

Medication overuse

A

One of the most common causes of daily chronic HA
Results in a pattern of increasing HA frequency
HA returns as medication wears off
Discontinuation of the offending agent leads to a decrease in HA frequency and severity
Limit use of acute therapies to 10 days/mo

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18
Q

Nonpharmacologic tx of migraine

A

Application of ice to head
Periods of rest or sleep
Avoidance of common and personal triggers
Behavioral therapy

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19
Q

Acute tx of migraines

A 
Migraine-specific
-Ergots
-Triptans
Nonspecific
-Analgesics
--OTC combo product
-NSAIDS
-Antiemetics
-Corticosteroids
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20
Q

Regimen of acute tx for migraines

A

Should be given at the FIRST sign of sx

Migraine-specific medications used for more severe sx or sx unresponsive to NSAIDs/OTC analgesics

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21
Q

Ergot alkaloids

A

Consider for moderate to severe migraine attacks
Ergotamine tartrate and dihydroergotamine
MOA: nonselective 5-HT receptor agonists
-Constrict intracranial blood vessels
-Inhibit the development of neurogenic inflammation in the trigeminovascular system

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22
Q

Ergotamine tartrate (Cafergot)

A

Routes: oral, SL, rectal
Oral and rectal forms contain caffeine
Has both a daily and weekly maximum dose
Dosed at onset of sx and every 30-60 mins as needed

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23
Q

Dihydroergotamine (Migranal)

A

Routes: intranasal, IM, SQ, IV

Pts can be trained to give IM or SQ at home

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24
Q

Adverse effects of ergot alkaloids

A 
Nausea, vomiting, diarrhea
Abdominal pain
Weakness
Fatigue
Paresthesias
Muscle pain
Chest tightness
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25
Q

Contraindications of ergot alkaloids

A 
Renal or hepatic failure
Coronary, cerebral, or peripheral vascular disease
Uncontrolled htn
Sepsis
Nursing or pregnant women
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26
Q

Triptans

A

First line for mild to severe migraine

Typically want to treat at least 2-3 attacks before judging efficacy

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27
Q

MOA of triptans

A

5-HT (1b/1d) receptor agonists
Inhibit release of vasoactive peptide
Promote vasoconstriction
Block pain pathways in the brainstem

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28
Q

Contraindications of triptans

A

Hx of ischemic heart disease
Uncontrolled htn
Cerebrovascular disease
Hemiplegic and basilar migraine

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29
Q

Drug interactions of triptans

A

Do not give within 24 hrs of ergotamine derivatives

SSRIs/SNRIs potential to cause serotonin syndrome

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30
Q

Serotonin syndrome

A

Muscle rigidity, hypothermia, sweating

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31
Q

Adverse effects of triptans

A 
Paresthesias
Fatigue
Dizziness
Flushing
Warm sensations
Somnolence
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32
Q

Local SQ effects of triptans

A

Injection site reactions

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33
Q

Intranasal adverse effects of triptans

A

Taste perversion

Nasal discomfort

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34
Q

Second generation triptans

A 
Almotriptan
Eletriptan
Frovatriptan
Naratriptan
Rizatriptan
Zolmitriptan
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35
Q

Sumatriptan (Imitrex) oral dosage

A

25 mg, 50mg, 100mg

Repeat after 2 hrs

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36
Q

Sumatriptan (Imitrex) nasal dosage:

A

5, 10, 20mg

Repeat after 2 hrs

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37
Q

Sumatriptan (Imitrex) SQ dosage

A

4mg, 6mg

Repeat after 1 hr

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38
Q

Sumatriptan (Imitrex) max oral daily dose

A

200mg

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39
Q

Sumatriptan (Imitrex) max nasal daily dose

A

40mg

40
Q

Sumatriptan (Imitrex) SQ max daily dose

A

12mg

41
Q

1/2 life of sumatriptan

A

2-2.5 hrs

42
Q

Onset of oral sumatriptan

A

20-30 min

43
Q

Onset of nasal sumatriptan

A

15 min

44
Q

Onset of SQ sumatriptan

A

10-15 min

45
Q

Oral rizatriptan dose

A

5mg, 10mg
5mg with propranolol
May repeat after 2 hrs

46
Q

Max daily dose oral rizatriptan

A

30 mg

Pts taking propranolol: 15 mg

47
Q

Onset of oral rizatriptan

A

0.5-2 hrs

48
Q

1/2 life of rizatriptan

A

2-3 hr

49
Q

Oral dose of zolmitriptan

A

1.25 mg, 2.5mg, 5mg

May repeat after 2 hrs

50
Q

Nasal dose of zolmitriptan

A

2.5mg, 5mg

May repeat after 2 hrs

51
Q

Max daily dose of oral zolmitriptan

A

10mg

52
Q

Max daily dose of zolmitriptan

A

10mg

53
Q

Onset of oral zolmitriptan

A

45 mins

54
Q

Onset of nasal zolmitriptan

A

15 mins

55
Q

Almotriptan oral dosing

A

6.25mg or 12.5 mg

May repeat after two hours

56
Q

Almotriptan max daily dose

A

25 mg

57
Q

almotriptan onset

A

0.5-2 hrs

58
Q

eletriptan oral dose

A

20mg, 40mg

May repeat after 2 hrs

59
Q

1/2 life of almotriptan

A

3-4 hrs

60
Q

naratriptan oral dose

A

1mg or 2.5mg

May repeat once after 4 hrs

61
Q

Max dose of naratriptan

A

5mg

62
Q

Max dose of eletriptan

A

80mg

63
Q

Oral dose of frovatriptan

A

2.5mg

May repeat after 2 hrs

64
Q

Max daily dose of frovatriptan

A

7.5mg

65
Q

Analgesics for migraine

A

First line for mild to moderate migraine
Appear to be effective for mild-moderate sx
Acetaminophen + aspirin + caffeine (Excedrin migraine)
Acetaminophen/aspirin + butalbital + caffeine (Fioricet or Fiorinal)
Limit use due to medication-overuse HA and withdrawal

66
Q

NSAIDs for migraine

A

First line for mild to moderate migraine

ASA, diclofenac, ibuprofen, ketorolac, naproxen

67
Q

MOA of migraine NSAIDs

A

Prevent neurogenically medicated inflammation in the trigeminovascular system through the inhibition of prostaglandin synthesis

68
Q

Adverse effects of migraine NSAIDs

A

Dyspepsia
N/V/D
Somnolence
Dizziness

69
Q

Opiates for migraine

A

Consider last line, when all else fails
Meperidine, butorphanol, oxycodone, hydromorphone
Frequent use can increase the risk of medication-overuse HA, dependency, and rebound HAs

70
Q

Antiemetics for migraine

A

Used as an adjunct for N/V that accompanies migraine and the medications used to treat migraines

71
Q

Metoclopramide

A

Available oral and IV, data is with IV

Appears to be the least effective of the three antiemetics

72
Q

Chlorpromazine

A

Available oral and IV, data is with IV

Antiemetic

73
Q

Prochlorperazine

A

Available oral, rectal, and IV, data is with IV

74
Q

Miscellaneous agents for migraine

A 
Corticosteroids for status migrainous
-IV/IM dexamethasone
Intranasal lidocaine
-Rapid pain relief within 15 mins
-Recurrence is common
IV valproate and magnesium sulfate
75
Q

Prophylaxis for migraine

A

Symptomatic therapies are ineffective or cannot be used
Very severe recurrent HAs (produces significant disability)
Frequency of attacks in a pt requires more than 2 symptomatic tx/wk
Uncommon migraine types that can potentially cause permanent neurologic injury

76
Q

Prophylaxis agent for migraine should be selected based on…

A 
Tolerability
Comorbid conditions
Pt response (efficacy)
Convenience of the drug formulation
To determine maximal benefit, 6 mo trial recommended
77
Q

Agents for migraine prophylaxis

A 
Beta-blockers
Antidepressants
-Tricyclic
-SNRI
Anticonvulsants
-Valproate
-Divalproex
-Topiramate
NSAIDs
Triptans
OnabotulinumtoxinA (Botox)
78
Q

Beta-blockers

A

First-line, established efficacy
Metoprolol, propranolol, timolol
May be useful in pts with comorbid htn, angina, or anxiety

79
Q

Adverse effects of beta-blockers

A

Drowsiness, fatigue, depression, bradycardia, hypotension

80
Q

Anticonvulsants

A

First-line, established efficiency
Useful with comorbid seizures, anxiety disorder, or bipolar illness
Valproate, divalproex

81
Q

Adverse effects of anticonvulsants

A 
N/V
Alopecia
Tremor
Asthenia
Somnolence
Weight gain
Hepatotoxicity
82
Q

Contraindications of anticonvulsants

A

Pregnancy and pts with a hx of pancreatitis or chronic liver disease

83
Q

Topiramate

A

First-line anticonvulsant

84
Q

Adverse effects of topiramate

A 
Paresthesia
Fatigue
Anorexia
Diarrhea
Weight loss
Difficulty with memory
Taste perversion
85
Q

Contraindications of topiramate

A

Use with caution in pts with a hx of kidney stones or cognitive impairment

86
Q

Amitriptyline

A 
Second-line
TCA
Anticholinergic side effects
-Increased appetite
-Weight gain
-Drowsiness
-Orthostatic hypotension
87
Q

Venlafaxine

A 
Second-line
SNRI
Adverse effects
-Nausea
-Vomiting
-Drowsiness
88
Q

Clinical presentation of tension HA

A

No aura or premonitory sx
Mild to moderate pain, bilateral “hatband” pattern
Dull, nonpulsatile tightness or pressure
Either episodic, frequent, or chronic

89
Q

Nonpharmacologic tx for tension HA

A 
Behavioral therapy
-Cognitive behavioral therapy
-Relaxation training
-Biofeedback
Physical therapy
-Heat/cold packs
-Stretching
-Massage
-Acupuncture
90
Q

Pharmacologic tx for tension HA

A

Analgesics +/- caffeine
Fioricet +/- codeine
High-dose NSAIDs

91
Q

Consider prophylaxis for tension HA if…

A

> 2 HAs/wk
Duration >3-4 hrs
Severity results in medication overuse or substantial disability

92
Q

Epidemiology of cluster HA

A

Most severe
Uncommon
More common in males than females

93
Q

Pathophysiology of cluster HA

A

Hypothalamic dysfunction with resulting alterations in circadian rhythms

94
Q

Clinical presentation of cluster HA

A 
Attacks daily for 2 weeks to several mos
Long pain free intervals
Occur suddenly, pain peaks quickly after onset
Cranial autonomic sx
No aura
95
Q

Acute tx for cluster HAs

A 
Oxygen
Triptans
-Subcutaneous
-Nasal
-Oral: limited use
Ergotamine derivatives
-Dihydroergotamine: IV
-Ergotamine tartrate: SL or rectal
96
Q

Prophylaxis for cluster HA

A

Verapamil
-AEs: gingival hyperplasia, constipation
-Monitoring: EKG for bradycardia and heart block
Lithium
-AEs: tumor, lethargy, nausea, diarrhea, abdominal discomfort
-Monitoring: lithium levels, renal, and thyroid function
Corticosteroids
-Taper, HAs may reoccur upon discontinuation

Pharm I (10 decks)

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