HEADACHE Flashcards
1
Q
What is the cause of rebound headaches?
A
simple and combination analgesics
2
Q
How many days should you limit medication use for migraines?
A
<10 days/month
3
Q
POUND mnemonic
A
pulsating headache with duration of 4-72 hrs, unilateral, nausea, and vomiting and disabling
4
Q
What are non pharmacological treatments?
A
sleep
dark room
cold compress
5
Q
What are the 4 stages of a migraine?
A
- premonitory symptoms-24 hours prior to onset of migraine attack, vague and vegetative symptoms
- Aura-focal neurological deficits
- Headache-unilateral, throbbing, photophobia and phonophobia
- Post drome: malaise, fatigue,
6
Q
What is cortical spreading?sensitization?
A
- causes aura
- prolonged activation of trigeminal nerve
- hyper excitable trigeminal nerve release sub P and CGRP leading to vasodilation and neurogenic inflammation
- sensitization: neuron response to nociceptive and non nocipective receptors
7
Q
T/F Blood brain barrier is altered by metalloproteinase activation and upregulation
A
TRUE
8
Q
What is the prototype of triptans?routes?
A
Sumatriptan
given as oral, injection, and nasal
9
Q
What is MOA of triptans?
A
- Bind 5-HT1B and 5-HT1D receptors
- enhanced vasoconstriction
- inhibition of pain transmission
- inhibition of vasoactive release of peptides from trigeminal neurons
10
Q
When do you use triptans?
A
first line therapy for moderate to severe migraines
11
Q
What is clinical use sumatriptan?
A
Migraines
Cluster headaches
12
Q
What are ADE of triptans?
A
coronary spasm, chest pain, parasthesias, dizziness
13
Q
What pt should avoid triptans?
A
uncontrolled HTN, PAD, brainstem or hemiplegic migraine
14
Q
what is “triptan sensation”?
A
- chest pain
- chest tightness
- chest heaviness
15
Q
What are drug interactions with triptans?
A
MAO-I and ergotamines
16
Q
Which triptans are used for patients that have long duration migraines?
A
Fovatriptan
Naratriptan
17
Q
Which triptan needs to be given at 5mg if taking propanolol?
A
Rizatriptan
18
Q
Which drugs can cause seratonin syndrome? 7
A
- SSRI
- fentanyl
- meperidine
- sumatriptan
- St. Johns Wart
- tramadol
- linezolid
19
Q
What are the symptoms of seratonin syndrome?
A
- hyperthermia
- clonus
- agitation
- tachycardia
20
Q
What is tx for seratonin syndrome?
A
- benzos, intubation, ventilation
2. 5-HT2 blockers chlorpromazine or cyproheptadine
21
Q
Which drugs cause neuroleptic malignant syndrome
A
D2 blocking anti psychotics
22
Q
What is CP of neuroleptic malignant syndrome?
A
- reduced bowels
- parkinsonism
- hyperthermia
23
Q
what is tx for neuroleptic malignant syndrome?
A
diphenhydramine parenteral
24
Q
What is the drug that causes malignant hyperthermia?
A
- volatile anesthetics
- succinylcholine
25
What is tx for malignant hyperthermia?
Dantrolene
| cooling
26
What is MOA Lasmitditan?
binds 5-HTF1 receptor that reduces stimulation of the trigeminal nerve but DOES NOT vasoconstrict
27
What are ADE of Lasmiditan?
palpitations, chest discomfort,
28
What is MOA of CGRP antagonists?
- block CGRP receptors
- blocks neurogenic inflammation
- decreases artery vasodilation
- blocks transmission of pain from trigeminal nerve to trigeminal nucleus accumbens
29
Name two CGRP antagonists?
Rimegapant
| Ubrogepant
30
What are ADE of ubrogepant?
CNS drowsiness
31
When should you avoid use of CGRP antagonists?
- hepatic impairment
| - drugs that are CYP3A4-Inhibitors (increase drug concentration)
32
what is ADE of both ubrogepant and rimepagant?
xerostomia , GI nausea
33
What is clinical use of CGRP antagonists?
acute migraine
34
Name three CGRP monoclonal antibodies?
- erenumab
- Fremanezumab
- Glacanezumab
35
What is MOA of CGRP monoclonal antibodies?
Ab block the CGRP ligand and blocks its binding to the receptor
36
what are benefits of using CGRP antibodies?
- long half lives with once monthly administration
| - they act at the periphery and thus avoid CNS side effects
37
what are the ADE of CGRP antibodies?
- flu like symptoms
- development of neutralizing antibodies
- constipation
- muscle cramps
38
what is the clinical use of CGRP antibodies?
prevention of migraines
39
What is the MOA of ergotamines?
- nonselective 5-HT1 receptor agonists
- vasconstricts intracranial blood vessels
- central inhibition of the trigeminalvascular system
40
what is clinical use of ergotamines?
-rescue drug
41
Name two ergotamines?
Ergotamine tartrate
| Dihydroergotamine
42
What is route of Ergotamine tartrate?which are treated with an anti emetic?
- rectal
- sublingual
- oral PO
* rectal and oral routes are treated with anti emetics
43
What is route of delivery for Dihydroergotamine?
Injection
| Nasal spray: prime spray 4 times in nose, dont tilt head back, discard open ampule after 8 hrs
44
who should avoid ergotamines?
PAD, HTN, people on triptans, coronary artery disease
45
Who gets preventive therapy for migraines?
- recurring migraines >2x/week
| - symptomatic therapies that produce serious side effects
46
Name 4 preventive drugs?
- propanolol
- timolol
- topiramate
- divalproex sodium
47
T/F therapeutic drugs for prevention need a 2-3 month trial to determine reduced frequency of migraine
TRUE
48
How long does it take for preventative therapy to reduce severity of migraines
6-12 months
49
How long is tx continued after HA severity and frequency is reduced?
6-12 months
50
Which drug is used for menstrual migraine prevention?
Ibuprofen given 2-3 days before cycle
51
Which triptan can be used to prevent menstrual migraines?
Fovatriptan taken 1-2 days before and continued during period of vulnerability
52
Which supplement may help with menstrual migraine or migraines with aura?
Mg
53
Which drug acts as a prokinetic and can be given in cancer patients to propel the medication into the intestine and speed up the effect of sumatriptan?
Metoclopramide
54
Which triptans have a longer duration of action and slower onset?
Naratriptan
| Frovatriptan
55
T/F PK of Lasmiditan requires no renal adjustment
True
56
What is prophylactic tx for migraines that recur in a predictable pattern?
NSAID or triptan at time of vulnerability
57
What is prophylactic tx if migraine with co morbid HTN or angina?
beta adrenergic antagonist
| or verapamil if b-adrenergic contraindicated
58
What is prophylactic tx if migraine with co morbid insomnia or depression?
TCA
59
What is prophylactic tx if migraine with co morbid seizure or bipolar illness?
- anti-convulsants
| - use beta adrenergic antagonist or verapamil if beta adrenergic contraindicated
60
What is the most common primary headache type?
Tension type headache-like band squeezing the head
61
What is the presentation of a cluster headache?
- pain is in and around one eye
- unilateral, excruciating pain peaks within minutes and last about 3 hrs
- lacrimation, miosis, ptosis, rhinorrhea on ipsilateral side
- HA lasts weeks to months followed by periods of remission
62
What is 1st line tx for TTHA?
simple analgesics:Acetaminophen +/- caffeine
63
What is 2nd line tx for TTHA?
Aspirin, NSAIDS
64
Acute TTHA tx?
codeine or butalbital
65
What are the limits (# days) you can use butalbital,combination analgesics, or NSAIDS
butalbital < 3 days/month
analgesics <9 days/month
NSAIDS <15 days /month
66
T/F There is no evidence to support the use of muscle relaxants in the management of TTHA?
TRUE
67
Which drugs are not recommended for TTHA?
- SSRI's
| - botulinum
68
Which drug might work in TTHA?
SNRI: Mirtazapine
TCA
Topiramate or gabapentin
69
T/F Hypothalamus might be a modulator in cluster HA
TRUE
70
What is the hallmark sign of cluster headaches?
circadian rhythm of painful attacks
71
T/F People with migraine headaches sit quietly while people with cluster headaches pace the room
TRUE
72
What is the tx for acute cluster HA aka abortive therapy?
- 100% oxygen non rebreather mask at 12L/min for 15-30 min
| - serotonin agonist or ergotamines
73
Which Triptans are highly effective for cluster HA?
injection or nasal Triptan
| exception: oral zolmitriptan 10 mg
74
Which ergotamines are helpful in the tx of cluster HA?
IV dihydroergotamine
| ergotamine tartrate
75
What is prophylactic tx for cluster HA?
1st: Verapamil
2nd: lithium, monitor thyroid and renal function, ADE: lethargy, nausea, diarrhea
3rd: corticosteroids (prednisone X 5 days and then tapered)
4th: Galcanezumab, binds to CGRP ligand
76
What are miscellaneous agents in tx of cluster HA?
intranasal lidocaine
hyperbaric oxygen
subQ octreotide
