headache, dementia Flashcards
1
Q
primary headache disorders
A
- migraine
- tension-type HA
- cluster-HA
- hemicrania continua
2
Q
secondary headache disorders
A
- traumatic brain injury HA
- pseudotumor cerebri
- brain tumor HA
- reversible cerebral vasoconstriction syndrome
- subarachnoid HA
- medication overuse HA (MOH)
- substance withdrawal HA
3
Q
migraine aura types
A
1) visual
2) sensory
3) language
4
Q
most common aura type
A
visula
- zig zag that slowly spreads across visual field
5
Q
diclofenac potassium
A
oral solution
- mix with specific amount of water bc pH sensitivity
6
Q
celecoxib
A
oral solution
7
Q
butalbital/APAP/caffeine
A
BBW: hepatotoxicity (APAP)
risk of medication overuse headache
8
Q
butalbital/APAP/caffein max use
A
3 or fewer days/month
**prevent MOH!!
9
Q
butalibital/ASA/caffein
A
**risk MOH
10
Q
butalbital/ASA/caffeine max use
A
3 days/month
11
Q
triptans MoA
A
serotonin selective agonists –> vasoconstrict cranial arteries –> dec neurogenic inflammation –> dec antidromic neuronal transmission –> dec migraine
12
Q
triptans counseling
A
*administer early in course of migraine attack
13
Q
triptan AEs
A
- flushing
- chest pain
- palpitations
- dizzy
- fatigure
- xerostomia
- **serotonin syndrome!!
14
Q
triptan dose
A
at onset
may repeat once in 2 hours
MDD: 2 tab/24 hours
MDD: 3 tab/wk
MDD: 10 days/month
15
Q
triptan max use
A
< 10 days/month
**MOH risk
16
Q
triptan CIs
A
- hemiplegic migraine
- basalar migraine (migraine with brainstem aura)
- known or suspected IHD (angina, MI, ischemia)
- underlying CVD
- arrythmias
- TIA, stroke
- PVD
- uncontrolled HTN
- within 24 hours of an ergot or another triptan
ONLY rizatriptan, sumatriptn, zolmitriptan:
- MAOIs –> serotonin syndrome
17
Q
triptans in older adults
A
caution bc probably have CV issues –> may have cardiovascular or cerebravascular risk –> not studied in these populations tho
18
Q
can you try a second triptan if the first fails?
A
YESS!! –> have to try atleast 2 before move on
different characteristics and efficacy
19
Q
which triptan is CI with potent CYP3A4 inhibitors?
A
eletriptan
CI within 72 hours of ketoconazole, clarithromycin, ritonavir
20
Q
which triptan is most lipophilic
A
eletriptan
**penetrate BBB bettwe –> inc CNS AEs, dec recurrence migraine rates!!
21
Q
which triptans have the longest half lives?
A
1st: frovatriptan
2nd: naratriptan
**longer = better prevention of migraine recurrence
22
Q
which triptan is intranasal?
A
sumtriptan
23
Q
which triptan is SQ?
A
sumatriptan
**AEs more frequent after SQ
24
Q
which triptan has the worst AEs?
A
sumatriptan
*chest-tightness, pressue, SOB, palpitations
25
lasmiditan MoA
serotonin receptor agonist
26
lasmiditian MDD
1 tab/day
27
lasmiditan AE
***CNS DEPRESSION --> must wait 8 hours between dosing and driving/heavy machinery!!
28
gepant options
atogepant --> only prevent
rimegepant --> prevent and acute
ubrogepant --> acute only
29
rimegepant (Nurtec) dosing
acute: 75mg ONCE, max 1/day
prevent: 75mg po every OTHER day
30
rimegepant CI
< 15 mL/min CrCl
31
ubrogepant (Ubrelvy) dosing
prevent: 50-100mg once, MAY REPEAT after 2 hours
MDD: 2 doses/day
32
ubrogepant CI
- strong CYPA3A4 inhibit
- CrCl < 15 mL/min
*dose reduce CrCl < 30 mL/min
33
ubrogepant counseling
do not take with high-fat meal --> dec concentration
34
ergot place in therapy
general later line bc of lots of AEs and CIs
35
ergot MoA
activate serotonin receptors on intracranial blood vessels --> vasoconstrict trigeminal system --> inhibit pro-inflammatory neuropeptide release ---> dec migraine
*high binding affinity: serotonin, noradrenaline, DA
36
ergot CIs
- potent CYP3A4 inhibitors
- pregnancy
- PVD
- CAD
- hepatic impairment
- renal impariment
- uncontrolled HTN
- spesis
- breatfeeding
- within 24 hours of: triptans, serotonin agonists, other ergots
37
which drugs are CI with potent CYA 3A4 inhibitors bc they are mostly metabolized by 3A4?
- eletriptan
- ubrogepant
- ergots
38
serious ergot AEs?
- cardiac vavular fibrosis
- ergotism (ischemia and gangrene)
- serotonin syndrome
39
which drugs have the cardiac CIs?
- triptans
- ergots
- CGRP mAb
40
which drugs have the 24 horus wash out CI?
omg its with eachother or themseleves !!!
- triptans
- ergots
41
ergots
- ergotamine
-dihydroergotamine (DHE)
42
ergotmaine dosage form
SL tab
43
ergotamine AE
N/V
ischemia
gangrene
44
when are ergots useful?
- migraine with attacks > 48 hours
- frequent HA recurrence
45
dihydroergotamine (DHE) dosage forms
injection (IM, IV, SQ): cluster headaches and migraine
intranasal: migraine
46
DHE side effects
fewer than ergotamine
47
DHE additional CIs
- after vascular surgery
- concurrent peripheral or central vasoconstrictors
- IN: hemiplagic or basalar migraine
48
DHE monitoring
ECG after first admin in facility
49
IV/IM dexamethasone use
dec rate of early HA recurrence when added to acute migraine therapy in the ED
50
diphenhydramine use
prevent akathesia (muscle quivering) and other med effects
51
why are opioids no goes in ED mirgaine?
more likely return to ED with HA within 7 days
dependence
MOH risk
52
when are opioids considered
infrequent rescue use when pt's initial treatment failed
CIs prevent other therapies
53
topiramte MoA
block Na channels
inc GABA
antagonize glutamate
inhibit carbonic anhydrase
54
topiramate AEs
- cognitive dysfunction
- CNS effects
- ***dehydration --> nephrolithiasis, angle closure glaucoma
- suicidal ideation
- weight loss
- paresthesia
55
topiramate CI
pregnancy
56
non-specific prevention adequate trial (antiepileptics and beta blockers)
2-3 months therapeutic dose
57
valproic acid MoA
block Na channel
inc GABA
58
valproic acid BBW
hepatotoxicity
fetal risk
59
valproic acid AEs
SJS/TENS (lamotrigine from seizures had too)
60
valproic acid CI
pregnancy and childbearing age --> spina bifida
61
beta blocker MoA
inhibit NE and E --> dec sympathetic
62
which beta blockers are indicated for migraine prevention
timolol
propanolol
63
why do propanolol and timolol work well?
- high serotonin receptor affinity --> help prevent migraine
- more lipophilic --> penetrate BBB better (also metoprolol
64
TCA MoA
inc serotonin and NE concentration by inhibit reuptak
65
TCA BBW
suicide
66
TCA dosing
LOWER than when for depression
67
TCA AEs
- anticholinergic effects
- cardiac conduction abnormalities
68
venlafaxine MoA
SNRI
69
venlafaxine AE
- CNS depression
- weight loss
- inc BP
70
venlafaxine BBW
suicide
71
atogepant dose
10, 30, 60 mg ONCE DAILY
72
atogepant CI
severe hepatic impairment
dose reduce < 30 CrCl
73
which drugs do we need to worry about hepatic and renal impairment?
gepants!!
74
CGRP mAb half life
very long --> dose every month or every 3 months
75
CGRP mAb CI
- recent cardiovascular or cerebraovascular ischemic events
- pregnancy
76
which CGRPs target CGRP ligand?
- eptinezumab (Vyepti)
- fremanezumab (Ajovy)
- galcanezumab (Emgality)
77
which CGRP targets CGRP receptor?
- erenumab (Aimovig)
78
which CGRP is also indicated for cluster HA prevention?
galcanezumab (Emgality)
79
epitinezumab (Vyepti) admin + AE
**IV
every 3 months
AE: infusion reactions, nasopharyngitis, N
80
erenumab (Aimovig) admin and AE
SQ
every month
AE: injection reactions, constipation (can be serious!!)
81
fremanezumab (ajovy) admin and AE
SQ
every month OR every 3 months
AE: injection reaction
82
galcanezumab (Emgality) admin and AE
SQ
every month
**dosing differs based on indication!! --> mg change, q month stays the same
AE: infusion reaction
83
CGRP adequet trials
if q month: 3 months
if q 3 months: 6 months
84
most common peripheral nerve block?
greater occipital nerve block
85
what part of greater occipital nerve block is CI in preg
methylprednisolone
86
non-pharm options for migraine prevention
- reduce stress
- diet change
- trigger avoidance
- OTC
87
what is po Mg good for?
migraine with aura
menstrual migraine
88
po Mg dose
oxide --> 400mg bid
89
po Mg AEs
- diarrhea, N/V
90
what is b2 good for?
menstruating women --> monthly blood loss can dec
91
feverfew CI
PREGNANCY ---> uterine contractions and abortions
92
feverfew AE
GI --> pain, bloat, constipate, diarrhea, N
93
butterbur AE
GI!, rash, drowsy
94
butterbur caution
only use products that are PA-free (pyrrolizidine alkaloid free) --> PA is toxic
95
which acute treatments can we use in pregnancy?
- APAP
- triptans
- lasmiditian
- gepants
96
which preventative treatments can we use in pregnancy?
- beta blockers
- venlafaxine?
- TCAs?
- gepants
- peripheral nerve block without methyl pred
- po Mg
- butterbur
- vitamine b2 (riboflavin)
- neuromodulation
97
onabotulinumtoxin A (Botox) MoA
neurotoxin --> prevent calcium dependent ACh release --> denervation
98
Botox BBW
spread of toxin out of injection site --> muscle wekaness, dysphagia)
99
Botox dose
155 units qually divded between 31 bilateral sites
everu 12 weeks
100
botox AE
- injection site pain
- neck pain
- myalgia
- facial paresis/weakness
101
botox adequate trial
36 weeks (3 treatments)
102
carbonic anhydrase inhibiotr MoA
dec rate of CSF production
**therefore use in pseudomotor cerebri bc intracranial HTN --> dec CSF --> dec BP
103
which drugs can induce pseudomotor serebri
growth hormones
retinoids
tetracyclines
104
anticholinergic effects
- pupils dilate
- dry
- flushed
- depressed
- agitated
- fever
105
acteylcholinesterase inhibitor MoA
active ACh ---acetylcholinesterase--> broken down ACh
- inhibits acteylcholinesterase --> therefore less ACh breakdown
- inhibits ACh metabolim --> therefore less ACh breakdown
both inc ACh
**NOT CHANGING UNDERLYING PATHO OF LOSING NEURONS --> just delaying
106
acetylcholinesterase AEs
inc ACh --> therefore cholinergic AEs (SLUDGE)
S: sialorrhea (saliva)
L: lacrimation
U: urination
D: defectation
G: GI
E: emesis
- CNS: vivid dreams
- cardiac: bradycardia, syncope, heart block, hypotension
- GI: weight loss
107
acwtylcholinesterase CIs
- baseline bradycardia
- baseline cardiac conduction disease (sinus syndrome, heart block)
inc risk falls, fractures
108
acetylcholinesterase inhibitors
- donezepil
- rivastigmine
- galantamine
109
donezepil MoA
selective, non-competitive ACheE-i
110
donezepil indication
mild-sev AD
111
donezepil dosing
1 tab at bedtime
5mg --> 10mg after 4-6 weeks --> 23mg after 3 months
all clinically effective, some pts may have better benefit with higher doses
112
donezepil PK
long half life
metaolized by P450
113
donezepil AE
- symptomatic bradycardia
- rare rhabdomyolysis
114
rivastigmine MoA
AChei
115
rivastigmine capsule indication
mild-sev AD
mild-mod parkinsons
116
rivastigmine form
capsule
patch
117
rivastigmine capsule dosing
1 capsule bid
1.5mg bid --> inc by 3 mg q 2 weeks --> 6-12 mg/day
118
rivastigmine capsile AE
- *GI
119
rivastigmine capsule PK
VERY SHORT HALF LIFE
**not metabolized by p450 (only one in class)
120
rivastigmine patch indication
mild-sev AD
121
rivastigmine patch dosing
qd
4.6mg --> MUST INC to 9.5mg after 4 weeks --> 13.3mg
hepatic dosing: 4.6mg
application: back, arms, chest
NOT torso or thigh
122
rivastigmine patch AE
site reactions
- less GI upset then capsules
123
galantamine MoA
AChe-i
124
galantamine indication
mild-mod AD
125
galantamine forms
IR
ER
126
galantamine dosing
IR: 4mg bid --> 8mg bid --> 12mg bid
ER: 8mg qd --> 16mg qd --> 24mg qd
127
galantamine CI
ESRD
severe hepatic impairment
max dose: 12mg
128
galantamine PK
metabolized by p450
129
how to optimize AChEi?
sleep disturbance --> take dose in morning
nausea --> take with food or at bedtime
**all agents about equal --> base on individual pt
130
memantine MoA
alzheimers --> abnormal glutamate activity --> always low level on --> neuronal damage and loss
therefore:
NMDA antagonist --> dec stimulatory --> dec neuronal harm
not disease modifying, just delay decline
131
memantine PK
not p450 metabolism
**CL reduced by alkaline (basic) urine
132
memtanine cautions/CI
- meds, diet, conditions that can change urine pH
- Hx seizure disorder --> inc risk
- Hx CV disease (cardiac failure, angina, bradycardia, HTN)--> small inc
133
memantidine dosing
IR: 5mg qd --> target 20mg TDD (10mg bid)
ER: 7mg qd --> target 28mg qd
**renal dose adjust
134
memantine AE
- ***confusion --> early on, mild
- dizzy
- constipation
135
memantine ER + donepezil
**must be stable on donezpeil 10mg before starting- --> involes starting at 5mg then inc to 10mg
136
anti-amyloid mAb drugs
- aducanumab
- lecanemab
137
anti-amyloid MoA
breaks down thw aggregated amyloid plaques
**ONLY DISEASE MODIFYING DRUG --> works against the actual patho cause
138
aducanumab
controversial accelerated approval basd on PET results
- CMS not paying for yet --> waiting for full FDA approval
139
aducanumab dosing
IV
goal: 10mg/kg q 4 weeks
start 1 mg/kg, inc from there
140
aducanumab BBW
ARIA: amyloid related imaging abnormalities
APoE 4 inc risk
141
aducanumab AE
- hypersensivity
142
aducanumab monitoring
MRI (prior to...)
- initial when start (can't be more than 1 year old)
- 5th infusion
- 7th infusion
- 9th infusion
- 12th infusion
143
ARIA MoA
amyloid related imaging abnormalities
remove amyloid plaques vis this drug --> lose blood vessel integrity --> predisposition to edema or hemorrhage --> dangerous1!!
144
ARIA types
ARIA-E: edema, exudates, effusions
ARIA-H: hemorrhages
145
ARIA s/s
- HA
- confusion
- AMS
- dizzy
- nausea
- visual disturbance
146
ARIA risk
- higher dose
- APoE4 carrier
- **treatment ith anticoagulants
147
anti-amyloid CI
anticoagulants -- bc ARIA
148
lecanemab
full FDA approval 2023 --> MCI, mild AD
- CMS will pay for
149
lecanemab requirements
need confirmed prescence of amyloid plaques
150
lecanemab dosing
IV
10 mg/kg q2 weeks
**NO TITRATION NEEDED***
151
lecanemab BBW
ARIA
APoE4 inc risk
152
lecanemab monitoring
MRI
- initial when starting (no more than 1 year old)
- 5th
- 7th
- 14th
153
what to do if see ARIA before s/s?
if severity on imaging or symptoms mod or higher --> D/C
if mild --> can continue
154
what inc risk of ARIA
APoE4 gene
155
treatments for behavior
1st: non-pharm
2nd: antidepressant, anxiolytics, antipsychotics, antiepileptic
156
treatments for sleep
TCA, benzos, sed/hypotnots, antiphyscotics
157
which drugs to avoid in whole pt treatment?
- anticholinergics
- benzos
- sedative/hypnotics
**try to avoid these
158
which whole pt drug has a BBW?
antipychotics
- elderly with dementia --> inc risk CV impact and death --> only use if have to, lowest dose
159
best antisychotic
risperidone
160
requirements of managing behavior
gradual dose reuction (GDR) guidlines!!
first year of LTC admission:
attempt dose reduction in 2 separate quarters, atleast one month apart
beyond year of LTC admission:
attempt dose reduction annually
161
non pharm behvior methods
- structure and routine
- plesat activities
- simple
- break down complex tasks into many small steps
