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p3 year :) > headache, dementia > Flashcards

headache, dementia Flashcards

1
Q

primary headache disorders

A
  • migraine
  • tension-type HA
  • cluster-HA
  • hemicrania continua
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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
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3
Q

migraine aura types

A

1) visual
2) sensory
3) language

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4
Q

most common aura type

A

visula
- zig zag that slowly spreads across visual field

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5
Q

diclofenac potassium

A

oral solution
- mix with specific amount of water bc pH sensitivity

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6
Q

celecoxib

A

oral solution

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7
Q

butalbital/APAP/caffeine

A

BBW: hepatotoxicity (APAP)
risk of medication overuse headache

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8
Q

butalbital/APAP/caffein max use

A

3 or fewer days/month
**prevent MOH!!

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9
Q

butalibital/ASA/caffein

A

**risk MOH

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10
Q

butalbital/ASA/caffeine max use

A

3 days/month

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11
Q

triptans MoA

A

serotonin selective agonists –> vasoconstrict cranial arteries –> dec neurogenic inflammation –> dec antidromic neuronal transmission –> dec migraine

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12
Q

triptans counseling

A

*administer early in course of migraine attack

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13
Q

triptan AEs

A
  • flushing
  • chest pain
  • palpitations
  • dizzy
  • fatigure
  • xerostomia
  • **serotonin syndrome!!
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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

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15
Q

triptan max use

A

< 10 days/month
**MOH risk

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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

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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

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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

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19
Q

which triptan is CI with potent CYP3A4 inhibitors?

A

eletriptan

CI within 72 hours of ketoconazole, clarithromycin, ritonavir

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20
Q

which triptan is most lipophilic

A

eletriptan

**penetrate BBB bettwe –> inc CNS AEs, dec recurrence migraine rates!!

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21
Q

which triptans have the longest half lives?

A

1st: frovatriptan

2nd: naratriptan

**longer = better prevention of migraine recurrence

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22
Q

which triptan is intranasal?

A

sumtriptan

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23
Q

which triptan is SQ?

A

sumatriptan

**AEs more frequent after SQ

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24
Q

which triptan has the worst AEs?

A

sumatriptan
*chest-tightness, pressue, SOB, palpitations

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25
Q

lasmiditan MoA

A

serotonin receptor agonist

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26
Q

lasmiditian MDD

A

1 tab/day

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27
Q

lasmiditan AE

A

***CNS DEPRESSION –> must wait 8 hours between dosing and driving/heavy machinery!!

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28
Q

gepant options

A

atogepant –> only prevent
rimegepant –> prevent and acute
ubrogepant –> acute only

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29
Q

rimegepant (Nurtec) dosing

A

acute: 75mg ONCE, max 1/day

prevent: 75mg po every OTHER day

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30
Q

rimegepant CI

A

< 15 mL/min CrCl

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31
Q

ubrogepant (Ubrelvy) dosing

A

prevent: 50-100mg once, MAY REPEAT after 2 hours
MDD: 2 doses/day

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32
Q

ubrogepant CI

A
  • strong CYPA3A4 inhibit
  • CrCl < 15 mL/min

*dose reduce CrCl < 30 mL/min

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33
Q

ubrogepant counseling

A

do not take with high-fat meal –> dec concentration

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34
Q

ergot place in therapy

A

general later line bc of lots of AEs and CIs

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35
Q

ergot MoA

A

activate serotonin receptors on intracranial blood vessels –> vasoconstrict trigeminal system –> inhibit pro-inflammatory neuropeptide release —> dec migraine

*high binding affinity: serotonin, noradrenaline, DA

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36
Q

ergot CIs

A
  • potent CYP3A4 inhibitors
  • pregnancy
  • PVD
  • CAD
  • hepatic impairment
  • renal impariment
  • uncontrolled HTN
  • spesis
  • breatfeeding
  • within 24 hours of: triptans, serotonin agonists, other ergots
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37
Q

which drugs are CI with potent CYA 3A4 inhibitors bc they are mostly metabolized by 3A4?

A
  • eletriptan
  • ubrogepant
  • ergots
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38
Q

serious ergot AEs?

A
  • cardiac vavular fibrosis
  • ergotism (ischemia and gangrene)
  • serotonin syndrome
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39
Q

which drugs have the cardiac CIs?

A
  • triptans
  • ergots
  • CGRP mAb
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40
Q

which drugs have the 24 horus wash out CI?

A

omg its with eachother or themseleves !!!

  • triptans
  • ergots
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41
Q

ergots

A
  • ergotamine
    -dihydroergotamine (DHE)
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42
Q

ergotmaine dosage form

A

SL tab

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43
Q

ergotamine AE

A

N/V
ischemia
gangrene

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44
Q

when are ergots useful?

A
  • migraine with attacks > 48 hours
  • frequent HA recurrence
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45
Q

dihydroergotamine (DHE) dosage forms

A

injection (IM, IV, SQ): cluster headaches and migraine

intranasal: migraine

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46
Q

DHE side effects

A

fewer than ergotamine

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47
Q

DHE additional CIs

A
  • after vascular surgery
  • concurrent peripheral or central vasoconstrictors
  • IN: hemiplagic or basalar migraine
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48
Q

DHE monitoring

A

ECG after first admin in facility

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49
Q

IV/IM dexamethasone use

A

dec rate of early HA recurrence when added to acute migraine therapy in the ED

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50
Q

diphenhydramine use

A

prevent akathesia (muscle quivering) and other med effects

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51
Q

why are opioids no goes in ED mirgaine?

A

more likely return to ED with HA within 7 days

dependence

MOH risk

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52
Q

when are opioids considered

A

infrequent rescue use when pt’s initial treatment failed

CIs prevent other therapies

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53
Q

topiramte MoA

A

block Na channels
inc GABA
antagonize glutamate
inhibit carbonic anhydrase

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54
Q

topiramate AEs

A
  • cognitive dysfunction
  • CNS effects
  • ***dehydration –> nephrolithiasis, angle closure glaucoma
  • suicidal ideation
  • weight loss
  • paresthesia
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55
Q

topiramate CI

A

pregnancy

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56
Q

non-specific prevention adequate trial (antiepileptics and beta blockers)

A

2-3 months therapeutic dose

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57
Q

valproic acid MoA

A

block Na channel
inc GABA

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58
Q

valproic acid BBW

A

hepatotoxicity
fetal risk

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59
Q

valproic acid AEs

A

SJS/TENS (lamotrigine from seizures had too)

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60
Q

valproic acid CI

A

pregnancy and childbearing age –> spina bifida

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61
Q

beta blocker MoA

A

inhibit NE and E –> dec sympathetic

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62
Q

which beta blockers are indicated for migraine prevention

A

timolol
propanolol

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63
Q

why do propanolol and timolol work well?

A
  • high serotonin receptor affinity –> help prevent migraine
  • more lipophilic –> penetrate BBB better (also metoprolol
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64
Q

TCA MoA

A

inc serotonin and NE concentration by inhibit reuptak

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65
Q

TCA BBW

A

suicide

66
Q

TCA dosing

A

LOWER than when for depression

67
Q

TCA AEs

A
  • anticholinergic effects
  • cardiac conduction abnormalities
68
Q

venlafaxine MoA

A

SNRI

69
Q

venlafaxine AE

A
  • CNS depression
  • weight loss
  • inc BP
70
Q

venlafaxine BBW

A

suicide

71
Q

atogepant dose

A

10, 30, 60 mg ONCE DAILY

72
Q

atogepant CI

A

severe hepatic impairment
dose reduce < 30 CrCl

73
Q

which drugs do we need to worry about hepatic and renal impairment?

A

gepants!!

74
Q

CGRP mAb half life

A

very long –> dose every month or every 3 months

75
Q

CGRP mAb CI

A
  • recent cardiovascular or cerebraovascular ischemic events
  • pregnancy
76
Q

which CGRPs target CGRP ligand?

A
  • eptinezumab (Vyepti)
  • fremanezumab (Ajovy)
  • galcanezumab (Emgality)
77
Q

which CGRP targets CGRP receptor?

A
  • erenumab (Aimovig)
78
Q

which CGRP is also indicated for cluster HA prevention?

A

galcanezumab (Emgality)

79
Q

epitinezumab (Vyepti) admin + AE

A

**IV
every 3 months

AE: infusion reactions, nasopharyngitis, N

80
Q

erenumab (Aimovig) admin and AE

A

SQ
every month

AE: injection reactions, constipation (can be serious!!)

81
Q

fremanezumab (ajovy) admin and AE

A

SQ
every month OR every 3 months

AE: injection reaction

82
Q

galcanezumab (Emgality) admin and AE

A

SQ
every month
**dosing differs based on indication!! –> mg change, q month stays the same

AE: infusion reaction

83
Q

CGRP adequet trials

A

if q month: 3 months
if q 3 months: 6 months

84
Q

most common peripheral nerve block?

A

greater occipital nerve block

85
Q

what part of greater occipital nerve block is CI in preg

A

methylprednisolone

86
Q

non-pharm options for migraine prevention

A
  • reduce stress
  • diet change
  • trigger avoidance
  • OTC
87
Q

what is po Mg good for?

A

migraine with aura
menstrual migraine

88
Q

po Mg dose

A

oxide –> 400mg bid

89
Q

po Mg AEs

A
  • diarrhea, N/V
90
Q

what is b2 good for?

A

menstruating women –> monthly blood loss can dec

91
Q

feverfew CI

A

PREGNANCY —> uterine contractions and abortions

92
Q

feverfew AE

A

GI –> pain, bloat, constipate, diarrhea, N

93
Q

butterbur AE

A

GI!, rash, drowsy

94
Q

butterbur caution

A

only use products that are PA-free (pyrrolizidine alkaloid free) –> PA is toxic

95
Q

which acute treatments can we use in pregnancy?

A
  • APAP
  • triptans
  • lasmiditian
  • gepants
96
Q

which preventative treatments can we use in pregnancy?

A
  • beta blockers
  • venlafaxine?
  • TCAs?
  • gepants
  • peripheral nerve block without methyl pred
  • po Mg
  • butterbur
  • vitamine b2 (riboflavin)
  • neuromodulation
97
Q

onabotulinumtoxin A (Botox) MoA

A

neurotoxin –> prevent calcium dependent ACh release –> denervation

98
Q

Botox BBW

A

spread of toxin out of injection site –> muscle wekaness, dysphagia)

99
Q

Botox dose

A

155 units qually divded between 31 bilateral sites

everu 12 weeks

100
Q

botox AE

A
  • injection site pain
  • neck pain
  • myalgia
  • facial paresis/weakness
101
Q

botox adequate trial

A

36 weeks (3 treatments)

102
Q

carbonic anhydrase inhibiotr MoA

A

dec rate of CSF production

**therefore use in pseudomotor cerebri bc intracranial HTN –> dec CSF –> dec BP

103
Q

which drugs can induce pseudomotor serebri

A

growth hormones
retinoids
tetracyclines

104
Q

anticholinergic effects

A
  • pupils dilate
  • dry
  • flushed
  • depressed
  • agitated
  • fever
105
Q

acteylcholinesterase inhibitor MoA

A

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
Q

acetylcholinesterase AEs

A

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
Q

acwtylcholinesterase CIs

A
  • baseline bradycardia
  • baseline cardiac conduction disease (sinus syndrome, heart block)

inc risk falls, fractures

108
Q

acetylcholinesterase inhibitors

A
  • donezepil
  • rivastigmine
  • galantamine
109
Q

donezepil MoA

A

selective, non-competitive ACheE-i

110
Q

donezepil indication

A

mild-sev AD

111
Q

donezepil dosing

A

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
Q

donezepil PK

A

long half life
metaolized by P450

113
Q

donezepil AE

A
  • symptomatic bradycardia
  • rare rhabdomyolysis
114
Q

rivastigmine MoA

A

AChei

115
Q

rivastigmine capsule indication

A

mild-sev AD
mild-mod parkinsons

116
Q

rivastigmine form

A

capsule
patch

117
Q

rivastigmine capsule dosing

A

1 capsule bid
1.5mg bid –> inc by 3 mg q 2 weeks –> 6-12 mg/day

118
Q

rivastigmine capsile AE

A
  • *GI
119
Q

rivastigmine capsule PK

A

VERY SHORT HALF LIFE
**not metabolized by p450 (only one in class)

120
Q

rivastigmine patch indication

A

mild-sev AD

121
Q

rivastigmine patch dosing

A

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
Q

rivastigmine patch AE

A

site reactions
- less GI upset then capsules

123
Q

galantamine MoA

A

AChe-i

124
Q

galantamine indication

A

mild-mod AD

125
Q

galantamine forms

A

IR
ER

126
Q

galantamine dosing

A

IR: 4mg bid –> 8mg bid –> 12mg bid

ER: 8mg qd –> 16mg qd –> 24mg qd

127
Q

galantamine CI

A

ESRD
severe hepatic impairment

max dose: 12mg

128
Q

galantamine PK

A

metabolized by p450

129
Q

how to optimize AChEi?

A

sleep disturbance –> take dose in morning

nausea –> take with food or at bedtime

**all agents about equal –> base on individual pt

130
Q

memantine MoA

A

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
Q

memantine PK

A

not p450 metabolism

**CL reduced by alkaline (basic) urine

132
Q

memtanine cautions/CI

A
  • meds, diet, conditions that can change urine pH
  • Hx seizure disorder –> inc risk
  • Hx CV disease (cardiac failure, angina, bradycardia, HTN)–> small inc
133
Q

memantidine dosing

A

IR: 5mg qd –> target 20mg TDD (10mg bid)

ER: 7mg qd –> target 28mg qd

**renal dose adjust

134
Q

memantine AE

A
  • ***confusion –> early on, mild
  • dizzy
  • constipation
135
Q

memantine ER + donepezil

A

**must be stable on donezpeil 10mg before starting- –> involes starting at 5mg then inc to 10mg

136
Q

anti-amyloid mAb drugs

A
  • aducanumab
  • lecanemab
137
Q

anti-amyloid MoA

A

breaks down thw aggregated amyloid plaques

**ONLY DISEASE MODIFYING DRUG –> works against the actual patho cause

138
Q

aducanumab

A

controversial accelerated approval basd on PET results
- CMS not paying for yet –> waiting for full FDA approval

139
Q

aducanumab dosing

A

IV
goal: 10mg/kg q 4 weeks

start 1 mg/kg, inc from there

140
Q

aducanumab BBW

A

ARIA: amyloid related imaging abnormalities

APoE 4 inc risk

141
Q

aducanumab AE

A
  • hypersensivity
142
Q

aducanumab monitoring

A

MRI (prior to…)
- initial when start (can’t be more than 1 year old)
- 5th infusion
- 7th infusion
- 9th infusion
- 12th infusion

143
Q

ARIA MoA

A

amyloid related imaging abnormalities

remove amyloid plaques vis this drug –> lose blood vessel integrity –> predisposition to edema or hemorrhage –> dangerous1!!

144
Q

ARIA types

A

ARIA-E: edema, exudates, effusions
ARIA-H: hemorrhages

145
Q

ARIA s/s

A
  • HA
  • confusion
  • AMS
  • dizzy
  • nausea
  • visual disturbance
146
Q

ARIA risk

A
  • higher dose
  • APoE4 carrier
  • **treatment ith anticoagulants
147
Q

anti-amyloid CI

A

anticoagulants – bc ARIA

148
Q

lecanemab

A

full FDA approval 2023 –> MCI, mild AD
- CMS will pay for

149
Q

lecanemab requirements

A

need confirmed prescence of amyloid plaques

150
Q

lecanemab dosing

A

IV
10 mg/kg q2 weeks
NO TITRATION NEEDED*

151
Q

lecanemab BBW

A

ARIA
APoE4 inc risk

152
Q

lecanemab monitoring

A

MRI
- initial when starting (no more than 1 year old)
- 5th
- 7th
- 14th

153
Q

what to do if see ARIA before s/s?

A

if severity on imaging or symptoms mod or higher –> D/C

if mild –> can continue

154
Q

what inc risk of ARIA

A

APoE4 gene

155
Q

treatments for behavior

A

1st: non-pharm
2nd: antidepressant, anxiolytics, antipsychotics, antiepileptic

156
Q

treatments for sleep

A

TCA, benzos, sed/hypotnots, antiphyscotics

157
Q

which drugs to avoid in whole pt treatment?

A
  • anticholinergics
  • benzos
  • sedative/hypnotics
    **try to avoid these
158
Q

which whole pt drug has a BBW?

A

antipychotics
- elderly with dementia –> inc risk CV impact and death –> only use if have to, lowest dose

159
Q

best antisychotic

A

risperidone

160
Q

requirements of managing behavior

A

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
Q

non pharm behvior methods

A
  • structure and routine
  • plesat activities
  • simple
  • break down complex tasks into many small steps

p3 year :) (5 decks)

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