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Pharmacology II > Headache Disorders > Flashcards

Headache Disorders Flashcards

1
Q

What are the three types of primary headaches?

A 
Migraine (w/ and w/out auroa)
Tension-type headache
Cluster headache (and other trigeminal autonomic cephalalgias)
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2
Q

What can cause a secondary headache?

A 
Head and/or neck trauma
Cranial or cerebral vascular disorder
Substance abuse or withdrawal
INfection
Disorder of homeostasis
DIsorder of cranium, neck, ears, eyes, nose, sinus, mouth, or other facial or cranial structures
Psychiatric disorders
Cranial neuralgias, central and primary facial pain, and other headaches.
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3
Q

What is the most prevalent type of primary headache?

A

Tension-type headache

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4
Q

Which two types of primary headaches are more common in women and which one is the most common in men?

A

Migraines and tension headaches occur more in women

Cluster headaches occur more in men

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5
Q

What primary headache is more common in spring/fall and at night?

A

Cluster headaches

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6
Q

What is the vascular hypothesis for migraines?

A

Vasoconstriction in the cerebrum causes aura.
Aura related to changed in blood flow in the cranial vessels reduces blood flow by 25-35%
Followed by vasodilation in the extra cranial and intracranial vessels leading to headache pain.
Serotonin is believed to play important role in migraine development. Many meds used to tx migraines are agonists of the serotonin receptors, causing vasoconstriction, based on the theory that migraine pain result of cranial artery vasodilation.

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7
Q

What is the neuronal dysfunction hypothesis?

A

Pain of a migraine is through to originate from trigeminovascular system of the cerebrum
The trigeminovascular system is an initiator and promotor of tissue inflammation & when activation it releases neuropeptides that cause vasodilation and inflammation.

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8
Q

What are the modifiable risks for migraines?

A 
Attack frequency
Central sensitization
Obesity
Medication Overuse
Stress snoring
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9
Q

What are the non-modifiable risks for migraines?

A

Sex-female
Low education/socioeconomic status
Head Injury

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10
Q

What are the medications that are common triggers of migraines?

A 
Cocaine
Nicotine
NTG
Hormones
NTG
Hormones
Indomethacin
Cimetidine
Nifedipine
Fluoxetine
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11
Q

What are the Dietary factors that are common triggers of migraines?

A 
ETOH
chocolate
aspartame
monosodium glutamate
caffeine
Tyramine
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12
Q

What are the environmental factors that are common triggers of migraines?

A 
Bright flashing lights
Loud noises
Strong odors
Tobacco smoke
High Altitude
Weather changes
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13
Q

What are the lifestyle factors that are common triggers of migraines?

A

Sleeping disorders
Dieting/skipping meals
Strenuous exercise

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14
Q

What are the hormonal factors that are common triggers of migraines?

A

Menopause
Menses
Pregnancy

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15
Q

What are the psychological factors that are common triggers of migraines?

A

Anxiety
Depression
Stress

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16
Q

What is the criteria for a migraine w/out aura (common migraine)?

A

Must have 2 of the following: aggravated by routine physical activity, pulsating, unilateral, moderate or severe pain
And
At least 1 of the following_ N/V, photophobia/phonophobia

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17
Q

What is the criteria for a migraine w/ aura (classic migraine)?

A

Criteria at least 2 of the following:
Homonymous visual sx, unilateral sense sx
At least 1 aura sx develops over >/=5 min and/or different aura sx develop in succession over >/=5 min.
Each sx lasts >/= 5min and < / = 60 min
Aura consists of > / = 1 of the following:
Fully reversible visual sx (+ or -)
Fully reversible dysphasic speech disturbance
Fully reversible sensory sx (+ or -)
Approximately 15%; aura allow dx

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18
Q

What are the long-term goals of migraine treatment therapy?

A

Decrease the number and severity of future migraines
Improves patients quality of life
Supporting the resumption of normal activities Reducing ADRs.

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18
Q

What are the 3 nonpharmacologic treatment?

A 
Ice to head w/ periods of rest and sleep in a dark, quiet environment
Avoid triggers
Behavioral interventions (relaxation therapy, biofeedback, cognitive therapy)
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18
Q

What is step-therapy?

A

ACP-ASIM 1st line therapy
NSAIDs (nonsteroidal anti-inflammatory drug) or combo (opiate or migraine drug)
Migraine specific agents if no response to NSAIDS
Involves non-oral route if N/V, guard against medication overuse, educate patients

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18
Q

What is stratified therapy?

A

USHC 1st line therapy
Migraine specific agents in severe migraine
Involves non-oral route if N/V, guard against medication overuse, educate patients

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18
Q

What are the non-specific pharmacological treatments?

A

NSAIDs, analgesics, antiemetics (phenergan, compazine), corticosteroids

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18
Q

What are migraine-specific pharmacological treatments?

A

Ergot derivatives

5-HT1B/1D (seratonin agonists)

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18
Q

NSAIDs

A

Non-specific meds for migraines
FIrst line for mild to moderate migraines.
Inhibit prostaglandin synthesis (inhibits inflammation in trigeminovascular system)
Includes- ASA (aspirin), naproxen, ibuprophen, APAP + ASA + Caffeine (Excedrin Migraine)

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18
What are the first line NSAIDs?
ASA (aspirin), naproxen, ibuprophen, APAP (acetaminophen) + ASA + Caffeine (Excedrin Migraine)
18
What are the short-term goals of migraine treatment therapy?
Decrease severity and duration, restore ability to function
18
Ergotamine acute side effects
``` N/V (pretreatment with antiemetic) Diarrhea Abdominal pain Weakness Leg cramps Tremor Dizziness Syncope Chest pain Intermittent claudication Syndrome of ergotism ```
19
what nonsepecific treatment for migraines involves a local anesthetic into the area where pain is felt?
Intranasal lidocaine
19
Which nonspecific treatment is reserved for severe migraine HA that is unresponsive to other treatments?
Opioids | Little data for use in migraines
19
Butorphanol (Stadol nasal spray)
Synthetic narcotic antagonist-agonist | Abuse potential
20
Barbiturate Combinations (hypnotics)
Non-specific migraine treatment Combined w/ analgesics or codein Potential for overuse, mod-severe migraine EX- butalbital, aspirin & caffeine (fiorinal)
21
What are the drug interactions of barbiturate combinations (hypnotics)?
Effects reduced by barbiturates- phenotiazine, quinidine, cyclosporine, theophylline, & BETA BLOCKERS Effects increased by barbiturates- chloramphenicol, benzodiazepines, CNS depressents
22
Triptan Side effects
``` Dizziness Fatigue Flushing Nausea Chest tightness, pressure, heaviness, pain Injection rxn Taste perversion from nasal spray ```
23
Ergotamine tartrate pharmacokinetics
Oral tablet and retal tablet
24
Dihydroergotamine
Nasal spray
25
Ergotamine acute side effects
``` N/V (pretreatment with antiemetic) Diarrhea Abdominal pain Weakness Leg cramps Tremor Dizziness Syncope Chest pain Intermittent Claudication Syndrome of Ergotism ```
26
What does syndrome of ergotism consist of?
Peripheral ischemia, cold, numb extremities, diminished peripheral pulses.
27
Ergotamine chronic side effects
``` Cerebral/peripheral ischemic disorders Hypertension TACHY/BRADY Medication overuse HA Renal D/O Withdrawal signs: severe HA, N/V, malaise ```
28
Ergotamine Contraindications
``` Sepsis Renal/hepatic failure Pregnancy/lactation Gluacoma Peptic ulcer disease Uncontrolled HTN CHD/Stroke/PVD Potential interactions w/ protease inhibitors USE OF TRIPTANS W/IN 24 HOURS ```
29
Ergotamine Drug Interactions
CYP 3A4 substrate Interactions w/ strong 3A4 inhibitors (azole antifungals, macrolides, protease inhibitors) Triptans (additive vasoconstrictive effect) Fluoxetine, fluvoxamine (competes for metabolism by 3A4)
30
Triptans
Selective 5-HT1b/d agonists- intracranial vasoconstriction, inhibition of neuropeptide release from trigeminovascular nerves, interrupts pain signal w/in brain stem trigeminal nuclei 1ST LINE FOR MODERATE TO SEVERE MIGRAINE
31
Triptan- sumatriptan (imitrex)- ROA
SQ injection, oral tabs, nasal spray
31
Beta-blockers MOA and contraindications
1st line agents for prophylactic treatment- agents include propranalol (inderal), metoprolol (lopressor), atenolol(tenormin), & nadolol MOA- unknown theory is that it may regulate serotonin transmission in cortical pathways Contraindications- pts w/ peripheral vascular disease, depression, asthma
32
Triptans- Rizatriptan (Maxalt)-ROA
Oral tabs, oral disintegrating tabs
33
Beta-blocker ADRs
Fatigue, vivid dreams, depression, impotence, BRADYCARDIA, HYPOTENSION
34
If you have controlled HTN can you take triptans?
Yes, only those with UNCONTROLLED cannot
35
Triptan Contraindications
``` Ergot alkaloid in last 24 hrs MAOI in last two weeks Ischemic heart disease/cerebrovascular Uncontrolled HTN Hemiplegic and basilar migraines ```
36
What does MAOI do?
It inhibits the break down of DA, NE, and serotonin increasing the amounts of all of these leading to tachycardia and other cardiac abnormalities
37
What does the triptan drug interaction MAOI result in?
Inhibits clearance of triptans | Risk of serotonin syndrome
38
What does the triptan drug interaction w/ SSRIs result?
Risk of serotonin syndrome
39
What does the tiptan drug interaction w/ ergotamine containing products result in?
Increased vasoconstrictive effects
40
What is serotonin syndrome?
Hyperthermia, muscle rigidity, myoclonus, rapid change in mental status and vitals Results from too much serotonin
41
When is prophylactic drug therapy indicated?
Migraines occur 2-3 times monthly Occur in a predictable pattern Patients that aren't able to tolerate or unable to take abortive therapies Migraines are long lasting and lead to severe impairment (>3 days disability/month)
42
If a patient is on prophylactic drug therapy trial and gets a headache in the first month should the trial be stopped?
No give the medication time to work, only stop the trial if a negative side effect is noted.
43
Beta-blockers MOA and contraindications
1st line agents for prophylactic treatment- agents include propranalol (inderal), metoprolol (lopressor), atenolol(tenormin), & nadolol MOA- unknown theory is that it may regulate serotonin transmission in cortical pathways Contraindications- pts w/ peripheral vascular disease, depression, asthma
44
Beta-blocker ADRs
Fatigue, vivid dreams, depression, impotence, BRADYCARDIA, HYPOTENSION
45
What are beta-blockers used for and which ones are used?
1st line agents for prophylactic treatment of migraines- agents include propranalol (inderal), metoprolol (lopressor), atenolol(tenormin), & nadolol
46
Tricyclic antidepressants (TCAs) MOA
Also used as 1st line agents for migraines- include imipramine (tofranil), nortriptyline (pamelor), & AMITRIPTYLINE (elavil) MOA- antagonist of 5-HT2 receptors inhibiting the reuptake of serontonin and causing increased concentration of serotonin in the synaptic cleft
47
What medications are used to tx intractable migraines?
DHE (dihydroergotamine)- SQ, IV, IM Sumatriptan (imitrex) Prchlorperazine (compazine) or chlorpromazine (thorazine)- antimigraine and antiemetic properties Narcotics Corticosteroids- suppress perivascular inflammation of resistant HA
48
Tricyclic antidepressants (TCAs) ADRs and Drug interactions
ADRs-Sedation, constipation, blurred vision, HPOTN | Drug interactions- MAOIs
49
Valproic acid (depakene) and divalproex sodium (depakote) MOA and contraindications
Anticonvulsant MOA- increased activity of GABA inhibitory transmitter Contraindications- liver-disease, monitor liver enzymes
50
Valproic acid (depakene) and divalproex sodium (depakote) ADRs and drug interactions
Anticonvulsant ADRs- tremor, weight gain, hair loss, nausea Drug interactions- other anticonvulsants, CNS depressants, absence sz in combo w/ clonazepam
51
What other anticonvulsants besides Valproic acid (depakene) and divalproex sodium (depakote) can be used in the prophylaxis of migraines?
Carbamazepine (tegretol), topiramate (topamax), gabapentin (neurontin)
52
Methysergide (Sansert)
Should not be used unless nothing else worse and a patient has severe migraines due to black box warning of fatal pulmonary fibrosis MOA- peripheral 5-HT inhibitor but central 5-HT agonist Use only for 6 mo. followed by 3-4 week drug free period. Effective but has serious side effects
53
Botulinum Toxin Type A (Botox)
Prophylaxis of migraines Inhibits acetylcholne release at the presynaptic cholinergic junction (inhibition of overactive peripheral neurons, possibly modulates substance P, and does not cross BBB) Not FDA approved indication Prophylactic effect seen 60-90 days after injection Inconsistent clinical trials
54
What are the effective natural products for migraine used in acute therapy?
Caffeine in combo w/ ASAP and ASA
55
What are the possibly effective natural products for migraine used in prevention
Butterbur Coenzyme Q-10 (can take 3 mo. to benefit) Feverfew- difference in extraction method and bioavalability
56
Which natural product is used for prevention of headaches associated with menstruation and female hormone changes?
Feverfew
57
What are the possibly effective natural products for migraine used in prevention that are only useful if there is a deficiency?
Magnesium Riboflavin (B2 Ineffective or insufficient evidence- fish oils, intranasal capsaicin, ginger, L-arginine, melatonin, olive oil
58
What medications are used to tx intractable migraines?
DHE (dihydroergotamine)- SQ, IV, IM Sumatriptan (imitrex) Prchlorperazine (compazine) or chlorpromazine (thorazine)- antimigraine and antiemetic properties Narcotics Corticosteroids- suppress perivascular inflammation of resistant HA
59
What distinguishes tension type headaches from migraines?
Bilateral location Pressure/tightening (non-pulsating) quality Not aggravated by routine physical activity
60
Tension type Headache
Most prevalent type of chronic and recurrent HA Pathophys is not well understood; but might have similar mechanism as migraine (muscle contractions, vasodilation, secondary to TMJ or cervical spondylosis) HA lasts 30 minutes- 7 days with at least 2 of the following: bilateral location, pressure/tightening (nonplusating) quality, mild or moderate intensity, not aggravated by routine physical activity Precipitants include anxiety, depression, situational stress
61
What type of headache involved a BILATERAL feeling of band-like sensation around head, pain that is dull, steady, and worsening as the day progresses w/out N/V?
Tension type HA
62
What are the non-pharmacologic treatments for tension type headaches?
``` Stress management Relaxation training Physical therapy Counseling Regulation of sleep/meal schedules Acupuncture ```
63
What is the pharmacologic tx of tension type headaches?
Analgesics w/ or w/out caffeine for mild-moderate (APAP, ASA, ibuprofen, naproxen) Sedatives- butalbital (Fiorinal/fioricet) Prophylactic- TRICYCLIC ANTIDEPRESSANTS- muscle relaxants (methocarbemol [robaxin], orphenadrine [norflex], cyclobenaprine [flexeril] Botulinum toxin
64
What sx are associated with a cluster headache?
Intense, non-throbbing, unilateral HA, behind the eye that is searing, stabbing, or burning and accompanied by ipsilateral lacrimation, nasal stuffiness, and facial flushing
65
What type of headache occurs at night, lasts 30-90 minutes, occurs nightly for 2-3 months and then is gone only to return months or years later? Hint - sx include Intense, non-throbbing, unilateral HA, behing the eye that is searing, stabbing, or burning and accompanied by ipsilateral lacrimation, nasal stuffiness, and facial flushing
Cluster headache
66
Cluster HA- acute treatment
``` Imitrex SQ (nasal is less effective) O2 inhalation Ergotamine +/- caffeine DHE-45 Lidocaine nasal spray 4% ```
67
Cluster HA- prophylaxis
``` Verapamil (ca++ blocker) Prednisone Ergotamine Methysergide Lithium ```

Pharmacology II (23 decks)

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