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Therapeutics > Headache Disorders > Flashcards

Headache Disorders Flashcards

1
Q

Differentiate an aura from a TIA…

in terms of symptoms

A

aura is a positive visual symptom and a headache typically follows

TIA is associated with vision loss and headache is uncommon

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2
Q

Differentiate an aura from a TIA…

in terms of onset

A

auras have gradual onset with a sequential progression of symptoms

TIA is abrupt onset with simultaneous occurrence of symptoms

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3
Q

Differentiate an aura from a TIA…

in terms of duration

A

auras can last up to 60 minutes

TIAs usually last under 15 minutes

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4
Q

What are differentiating characteristics of a migraine?

more common gender?

type of pain?

duration?

additional symptoms?

A

females

UNILATERAL, PULSATING moderate to severe pain aggravated by physical activity

lasts 4-72 hours

+/- N and/or V
+/- photophobia AND phonophobia
+/- aura

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5
Q

When is preventative migraine therapy indicated? (5 reasons)

A
  • attacks interfere w/ daily routine despite acute therapy
  • frequent attacks (min > 2/mo, lower end of frequency has to be more debilitating)
  • CI, failure or overuse of acute therapy
  • ADR w/ acute therapy
  • pt preference
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6
Q

Migraine classification definitions…

episodic migraine:

chronic migraine:

A

less than 14 days/mo

15 or more days/mo for 3 months; HA 4 hours or more of each day

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7
Q

What are the two migraine specific NSAIDs?

A
  1. diclofenac potassium oral solution (Cambia)
  2. celecoxib oral solution (Elyxyb)
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8
Q

What agents/classes are used in acute migraine therapy? (7)

What ones are for refractory? (+1)

What ones are LAST LINE? (+2)

A
  1. APAP
  2. NSAIDs
  3. triptans
  4. rimegepant (Nurtec)
  5. ubrogepant (Ubrelvy)
  6. zavegepant (Zavzpret)
  7. ergots

refractory: lasmiditan (Reyvow)

LAST LINE: Fioricet, Fiorinal

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9
Q

What are the similarities & differences between Fioricet and Fiorinal?

A

BOTH: bubtalbital, caffeine AND…

Fioricet: APAP (only CIII when codeine is added)

Fiorinal: ASA (CIII)

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10
Q

What is the benefit for using an NSAID oral solution for acute migraine therapy?

A

FASTER onset!

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11
Q

What is the main class ADR for triptans?

A

VASOCONSTRICTION!
- flushing , chest pain, palpitations

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12
Q

Which triptan contains a sulfa group?

A

almotriptan

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13
Q

Which triptans are CI in severe hepatic impairment?

A
  1. naratriptan (Amerge)
  2. eletriptan (Relpax)
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14
Q

Which triptan is CI with potent CYP3A4 inhibitor use in last 72 hours?

A

eletriptan (Relpax)

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15
Q

Which triptans have the longest & second longest half life?

A
  1. frovatripin (Frova) - 26 hours
  2. naratripran (Amerge) - 6 hours
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16
Q

Which triptans are CI with MAOIs?

A
  1. rizatriptan (Maxalt, RizaFilm)
  2. sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)
  3. zolmitriptan (Zomig)
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17
Q

Which triptans have ODT formulations?

A
  1. rizatriptan (Maxalt, RizaFilm)
  2. zolmitriptan (Zomig)
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18
Q

Which triptans have intranasal formulations?

A
  1. sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)
  2. zolmitriptan (Zomig)
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19
Q

Which triptans have subQ formulations?

A

sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)

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20
Q

Which triptans have the fastest & second fastest onset of action?

A
  1. sumatriptan subQ
  2. sumatriptan intranasal
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21
Q

What triptan has the lowest oral bioavailability?

A

sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)

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22
Q

What triptan has the lowest incidence of chest pain/tightness?

A

almotriptan

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23
Q

What triptan has the highest incidence of CNS ADR?

Why?

A

eletriptan (Relpax)

most lipophilic, increased BBB penetration

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24
Q

What is the CI for lasmiditan (Reyvow)?

A

severe hepatic impairment

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25
Q

What is the frequency of dosing for lasmiditan (Reyvow)?

A

MDD of 1 because no efficacy with repeated dosing

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26
Q

What is a significant ADR of lasmiditan (Reyvow)?

A

profound CNS depression (8 hours between dosing and driving)

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27
Q

What agents/classes are used in preventative migraine therapy?

A
  1. atogepant (Quilipta)
  2. rimegepant (Nurtec)
  3. antiepileptics
  4. beta blockers
  5. TCAs
  6. SNRI
  7. CGRP mAbs

OTC
1. magnesium
2. riboflavin (B2)
3. feverfew
4. butterbur

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28
Q

Which gepant is used for both acute and preventative migraine therapy?

A

rimegepant (Nurtec)

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29
Q

What CI do all gepants have?

A

severe hepatic impairment

renal impairment
RIM & UBO -> CrCl < 15
ATO & ZAV -> CrCl < 30

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30
Q

Which gepant has the fastest onset of action?

A

zavegepant (Zavzpret)

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31
Q

Which gepant comes as an intranasal spray?

A

zavegepant (Zavzpret)

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32
Q

Which gepant comes as an ODT?

A

rimegepant (Nurtec)

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33
Q

What is the rimegepant (Nurtec) dosing when used for migraine prevention?

A

75 mg every other day

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34
Q

What gepant can you repeat the PRN dose after 2 hours if needed?

What other gepants are used for acute migraine therapy?

Can you repeat the doses of these other gepants?

If so how many times/how long between?

A

ubrogepant (Ubrelvy)

NO NO NO

MDD of 1 for both rimegepant (Nurtec) & zavegepant (Zavegepant)

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35
Q

What is the common ADR associated with gepant use?

A

GI related: nausea, constipation, abdominal pain, dyspepsia

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36
Q

What specific ADR does zavegepant (Zavzpret) that differs from the other gepants?

A

taste disturbances & nasal discomfort

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37
Q

What is the class ADR causing many CI for ergots?

A

VASOCONSTRICTION

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38
Q

What monitoring is needed while using ergots?

A

liver & renal fxn

cardiovascular status

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39
Q

What is the indication for ergotamine (Ergomar)?

A

acute migraine therapy

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40
Q

What an important ADR consideration for ergotamine (Ergomar)?

**Think: What patients should you avoid it in?

A

WORSENS N/V!!

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40
Q

How is ergotamine (Ergomar) supplied?

A

sublingual tablet

also has combo w/ caffeine as PO and PR

41
Q

How is dihydroergotamine (DHE) supplied?

A

intranasal, IV, IM, or subQ

42
Q

What is the indication for dihydroergotamine (DHE) injection & intranasal formulations?

What is the indication for dihydroergotamine (DHE) injection only?

A

acute migraine therapy

acute cluster HA therapy

43
Q

What is the benefit of using dihydroergotamine (DHE) over ergotamine (Ergomar)?

A

less ADR than ergotamine

44
Q

What substance increases ergotamine (Ergomar) levels?

A

grapefruit juice

45
Q

What is required when initiating therapy with dihydroergotamine (DHE)?

A

1st dose has to be given in a facility

+/- ECG for patients w/ CAD risk factors

46
Q

What is true of Migranal vs Trudhesa?

BOTH are brands of dihydroergotamine (DHE)

A

Migranal contains caffeine

47
Q

Which AEDs are used for preventative migraine therapy?

A
  1. topiramate (Topamax, Trokendi Xr, Quedexy Xr)
  2. valproic acid (Divalproex Sodium, Sodium Valproate)
48
Q

When can you assess the effectiveness of gepants as preventative migraine therapy?

A

8 weeks

49
Q

When can you assess the effectiveness of beta blockers as preventative migraine therapy?

A

2-3 months

50
Q

When can you assess the effectiveness of AEDs as preventative migraine therapy?

A

2-3 months

51
Q

What are some ADR of topiramate (Topamax, Trokendi Xr, Quedexy Xr)?

List 6!

A

cognitive dysfunction

nephrolithiasis

oligohidrosis

hyperthermia

suicidal ideation

weight loss

52
Q

What is an important counseling point for topiramate (Topamax, Trokendi Xr, Quedexy Xr)?

A

HYDRATION!!!

53
Q

What preventative migraine therapy is associated with a risk of SJS/TEN & DRESS?

A

valproic acid (Divalproex Sodium, Sodium Valproate)

54
Q

What are the BBWs for valproic acid (Divalproex Sodium, Sodium Valproate)?

A
  1. hepatotoxicity
  2. patients w/ mitochondrial diseases
  3. teratogenicity
  4. pancreatitis
55
Q

What beta blockers are indicated for preventative migraine therapy? (2)

What about off label ones? (3)

A

propranolol & timolol

metoprolol, atenolol & nadolol

56
Q

Which 3 beta blockers are more lipophilic and have better BBB penetration in migraine therapy?

A

propranolol, timolol & metoprolol

57
Q

What TCAs are indicated for preventative migraine therapy?

A

amitriptyline

nortriptyline

58
Q

What is the common ADR of TCAs?

A

anticholinergic ADR!!

59
Q

When can you assess the effectiveness of TCAs and SNRIs as preventative migraine therapy?

A

2-3 months

60
Q

What is the BBW for TCAs & SNRIs as preventative migraine therapy?

A

suicidality

61
Q

Which SNRI can be used for migraine preventative therapy?

A

venlafaxine (Effexor)

62
Q

What mAbs are used for preventive migraine therapy?

Which ones target the CGRP receptor?

Which ones target the CGRP ligand?

A
  1. Vyepti (eptinezumab)
  2. Aimovig (erenumab) RECEPTOR
  3. Ajovy (fremanezumab)
  4. Emgality (galcanezumab)

the rest target the ligand

63
Q

What CGRP mAbs are used given subQ?

How often are they administered?

When can you assess effectiveness?

A
  1. Aimovig (erenumab)
  2. Ajovy (fremanezumab)
  3. Emgality (galcanezumab)

MONTHLY

after 3 months

64
Q

What CGRP mAbs are used given IV?

How often are they administered?

When can you assess effectiveness?

A
  1. Vyepti (eptinezumab)
  2. Ajovy (fremanezumab)

every 3 months

after 6 months

65
Q

Which CGRP mAb has the highest rates of antibody development?

A

Vyepti (eptinezumab)

66
Q

Which CGRP mAb can also be used for preventative cluster HA therapy?

A

Emgality (galcanezumab)

67
Q

What are peripheral nerve blocks indicated for in terms of migraine therapy?

A

ACUTE therapy for…

SEVERE/PROLONGED attacks
or
REFRACTORY/CI to standard therapy

68
Q

Which agents are used in migraine peripheral nerve blocks?

Which one CANNOT be used in pregnancy?

A

lidocaine
and/or
bupivacane
and/or
methylprednisolone CI pregnancy

69
Q

How is magnesium dosed for preventative migraine therapy?

A

400 mg Mag Ox BID

70
Q

What ADR are associated with magnesium therapy?

A

diarrhea, N/V (titrate dose)

hypermagnesemia

71
Q

What needs to be avoided when choosing butterbur as preventative migraine therapy?

A

products NOT labeled as PA free

72
Q

What are the symptoms associated with hypermagnesemia?

A

hypotension, N/V, bradycardia

73
Q

How are neuromodulation devices used in migraine therapy?

A

ACUTE & PREVENTATIVE therapy

74
Q

How is botox used in migraine therapy?

How often & when is affect assessed?

BBW?

A

PREVENTATIVE for CHRONIC migraine

every 3 months; after 3 treatments

spreading of toxin effect

75
Q

What are the preferred acute & preventative therapies for migraine during pregnancy?

A

acute: APAP

preventative: magnesium or riboflavin (B2)

76
Q

What are the preferred acute & preventative therapies for migraine in patients with cardiovascular/cerebrovascular disease?

A

acute: APAP, gepants, lasmiditan (Reyvow)

preventative: gepants

77
Q

What agents are specifically used to treat menstrual migraine?

(can really use almost any migraine therapy)

A
  1. frovatriptan (Frova)
  2. naratriptan (Amerge)
  3. zolmitriptan (Zomig)
  4. magnesium
  5. combined hormonal contraceptives
78
Q

What is the caveat for use of combined hormonal contraceptives for menstrual migraine therapy?

A

CONTRAINDICATED in migraine w/ aura

estrogen increases stroke risk!!!

79
Q

What is the dosing of frovatriptan (Frova) for menstrual migraine?

KNOW START & TOTAL DAYS

A

2.5 mg PO QD-BID

START 2 DAYS BEFORE MENSES

6 DAYS TOTAL

80
Q

What is the dosing of naratriptan (Amerge) for menstrual migraine?

KNOW START & TOTAL DAYS

A

1mg PO BID

START 2-3 DAYS BEFORE SYMPTOM ONSET

5-6 DAYS TOTAL

81
Q

What is the dosing of zolmitriptan (Zomig) for menstrual migraine?

KNOW START & TOTAL DAYS

A

2.5 mg PO QD-BID

START 2 DAYS BEFORE MENSES

7 DAYS TOTAL

82
Q

What are differentiating characteristics of a tension type HA?

type of pain?

duration?

A

mild to moderate bilateral (band like) pressing or tightening, that is not aggravated by activity

lasts 30 mins-7 days

83
Q

What are differentiating characteristics of a cluster HA?

more common gender?

type of pain?

duration? & frequency?

additional symptoms?

A

males

severe unilateral orbital, supraorbital and/or temporal pain

lasts 15-180 mins; occur QOD up to 8x a day

additional symptoms
on same side of pain
- conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, forehead/facial sweating, mitosis, ptosis (eye droop)

agitation, restlessness

84
Q

What are differentiating characteristics of hemicrania continua?

type of pain?

duration?

additional symptoms?

A

unilateral pain with exacerbations of moderate or greater intensity

lasts > 3 mo

additional symptoms
on same side of pain
- conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, forehead/facial sweating

agitation, restlessness

RESPONDS THERAPEUTICALLY TO INDOMETHACIN*

85
Q

What are differentiating characteristics of a TBI HA?

type of pain?

onset?

additional symptoms?

A

resembles migraine-like and/or tension type HA

within 7 days of head trauma

assoc w/ post-concussive symptoms
- fatigue, dizziness, insomnia, concentration impairment, seizures, depression, anxiety

86
Q

What are differentiating characteristics of psuedotumor cerebri?

what is it?

symptoms?

who is it most common in?

which drugs can induce it?

A

increased intracranial pressure

HA, papilledema, vision loss

overweight females of childbearing age

growth hormones, tetracyclines, retinoids

87
Q

What are differentiating characteristics of a brain tumor HA?

type of pain?

additional symptoms?

A

features vary based on location & tumor type
- common phenotype is tension type HA
- typically bilateral pain or on same side as tumor

assoc w/ neurosymptoms
- seizures, fatigue, cognitive dysfunction, focal weakness

88
Q

What are differentiating characteristics of a reversible cerebral vasoconstriction syndrome (RCVS)?

what is it?

type of pain?

additional symptoms?

who is it most common in?

what is needed for it to occur?

what meds are associated with it?

A

reversible multi-focal narrowing of cerebral arteries that can cause permanent brain damage

thunderclap HA

neuro deficits related to brain edema, seizure or stroke

triggering event -> stress, exertion

SSRI, triptans, ergots, cyclophosphamide, tacrolimus, nasal decongestants, illegals drugs

89
Q

What are differentiating characteristics of a subarachnoid hemorrhage HA?

type of pain?

onset?

additional symptoms?

A

MAX INTENSITY within seconds (worst pain of life)

sudden or thunderclap onset

N/V, photophobia, neck stiffness, focal neurologic deficit, brief loss of consciousness

LIFE THREATENING EMERGENCY

90
Q

What agents are used for acute therapy in tension type HA? (3 ish)

A
  1. NSAIDs or APAP
  2. combo analgesics w/ caffeine
  3. combo analgesics w/ butalbital or codeine
91
Q

What agents are used for preventative therapy in tension type HA? (6)

A

TCAs, mirtazapine, venlafaxine

gabapentin, topiramate

trigger point injections (nerve block)

92
Q

What agents are used for acute therapy in cluster HA? (3)

A
  1. O2
  2. subQ (preferred) or intranasal sumatriptan
  3. intranasal zolmitriptan
93
Q

What agents are used for preventative therapy in cluster HA? (6)

A

GOLD STANDARD: verapamil

  • glucocorticoids
  • Emgality (galcanezumab)
  • lithium
  • topiramate
  • greater occipital nerve blocks
94
Q

What is the GOLD STANDARD of cluster HA preventative therapy?

A

verapamil

95
Q

What is the GOLD STANDARD of hemicrania continua treatment?

A

indomethacin

96
Q

What is the treatment for psuedotumor cerebri?

A
  1. D/C offending agents
  2. weight loss
  3. carbonic anhydrase inhibitor to dec CSF production
    - acetazolamide
    - topiramate
97
Q

What agents are associated with medication overuse headaches? (5)

What are the thresholds of risk for each? (i.e. max days per month)

A

greater than 10 days/month
1. ergots
2. triptans
3. opioids

greater than 15 days/month
4. non-opioid analgesics

greater than 5 days/month
5. butalbital

98
Q

Define medication overuse HA:

A

HA greater than 15 days/month in pt w/ pre-existing HA disorder

with regular overuse for > 3 mo of one or more acute HA therapies

99
Q

What is the treatment of medication overuse HA?

A
  • D/C (taper off) overused med
  • consider bridge therapy during initial period after D/C
  • initiate preventative therapy with PRN breakthrough therapy
100
Q

What are the HA Red Flags?

hint: acronym, think of a famous rapper

A

SNOOP

S - Systemic signs/symtoms OR Systemic disease

N - Neurologic signs/symptoms

O - sudden Onset (thunderclap)

O - Onset after 40 yo

P - Pattern change

Therapeutics (17 decks)

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