Headache disorders

Question 1

Drugs for migraine prevention

Answer 1

Valproate
Fluoxetine, 
Amitriptyline, 
Desipramine, 
Phenelzine, 
Naproxen, 
Timolol, 
Propanolol, 
Verapamil, 
Methysergide,
Gabapentin, 
Botulinum toxin A.

Question 2

Valproate- Adverse effects

Answer 2

Sedation
Tremor
Weight gain

Question 3

Fluoxetine - MoA

Answer 3

Selective serotonin reuptake inhibitors(SSRIs)

Question 4

Fluoxetine - Adverse effects

Answer 4

Anxiety
Insomnia
Tremor
Anorexia
Sexual dysfunction

Question 5

Tricylic antidepressants (TCA’s)

Answer 5

Amitriptyline and Desipramine

Question 6

Amitriptyline and Desipramine - Adverse effects

Answer 6

Drowsiness
Tremor
Anticholinergic effects( dry mouth, blurred vision, urinary retention)

Question 7

What is more effective of Amitriptyline and Desipramine?

Answer 7

Amitriptyline

Question 8

Phenelzine - MoA

Answer 8

Monoamine oxidase inhibitors(MAOIs)

Can block serotonin degradation

Question 9

Phenelzine - Adverse effects

Answer 9

Hypertensive crisis if they are taken with tyramine containing foods or with sympathomimetic amine drugs

Question 10

Naproxen - MoA

Answer 10

Blocking thromboxane synthesis and platelet aggregation and thereby reducing the release of serotonin

Question 11

Naproxen - Clinical use

Answer 11

Prevention AND treatment of migraine

Prevention of migraine headaches associated with menstruation cycle (arm 1 week before menstruation)

Question 12

Timolol - MoA

Answer 12

Only B-blockers that lack intrinsic sympathomimetic activity are effective for prevention of migraine.

MOA for migraine is uncertain, but might block vasodilation mediated by B2 adrenoceptors. They may also reduce platelet aggregstion and decrease the level of serotonin from platelets.

Question 13

Propanolol - MoA

Answer 13

MOA for migraine is uncertain, but might block vasodilation mediated by B2 adrenoceptors. They may also reduce platelet aggregstion and decrease the level of serotonin from platelets.

Question 14

Verapamil - MoA

Answer 14

Preventing the vasocontrictive phase of migraine headaches

Question 15

B-adrenoceptor antagonists used for prophylaxis of migraine

Answer 15

Timolol and Propranolol

Question 16

Calcium channel blockers used for prophylaxis of migraine

Answer 16

Verapamil. But less effective than other classes of drugs.

Question 17

Methysergide- MoA

Answer 17

Block 5-HT2 receptors and thereby prevent vasocontrictive phase of migraine from occuring

Question 18

Methysergide- Adverse effect

Answer 18

Abdominal pain
Weight gain
Hallucinations

Life threatning:
Retroperitoneal, pleural and cardiac valve fibrosis

Question 19

Gabapentin - MoA

Answer 19

Enhance GABA action in the tratment of seizure disorder, its migraine action is unknown.

Question 20

Gabapentin - Clinical use

Answer 20

Seizure disorders
Postherpetic neuralgia

Moderatley effective in preventing occurence of migraine

Question 21

Botulinum toxin A - MoA

Answer 21

Disrupts the neurotransmission of acetylcholine by preventing vesicle fusion with membrane of the presynaptic termina

Question 22

Drugs for migraine termination

Answer 22

Ergot drugs:
Ergotamin
Dihydroergotamine

Triptan agents:
Sumatriptan
Naratriptan
Rizatriptan
Zolmitriptan
Frovatriptan
Almotriptan
Eletriptan

Isometheptene

Opioids:
Tramadol
Butorphanol
Acetaminophen with codeine
Prochlorperazine

Question 23

Ergot agents - MoA

Answer 23

Activating serotonin 5-HT1B/1D receptors

Activate receptors on pial and dural vessels leads to Vasocontriction

Activate presynaptic receptors to inhibit the release of peptides and other mediators from trigeminal neurons
Activate receptors in brain stem inhibit activation of trigeminal neurons responsible for migraine attacks.

Question 24

Ergotamine and Dihydroergotamine - Clincal use

Answer 24

Migraine headache
Cluster headache
Parkinson disease
Hyperprolactinema

Question 25

Ergotamine and Dihydroergotamine - Adverse effects

Answer 25

Nausea
Vomitting
Diarrhea
Muscle cramps
Cold skin
Paresthesias
Vertigo

Excessive dose can cause severe cerebral vaspcontriction, ischemia and reboud vasodilation and headache

Question 26

Ergotamine and Dihydroergotamine - Special considerations and contraindications

Answer 26

Should not be used with B-adrenoceptor antagonists –> severe peripheral ischemia

Dihydroergotamine given with an antiemetic drug- metoclopramide when adm parenterally

Contraindicated in persons with coronary artery disease, or peripheral vascular disease

Question 27

Triptan agents - Adverse effects

Answer 27

Chest tightness
Weakness
Somnolence
Dizziness
Abnormal tingling and burning sensation(paresthesias)
Coronary vasospasm
Increased blood pressure

Question 28

Triptants - Contraindications

Answer 28

Coronary vasospasm:
Patient with history of angina pectoris, myocardial infarction or other coronary diseases.

Increased blood pressure:
patients with uncontrolled hypertension

Not be used with MAOIs, or within 24h og adm of an ergot alkaloid or methysergide.

Use of triptan with SSRI antidepressant agent increase the risk of triggering serotonin syndrome.

Question 29

Which drugs would you prescribe to adolescent (12-17 y) with history of migraine attacks?

Answer 29

Almotriptan

Question 30

Tramadol - MoA

Answer 30

Agonist at µ opioid receptors, and also inhibits serotonin and norepinephrine reuptake in CNS

Question 31

Tramadol - Clinical use

Answer 31

Chronic pain syndromes

Question 32

Butorphanol - MoA

Answer 32

Agonist at k opioid receptor and mixed agonist-antagonist at u opioid receptor.

Question 33

Prochlorperazine - Classification and Clinical use

Answer 33

Antipsychotic

Aborting unremitting migraine headache when given IV.

Question 34

What is the most used opioid for migraine?

Answer 34

Tramadol