Headache Pharmacotherapy Flashcards

Question

Agents used for acute tx list Ergot alkaloids

Answer 1

```   Ergotamine tartarate (Egomar®)  Ergotamine + caffeine (Cafergot®, Wigrane®)  Available in PO, SL, PR forms  DHE 45® (Dihydroergotamine IV)  Migranal® nasal spray (DHE + caffeine) ```

Answer 2

Structurally related to amines (DA, EPI,NE) and can cause potent vasoconstriction MOA is by vasoconstriction of cranial arteries or by stimulating 5HT- 1 receptors (NON-SELECTIVE)

Answer 3

Peripheral vasoconstriction is most serious adverse event Numbness/tingling in extremities Muscle pain Gangrene Nausea/vomiting occur in up to 10% of pts Use lowest dose possible Use with metoclopramide (antiemetic)

Answer 4

``` Peripheral vascular disease hepatic impairment renal impairment coronary artery disease pregnancy concomitant triptan use ```

Answer 5

Active selectively at 5HT-1B and 1D subtypes unlike ergots (less nausea) Are effective in both migraine as well as cluster headache

Answer 6

``` Typically well tolerated Most severe adverse events are coronary vasospasm, MI, arrhythmias, stroke “Triptan” symptoms chest tightness, tingling, numbness neurologic- drowsiness, lethargy ```

Answer 7

PVD uncontrolled HTN coronary artery disease or significant cardiovascular disease concomitant MAO-A inhibitor within 2 weeks Except Almotriptan concomitant ergot use within 24hrs significant hepatic disease

Answer 8

Safest of all treatments Used in combination therapies (Midrin®) Major concern is rebound in combinations

Answer 9

Wide margin of safety Mech of action due to inhibition of prostaglandins as well as possible central mechanisms Commonly used in combinations GI bleeding and rebound are major concerns

Answer 10

Wide margin of safety Mech of action probably due to vasoconstriction properties Used in combinations (Excedrin®) Side effects related to stimulant properties  elevated mood, insomnia, palpitations, diuresis Major concern is rebound in combinations

Answer 11

Average caffeine intake 220-240mg/day Withdrawal syndrome characterized by yawning, decreased concentration and headache Headache occurs 18-24hrs after withdrawal Most effective therapy is reintroduction. May try taper of 5oz every week

Answer 12

Midrin (isometheptene + dichloralphenazone + acetaminophen) Isometheptene resembles epinephrine Dichloralphenazone is a sedative Side effects are numbness/dizziness

Answer 13

Metoclopramide - drug of choice for nausea in migraine often given in combination to increase gut motility Prochlorperazine Chlorpromazine

Answer 14

IV MSO4, butorphanol, codeine combinations Role in migraine controversial have few effects on fundamental pathogenesis habituation/ rebound headaches

Answer 15

``` TCA Beta-blockers Verapamil Valproic acid Topiramate Lithium Botulinum toxin ```

Answer 16

Tricyclics like amitryptyline (Elavil®) are drugs of choice for tension- type prophylaxis and are also effective in migraine prophylaxis Most common side effects are ANTICHOLINERGIC in nature Do not use in pregnant women, glaucoma, urinary retention, with MAO-I

Answer 17

Generally, treatment of choice for prevention of migraines Propranalol, atenolol, metoprolol effective MOA unknown; may raise migraine threshold Side effects include fatigue, hypotension, bradycardia. Caution in asthma, diabetes

Answer 18

CA channel blocker of choice for prevention of both cluster and migraine headaches Affects may take 3-8wks (limiting factor) Side effects include hypotension, edema, constipation

Answer 19

o MOA unknown, but has been effective in both migraine and cluster headache o Numerous side effects (n/v, weight gain, hepatotoxicity) o Consider for pts unresponsive to other agents or with a history of bipolar or seizure disorder

Answer 20

FDA approved for migraine prophylaxis o Effective at 100-200mg/day Several patients dropped out of studies due to adverse events. Cognitive (confusion, slowed speech,memory). Weight loss

Answer 21

O Treatment of choice for prophylaxis of chronic cluster headache O Benefits take 1-2 weeks Enhances serotenergic neurotransmission O Can also precipitate a headache as well as lethargy and abdominal discomfort O Avoid in pregnancy, renal disease

Answer 22

O Mechanism of action unknown. May reduce release of pain mediators (substance P, glutamate) O Administered by several intradermal injections q2-3 months O Early controlled studies found no benefit for several types of headaches O More recent PREEMPT trials showed reduction in headache frequency when compared to placebo in patients with chronic migraine o Most common side effects were neck pain and muscle weakness o Botox appears to have some efficacy, however questions regarding long term safety and conflicting evidence remain

Answer 23

ergots with P450 3A4 inhibitors | ergots with macrolide antibiotics

Answer 24

Tripatans with MAO-I (phenylzene) triptans metabolized by MAO, increase effect Triptans with ergots May cause extreme vasoconstriction

Answer 25

MAO-I and isometheptene excessive release of catecholamine MAO-I and antidepressants