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Pharmacology > Headaches > Flashcards

Headaches Flashcards

1
Q

tension-type headache (TTH)

A

all HA syndromes where sensitization to pericranial nociception is the most significant factor in pathogenesis of pain
more common in women
episodic TTH is most common f/b freq. episodic and chronic
increase with age until 40
**environmental factors **

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2
Q

cluster HA/trigeminal autonomic cephalalgias risk factors and overview

A

more common in men 20-40 y/o
genetic & other risks: tobcacco, caffeine, etoh abuse

debilitating unilateral head pain in series lasting up to months at a time then remission for months-years
sometimes chronic w/o remission
ANS dysfunction

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3
Q

migraines

A

imbalance in modulation of nociception and blood vessel tone by serotonergic and noradrenergic neurons
HA likely d/t overactivity in trigeminovascular system in brain

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4
Q

diet triggers to migraines

A

high tyramine (cheese, wine, organ meats, yeast breads), aspartame, monosodium glutamate, nitrites (processed meats)

alcohol
caffeine
chocolate
citrus fruit, banana, fig, avocado
dairy
fermented pickled products
missing meals
diet soda/food
sulfites (shrimp)

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5
Q

chronic migraines

A

migraine 15 or more days/month x3 month period or longer w/o overuse of analgesics

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6
Q

status migrainosus

A

severe migraine > 72 hours

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7
Q

TTH vs migraine

A

TTH mild-mod, nonpulsating, bilateral
described as band-like tightness or pressure around head
TTH= no neuro deficits & systemic sx rare

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8
Q

clustere HA characteristics

A

severe, intermittent, short in duration
typically at night and can be multiple times/day
unilateral pain but is not described a pulsing
no aura and pain intensity peaks early after onset & can persist for hours
“explosive, excrutiating, suicide HA”

parasympathetic overactivity sx: ipsilateral conjunctival injection & lacrimation, rhinorrhea, sweating
excited & restless during attacks

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9
Q

nonpharmacologic txs/prevention of headaches

A

relaxation timing, thermal biofeedback, acupuncture, CBT, electrical nerve stimulation

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10
Q

red flags of HA that warrant urgent physician referral & further diagnostics

A

new onset sudden/severe pain
stereotyped pain pattern worsens
systemic signs (fever, wt loss, HTN)
focal neuro sx other than typical visual or sensory aura
papilledema
cough, exertion, or valsalva triggered HA
pregnancy or PP state
cancer, HIV, or other
seizures

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11
Q

first line initial tx acute migraine HA

A

aspirin, NSAIDs, APAP, and combo products w/ or w/o caffeine, w/ or w/o opioid

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12
Q

second line tx migraines

A

triptans

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13
Q

ergotmaine derivatives & ex & risk

A

produce salutary effects on serotonin receptors similar to triptans for migraine tx but also impact adrenergic & dopaminergic receptors so MORE side effects

ex: ergotamine tartrate & dihydroergotamine (DHE; can be intranasal)

*risk for vascular events
given w/ antiemetic if given parenteral d/t nausea

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14
Q

triptans (mechanism of action, onset, adverse effects, contraindications)
exs

A

inhibit neuro path in trigeminal complex and active serotonin 1B/1D which modulate nociception, decrease vasoactivity causing vasoconstriction. Efficacy r/t dose.

onset 2-4 hours for relief

SE (not r/t dose)- dizziness, sense of warmth, chest fullness, nausea, paresthesia. RARE ischemic vascular events (bc they cause vasoconstriction)

contraindicated: migraine w/ neuro focality, h/o stroke, poorly controlled HTN, unstable angina, pregnancy, CANNOT be use with ergotamines (wait 24 hrs between)

7 approved: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumtriptan, zolmatriptan
intranasal, SQ, oral

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15
Q

what to do if pt doesn’t respond to triptan

A

try another agent since different pharmacokinetics

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16
Q

special consideration for triptan if cardiovascular risk

A

first dose in office under practitioner supervision

17
Q

CGRP antagonists (mech. of action, SE, ex)

A

ubrogepant & rimegepant
block CGRP which causes vasodilation & pain associated w/ migraine

well-tolerated, only nausea, but very expensive

18
Q

medication overuse headache (MOH)

A

rebound HA caused from:
use migraine meds >10 days/month or nonspecific analgesics > 15/month

19
Q

tx for severe acute migraine in hospital

A

IV metoclopramide supplemented with DHE or IV valproic acid

20
Q

tx of cluster HA

A

many of the same tx as migraines
specific to cluster HA: high flow rate O2 100% at 12-15L/min by nonrebreather x15 min. Can repeat

SQ sumatriptan & IN zolmitriptan; octreotide if contraindicated then can do glucocorticoids IV

prophylactic tx required

21
Q

when is prophylaxis for HA indicated

A

freq./severe, significant disability, pain meds freq., adverse effects w/ acute therapy, neuro focality

22
Q

first line/initial therapy for prophylaxis of migraines

A

no consensus for first initial tx; individualized based off patient tolerability & comorbidities

beta blockers, antidepressants (amitriptyline, venlafaxine, valproic acid & topiramate, monoclonal antibodies, methysergide, onabotulinumtoxin/Botox)

23
Q

beta blockers
use, contraindications, alternatives

A

migraine prevention; cautious dose titration

contraindicated: airway disease, cardiac conduction disturbances

alternatives: calcium channel blockers but none FDA approved for migraines, ARBS and ACEi lisinopril & candesartan only two that have shown low efficacy

24
Q

TCAs for migraine prevention, SE/warning

A

amitriptyline & other TCAs
admin & HS d/t sedation
anticholinergic SE

**dont use with triptans= serotonin syndrome

25
Q

what other antidepressant besides TCAs can help prevent migraines

A

venlafaxine
**dont use with triptans= serotonin syndrome

26
Q

antiseizure meds for migraine prevention

A

valproic acid, topiramate, carbamazepine (if r/t trigeminal neuralgia)
serum drug level not needed freq.

*topiramate better if metabolic syndrome, DM, dyslipidemia bc less likely to cause weight gain

27
Q

topiramate SE

A

paresthesia, fatigue, anorexia, nausea, cognitive impairment
mitigated by slow dose titration & hydration

28
Q

injections for migraine prevention

A

injectable monoclonal antibodies target CGRP
erenuman-aooe, galcanezumab-gnlm, fremanezumab-vfrm

monthly injection
SE- injection site rxn, constipation

29
Q

methysergide

A

ergotamine derivative impacts central serotonin balance
can help prevent migraines
best for refractory migraine w/ freq. attacks but d/t SE not marketed in US

SE- inflammatory fibrosis rate but serious w/ prolonged use, cardiac valvular damage can be irreversible

30
Q

menstrual migraines

A

NSAIDs prior to beginning of menstruation
triptans 2-3 days prior to menstruation (frovatriptan, naratriptan, zolmitriptan)

31
Q

2 complementary alternatives for migraine prevention

A

petasites (butterbur) effective but= liver toxicity & allergic rxn
riboflavin (vit B2)

32
Q

prevention of tension HA (TTH)

A

prevention of chronic TTH same as migraines
***TCAs mainstay of chronic therapy
muscle relaxants like methocarbamol often provided for prevention

33
Q

cluster HA prevention
SE, caution, interactions

A

1 **calcium channel blocker verapamil 240mg-360mg/day within attack period & 120-240mg/day in remission

Admin @ HS bc that’s when they occur

1-6 weeks to see benefit
SE- smooth muscle relaxation = GERD & constipation
caution w/ myocardial disease bc inotropic/chronotropic cardiac suppressant
metabolized through CYP450, AVOID with eletriptan

contraindicated if on thiazide diuretics, NSAID, ACEi, ARBs
SE: tremor, GI, lethargy

Both can be lowered if use w/ ERGOTAMINE

34
Q

HA in pregnancy

A

APAP
opioids
corticosteroids
triptans relatively contraindicated
*ergot compounds strictly avoided= contractions & placental ischemia = hypoxemia of fetus
antihypertensives to be used cautiously

Pharmacology (12 decks)

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