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3153 CNS - nat > ic4 + ic5 (tth, migraine) > Flashcards

ic4 + ic5 (tth, migraine) Flashcards

1
Q

Clinical presentation of TTH

A

No prodromal symptoms, aura
Bilateral
Nonpulsatile tightness
mild-moderate

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2
Q

What are the classifications of TTH?

What is the criteria?

A

Episodic infrequent: < 1 episode / month
Episodic frequent: 1-14 days / month
Chronic: ≥15 days / month

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3
Q

Triggers of TTH (7 points)

A

Stress
Holding head in one position for a long time
Alcohol
Caffeine
Cold / flu, sinus infections
Dehydration
Hunger

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4
Q

non pharm for TTH (5 points)

A

Patient education
Identify triggers via headache diary
CBT
Physical therapy
Lifestyle modification (improve sleep)

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5
Q

Pharmacological acute treatment for TTH (3 points)

A

Paracetamol (with caffeine)
Aspirin
NSAIDs (Ibuprofen, Diclofenac, Naproxen, Ketoprofen)

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6
Q

prophylactic treatment for TTH (3 points)

A

Amitriptyline (1st line, Tricyclic Antidepressants)
Mirtazapine
Venlafaxine

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7
Q

Requirements for medication overuse headache (3 points)

A

1) Headaches for ≥ 15 days / month, with pre-existing headache disorder

2) Regular overuse of medications for > 3 months eg.
Ergotamine, triptans, opioids at least 10 days / month
Paracetamol, NSAIDs at least 15 days / month

3) Headache cannot be diagnosed as something else

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8
Q

What are the phases of a migraine attack

A

Prodrome
Aura
Headache
Postdrome

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9
Q

Symptoms of prodrome phase

A

Fatigue
Cognitive difficulties
Mood changes
Food cravings
Neck pain
Yawning

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10
Q

symptoms of aura (2 points)

A

Visual aura
Speech, sensory disturbances

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11
Q

headache phase symptoms (3 points)

A

Nausea with or without vomiting
Photophobia
Phonophobia

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12
Q

postdrome symptoms (3 points)

A

Feeling weary
Difficulty concentrating
Neck stiffness

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13
Q

Classification of migraine

A

episodic VS chronic migraine

episodic: at leat 5 attacks a lifetime

Chronic: At least 15 Monthly Headache Day (MHD), out of which is 8 migraine days for 3 months

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14
Q

What is considered migraine without aura?

A

1) Headaches lasting up to 3 days when untreated / unsuccessfully treated

2) At least 2
- Unilateral location
- Pulsating
- Moderate - Severe intensity
- Aggravated or avoidance of routine physical activity

3) At least 1
- Nausea, vomiting
- Photophobia, phonophobia

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15
Q

What is considered migraine with aura?

A

1) Fully reversible aura symptoms
- Visual
- Sensory
- Speech, language
motor

2) At least 3
- Aura spreads over 5 mins
- 2 or more aura symptoms occur in succession
- Aura lasts 1hr
- Aura is unilateral
- Aura is positive
- Aura is accompanied by headache

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16
Q

what is the MOA of Migraines,

how do medications act on the pathway to relief headaches?

A

1) Vasodilation of intracranial, extracerebral (inside skull, outside brain) blood vessels
Cause 2) activation of trigeminal nerves to release vasoactive neuropeptides eg. CGRP to promote neurogenic inflammation

Cafergot and Sumatriptan acts on (1) vasodilation
Erenumab acts on (2) CGRP receptor

17
Q

What is the MOA of NSAIDs?

A

COX 2 inhibition inhibits prostaglandin synthesis
PGI2 causes neurogenically mediated inflammation in the trigeminovascular system

18
Q

MOA of Sumatriptan (3 points)

A

Selective vascular serotonin (1B and 1D) receptor agonist
1) Vasoconstriction of Intracranial Extracerebral BV
Does not affect cerebral blood flow (as it affects extracerebral (outside brain) blood vessels)

2) Inhibition of vasoactive peptide release by trigeminal neurons

3) Inhibit nociception neurotransmission within trigeminocervical complex

19
Q

If Sumatriptan does not work, what to do?

If there is a recurrence of migraine…

A

Can try another triptan (even though same class)

If have recurrence of migraine within 48hrs, take another dose of triptan

20
Q

DDI with sumatriptan

A

Concomitant MAO inhibitors
Take 2 weeks after MAOi

Concomitant Ergotamine / Ergot-type meds
Take 24hrs apart

21
Q

Adverse effect associated with Sumatriptan

Side effects (3 points)

A

Serotonin syndrome (transient BP increase, flushing)

Dysgeusia (unpleasant taste)
LFT disturbances
Sensation of pressure on chest

22
Q

MOA of cafergot

A

Ergotamine:
- Constrict vascular smooth muscles in intracranial extracerebral BV
- Lead to prolonged vasoconstriction by stimulating alpha adrenergic and serotonin receptors (1B and 1D receptors)

Caffeine:
- Adenosine A1, A2A, A2B receptor antagonist → vasoconstrict cerebral vasculature
- Enhance GI absorption of ergotamine by increasing solubility of ergotamine and decrease gastric PH

23
Q

PK differences between cafergot and sumatriptan

A

Plasma protein binding:
High -> Cafergot
Low -> Sumatriptan

Sumatriptan available nasal and IV, while Cafergot available oral and rectal

24
Q

DDI with Cafergot (2 points)

A

Vasconstrictor agents eg. ergots, sumatriptan

CYP3A4i eg. ritonavir, macrolides
Increases risk for vasospasm, leading to cerebral ischaemia

25
Q

Codeine and Tramadol place in therapy for migraines

A

should not be routinely used in migraine

26
Q

When should gepants and ditans be used?

A

1) Contraindicated or cannot tolerate triptans
2) Inadequate response to 2 triptans

27
Q

When should migraine prophylaxis be offered?

A

AHS: if migraine days at least 3 and degree of disability is severe

EHF: migraine impairs QOL and
disability on 2 days per month with optimised therapy OR risk of acute medication overuse

28
Q

Principles of preventative treatment (5 points)

A

Start low dose, titrate slowly

Can combine different drug classes if partial response or have adverse effects

Set a max target dose eg. Topiramate 100mg

Minimum 8 weeks of oral treatment before lack of efficacy can be determined

Set realistic expectations eg.
- 50% reduction in frequency of headache, migraine days
- Significant decrease in attack duration, severity
- Reduction in migraine disability and improvements in lifestyle

29
Q

First line for migraine prophylaxis

A

4 types
Candesartan
Fovatriptan
Beta-blockers MPT (Meto, Propra, Timo)
Anti-epileptics (Topiramate, Sodium valproate)

30
Q

Which agent is first line for TTH prophylaxis but 2nd line for migraine prophylaxis

A

Amitriptyline

31
Q

Where is CGRP released?

Where are CGRP receptors (4 points)

A

CGRP released from trigeminal neurons

CGRP receptors found in 2nd order neuron in cortex, SM cells in cerebral artery, on mast cells, SM cells in meningeal BV

32
Q

Role of CGRP

A

1) Pain transmission (via 2nd order neuron in cortex)

2) Blood flow in cerebral blood vessels

3) Neurogenic inflammation (through release of inflammatory regulators by mast cells + dilate meningeal BV)

33
Q

What is the MOA of gepants?

A

CGRP receptor antagonist, bind to CGRP receptor and prevent signalling

34
Q

non pharm of migraine

A

Identify triggers, migraine diary
adopt healthier lifestyle eg. eating habits, sleep early, regular exercise

3153 CNS - nat (11 decks)

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