Komiskey- HA drugs

Question 1

First Line for Acute RX of Episodic TH

Answer 1

OTC analgesics (acetaminophen, NSAIDS)
Triptans
Dihydroergotamine spray

Question 2

Second line for Acute RX for Episodic TH

Answer 2

Aspirin+acetaminophen+ caffiene

Question 3

Preventative RX for Chronic TH

Answer 3

Non Pharm: sleep hygiene, stress management, acupuncture, biofeedback, physical therapy
Pharm: TCA (better efficacy), SSRI’s ( better tolerated)

Question 4

Sumatriptan

Answer 4

Acute Migraine RX
5HT1B/1D receptor agonist-constricts large arteries, inhibits trigeminal nerve transmission, inhibit NT release
Poor oral absorption, short duration
Contraindicated in coronary disease

Question 5

Dihydroergotamine

Answer 5

Acute Migrane RX
5HT 1D receptor agonist
alpha adrenoreceptor 
vasoconstricts, blocks trigeminal, inhibit NT release 
poorly absorbed- suppository or inhaled

Question 6

FDA approved drugs for episodic migraine prevention

Answer 6

Propranolol (BB), timolol (BB), topiramate, divalproex sodium
Metaprolol (BB)

Question 7

FDA approved drug for chronic migraine prevention

Answer 7

onabotulinumtoxin A

Question 8

Acute Management of Migraine

Answer 8

Triptans, Dihydroergotamine, Diclofenac Potassium oral solution (strong NSAID, inhibits COX1 ad COX2)

Question 9

Beta Blockers for migraine prevention

Answer 9

Propanolol, timolol, matoprolol
Good choice for pts with HTN, CAD, tremor, or anxiety
SE: fatigue, dizzy, depression, exercise intolaerance, may worsen auro
Avoid: asthma, depression, bradycardia, Raynauds, CHF

Question 10

Divalporex/ sodium valproate

Answer 10

antiepileptic drug for migraine
SE: tremor, drowsy, N/V, easy bruising, weight gain, nystagmus
Dis: poorly tolerated, drug interactions, lab monitoring

Question 11

Topiramate

Answer 11

Antiepileptic drug for migraine
Blocks Na channel firing
Potentiates GABA
Depresses kainate on AMPA 
SE: Cognitive, dry mouth, fatigue, nausea, and mood changes, lab monitoring required, BID dosing

Question 12

Onubotulinumtoxin A

Answer 12

Adults with chronic migraine: 4 hrs per day >15 days per month
MOA: blocks release of substance P and CGRP
inhibits peripheral signals to CNS and blocks central sensitization
SE: muscle weakness, injection site pain, spread of toxin affect

Question 13

Herbal remedies for prevention of migraine

Answer 13

Butterbur, Riboflavin, Magnesium Oxide, Coenzyme Q, Feverfew

Question 14

Short term prevention of migraine associated with menstruation

Answer 14

A: Frovatriptan
B: Naratriptin, Zolmitriptan

Question 15

Frovatriptan

Answer 15

Long acting triptan
Longest half life (26 hrs)
used for the menstruation migrane
less effective than other triptans at 2 hr, same at 4 hrs

Question 16

Triptans

Answer 16

Agonist for 5HT1 B/D receptor-inhibit adenylate cyclase
Inhibit terminal excitability- blocks SP, CGRP release
Direct vasoconstrictive action, inhibit activation of trigeminal
Pre and post migraine treatments
Contraindicated: CHD, peripheral vascular disease, uncontrolled hypertension, and complex migraine, ergots
Pregnancy category C
SE: flush/feel warm, chest pressure, throat tightness, paresthesias, dizzy/fatigue, nausea, intolerable taste with nasal formulations

Question 17

Sumatriptan

Answer 17

Tablets, Nasal, Injection

Short acting

Question 18

Razitriptan

Answer 18

Short acting
Oral- now in generic form
Not used within 2 weeks of MAOI

Question 19

Zolmitriptan

Answer 19

Oral and nasal, short acting

not used within 2 weeks of MAOI

Question 20

Almotriptan

Answer 20

Short acting, less risk of chest pain

metabolized by CYP3A4

Question 21

Eletriptan

Answer 21

Metabolized by CYP3A4
Cannot be used within 3 days of ketoconazole, itraconazole, nefazodone, clarithromycin, ritonavir, nelfinavir
Only triptan superior to sumatriptan

Question 22

Naratriptan

Answer 22

Long acting
Fewer adverse affects
Less effective at 2 hr, same at 4

Question 23

Ergot derivatives

Answer 23

Sublingual or with caffeine

Avoid if pregnant (X), ischemic heart disease

Question 24

NSAIDS

Answer 24

Low risk of causing medication overuse headache
Consider for pts: have other chronic pain conditions, frequently use short acting NSAIDS for acute treatment, are at low risk for developing complications

Question 25

Cluster HA Treatment- first line

Answer 25

100% oxygen

Question 26

Cluster HA abortive treatment

Answer 26

Sumatriptan
Zolmitriptan
Lidocaine: SE: nasal congestion, unpleasant taste
Octreotide- SE: bloating diarrhea
Ergotamine- SE: angina, fibrosis, MI, withdrawal

Question 27

Cluster HA prevention

Answer 27

Verapamil: bradycardia, constipation , edema, hypotension
Steroids: hyperglycemia, hypertension, insomnia
Valproic acid- alopecia, thrombocytopenia
Topiramate
Ergotamine
Melatonin
Capascin

Question 28

Treatment for chronic cluster HA

Answer 28

Verapamil
Lithium: hypothyrodism, nephrogenic diabetes insipidus, polyuria, tremor
Deep Brain Stimulation