lecture 50 Flashcards
ott - pharmacotherapy of migraine
what are the two types of migraines?
migraines without aura (common)
migraine with aura (classic)
what are the phases of migraine HA?
prodrome
aura
migraine HA
postdromal
what is the prodrome phase?
hours or days before onset of HA where pt may experience different mood/health changes
what is the aura phase?
only 15-20% of pts get this
commonly visual (may be sensory, verbal, or motor tho)
photopsia, scotoma, or zigzag lines can occur
last under 60 minutes
what is the migraine HA phase?
dull ache that intensifies
unilateral and throbbing
what is the postdromal phase?
similar to prodrome where its several days after HA has ended, pt is experiencing mood/health changes
what are migraine triggers?
medication overuse HA
medications
diet
additives/perservatives
environment
too little or too much sleep, skipping meals, stress, hormone changes
what are the medications that can cause medication overuse headaches?
analgesic, ergots, triptans if used more than 2 times per HA or 2 times per week chronically
AVOID butabital/opioids due to withdrawal potential
what are medications that are migraine triggers?
oral contraceptives
hydralazine
nitroglycerin
nifedipine
cocaine
what are three options for general treatment?
acute migraine treatment
migraine prevention
avoid analgesics overuse
what are the tx goals for acute migraine control (abortive)?
rapid pain management
improve level of disability
minimal need for repeat dose or rescue medications
minimal or no AE from tx
what are the tx goals for migraine prevention?
reduce frequency, severity, duration, and disability
avoid escalation in use of acute treatment
improve QOL
what are the tx goals when avoiding analgesic overuse?
evaluate for drug interactions
limit use of abortive treatment to a maximum of 2-3 days per week
in abortive treatment, what is the best drug treatment based on type?
mild-moderate: NSAIDs, acetaminophen
moderate-severe: triptans, ergots (less so)
what is trying to be avoided in preventive treatment?
four or more attacks/month with disability at least 3 days/month
use of abortive meds more than 2 per week
how often should preventive meds be adjusted?
needs to adequate trial of at least 8 weeks for partial response
what NSAIDs are used in abortive treatment?
first line –> aspirin, diclofenac, ibuprofen, naproxen
second line –> ketoprofen, IV and IM ketorolac, flurbiprofen
what is first line preventative treatment?
monotherapy of valproate, topiramate, metoprolol, propranolol, frovatriptan
what is the only triptan approved for long term use?
frovatriptan
what are the second and third line preventative treatment?
second line –> monotherapy - amitriptyline
third line -> monotherapy - CGRP receptor antagonists
what are the non-pharmacological tx?
biofeedback and relaxation therapy
cognitive behavior therapy
diet
sleep
transcutaneous electrical nerve stimulation (TENS) device
exercise, massage, acupuncture, thermal biofeedback, heat/cold applications
HA diary!!!!
what is the drug class of triptans?
selective 5-HT1b and 5-HT1d receptor agonists
what are the CI of triptans?
recent use (within 24h) of an ergot or other triptan (due to increased vasoconstriction)
MAO-a inhibitor use in the last 2 weeks (frovatriptan, rizatriptan)
ischemic HD
angina
hx of stroke, TIA, or hemiplegic/basilar migraine
arrhythmias
peripheral vascular disease
uncontrolled HTN
ischemic bowel disease
severe hepatic impairment
what are the warning/precautions of triptans?
MI
pain, pressure, or tightness in the chest, throat, neck, or jaw
CVA
HTN
GI ischemic reactions or peripheral vasospasm
medication overuse HA
serotonin syndrome
sulfa allergy (almotriptan only)
corneal opacities (almotriptan only)
seizures (use with caution)
what are the SE of oral triptans?
tingling
dizziness
drowsiness
fatigue
chest tightness/pressure
flushing
what are important drug-drug interactions of triptans?
MAO inhibitors
propranolol
SSRIs/SNRIs (more theoretically due to SS)
3A4 inhibitors when using eletriptan
what are the CI of ergot alkaloids?
risk for coronary HD
avoid administration with strong 3A4 inhibitors
uncontrolled HTN
hepatic/renal impairment
peripheral vascular disease
what are the BBW of ergot alkaloids?
serious/life threatening peripheral ischemia
what are the warning/precautions of ergot alkaloids?
cardiac valvular fibrosis
vasospasm or vasoconstriction
cerebrovascular events
ergotism
what is ergotism?
overdose of ergot-containing medications
associate with cramps, spasms, dry gangrene from vasoconstriction
what are the SE of ergot alkaloids?
retroperitoneal, pleuropulmonary, and valvular fibrosis
ergotism
vasoconstrictive complications (ischemia, cyanosis, cold in extremities, gangrene, numbness, weakness, NV)
what are the drug-drug interactions of ergot alkaloids?
3A4 inhibitors lead to ergot toxicity
what drugs are calcitonin gene-related peptide (CGRP) receptor antagonists?
rimegepant, ubrogepant, zavegepant –> FDA-approved for abortive tx
atogepant, rimegepant –> for preventive tx
what are the drug-drug interactions of CGRP receptor antagonists?
CI with strong 3A4 inhibitors
interacts with other 3A4 inducers and inhibitors as well as p-glycoprotein inhibitors
what are the SE of CGRP receptor antagonists?
rimegepant - N, rash, dyspnea
atogepant - N, constipation, fatigue
what are the warning/precautions of lasmiditan?
medication overuse HA
sedation
dizziness
SS
driving impairment (avoid for at least 8h after dose)
what are the SE of lasmiditan?
dizziness, fatigue, paresthesia, sedation
what are the drug-drug interactions of lasmiditan?
caution with other CNS depressants and serotonergic medications
avoid with p-gp or BCRP substrates, other medication that can decrease HS
what are the monitoring parameters of lasmiditan?
LFTs
BP
HR (esp in pts with CVD)
what is butorphanol?
nasal spray used a rescue medication in abortive therapy
not used as much due to being a controlled substance
how are BB used in migraine therapy?
for preventative therapy
propranolol (80-240mg/day) or metoprolol (100-200mg/day) are only FDA-approvals
CI in asthma and raynaud’s syndrome
how are tricyclic antidepressants used in migraine therapy?
for preventive therapy
not FDA-approved but can use amitriptyline (25-150mg/day) for mixed migraine/tension-type
what antiseizure drugs are used in preventive migraine tx?
valproate (500-1500mg/day) and topiramate (50-100)
not recommended in people of child-bearing age unless using contraception
what is the role of butterbur/petasites in migraine therapy?
150mg/day can be helpful in preventive therapy
how does pregnancy and migraine therapy interact?
CI – dihydroergotamine/ergotamine, valproate
ok if benefit outweighs risk – triptans, botulinum toxin type A and BBs
monitor - topiramate
how does breastfeeding and migraine therapy interact?
certain drug therapies can be excreted in breastmilk so use caution or avoid during this time
what are important counseling notes about topiramate and pregnancy?
may cause fetal harm if used during pregnancy (cleft lip/palate and reduced birth weight)
monitor for development of metabolic acidosis during and after pregnancy
what drugs are approved for children migraine therapy?
over 12 years –> almotriptan, zomlitriptan nasal spray, topiramate, sumatriptan/naproxen combination
over 6 years –> rizatriptan, maybe sumatriptan nasal spray in the future but not yet FDA-approved
