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CDM 2 Exam 2 > Lecture 8 - Migraine 2 > Flashcards

Lecture 8 - Migraine 2 Flashcards

1
Q

Nerivio indiication

A

migraines in 12yrs or older

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2
Q

Relivion MG Indication

A

migraines in > 18yrs old

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3
Q

Spring TMS Indication

A

prevent & treatment > 12yrs old

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4
Q

Gammacore

A

prevention and treatment migraines > 12yrs old

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5
Q

Cefaly

A

prevention & treatment in pts over 18yrs old

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6
Q

Who should use migraine devices?

A

cant take other meds

prescribed by headache specialist

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7
Q

Acute migraine goals of therapy

A 
Restore ability to function
treat attacks rapidly and consistently 
minimize the use of backup/rescue meds
optimize self-care
utilize cost-effective management
cause minimal to no side effects
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8
Q

pts not candidates for self care

A 
recent trauma
new onset > 50
under age 18
history of liver disease or alcohol abuse
associated with fever
complains of confusion,dizziness,etc
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9
Q

Migraine step up approach

A

use of NSAIDs and combo products 1st, then move up to other therapies

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10
Q

Migraine stratified care

A

Initial migraine treatment used on symptoms severe and headache related disability

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11
Q

What did DISC study show

A

stratified care wasn’t better

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12
Q

Triptans MOA

A
  1. vasocronstriction via activation or 5-HT1B (postsynap) receptors on smooth-muscle of blood cells
  2. presynap 5-HT1D receptors activity leading to blockade of release of vasoactive peptides from trigeminal neurons. also leads to blockade of NT and activation of 2nd order neurons = facilitate descending pain inhibitory systems
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13
Q

Sumatriptan DDI

A

avoid in use w/in 2 weeks of MOAI

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14
Q

Sumatriptan Clinical considerations

A

not recommended with severe hepatic impairment

SQ has fastest onset and has some of best efficacy data

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15
Q

Zolmitriptan DDI

A

Avoid in use w/in 2 weeks of MAOI

max single dose = 2.5, max daily = 5mg when used with cimetidine

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16
Q

Zolmitriptan clinical considerations

A

no renal adjustment
CYP1A2

avoid ODT/nasal spray in mod/sev hepatic impairment

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17
Q

Almotriptan DDI

A

Redce dose to 6.25mg when w/ CYP3A4 inhib

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18
Q

Eletriptan DDI

A

should not use w/in 3 days of potent CYP3A4 inhib

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19
Q

Eletripatn Clinical considerations

A

avoid in sev hepatic impairment

CYP3A4

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20
Q

Almotriptan Clinical considerations

A

contains sulfa group, CI in sulfa allergy

dose adjust renal/hepatic impairment

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21
Q

Rizatriptan DDI

A

5mg/dose, max of 3/day w/ propranolol

dont use w/in 3 weeks of MAOI

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22
Q

Frovatriptn Clinical considerations

A

less effective than other triptans

slower onset/longer duration

CYP1A2

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23
Q

Naratriptan clinical considerations

A

Renal/hepatic impairment

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24
Q

Triptans CI

A

CAD - angina, vasospastic angina, uncontrolled HTN,etc
hepatic disease
if have risk factors for CAD

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25
Q

Triptans ADE

A 
Fatigue
Dizziness
flushing
warm sensations
somnolence
paresthesia
medication overuse headache
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26
Q

Triptan sensations

A

can go away by switching to another one

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27
Q

Triptan place in therapy

A

mod-seer migraine with no CI

severe migraine which responded poorly to NSAIDs or combo analgesics

28
Q

If triptans ineffective then….

A 
inc dose
try another one
try another formulation
combine with other agents
try different type of therapy
29
Q

Ergot-Alkaloids MOA

A

Non-selective 5-HT1 receptors agonists, a1/2 receptors, DA2 receptors

30
Q

Dihydroergotamine DDI

A

CI w/ CYP3A4 strong inhib

31
Q

Ergot-Alkaloids CI

A

Renal/hepatic failure
women preg/nursing (class X)
vascular disease

32
Q

Ergot-Alkaloids Side effects

A

Nausea + Vomiting super common, pretreat w/ antiemetic

33
Q

Ergot-Alkaloids DDI

A

dont use within 24hrs of triptans

34
Q

Ditans MOA

A

selective 5-HT1F agonist

35
Q

Lasmiditan DDI

A

Serotonergic agents

PGP substrates

36
Q

Lasmiditan precaution

A

impaired driving
CNS oppression
risk of med overuse headache
risk of SS

37
Q

Ditans place of therapy

A

pts who are CI to or unable to tolerate triptans or failed 2+ therapies

mod-severe headache

38
Q

Gepants moa

A

CGRP receptor antagonists

39
Q

Ubrogepant DDI

A

CI w/ strong CYP3A4

avoid grapefruit dose

40
Q

Rimegepant DDI

A

avoid w/in 48hr mod CYP3A4 inhib
avoid continent admin w/ strong CYP3A4 inhib or mod CYP3A4 induce

think about hepatic/renal disease

41
Q

Ditans and Gepants criteria for initiation

A

18+
licensed clinician
ICHD-3 Dx migraine

CI/cant tolerate triptan/2+ failed

42
Q

Lamiditain patient ed

A

avoid driving or operating heavy machinery 8hrs after

43
Q

Ergotamine patient ed

A

med can cause sensitivity to cold temp

44
Q

NSAIDs with best efficacy

A

Excedrin
ASA
Ibuprofen
Naproxen

45
Q

Antiemetics Agents Side effects

A

QTc prolongation

46
Q

Antiemetics place in therapy

A

adjunct in tx of N/V
pre tx to prevent induced N/V

metoclopramide can improve absorption of oral meds

Prochlorperazine/metoclopramide can be used as monotherapy in intractable headaches

47
Q

Pediatrics w/ migraines

A 
Management:
APAP
Ibuprofen 
Rizatriptan
Zolmitriptan nasal spray
48
Q

Pregnancy w/ migraines

A
  1. inc risk of pre-eclampsia and gestational HTN
Management:
APAP
NSAIDs in 1/2 trimester, avoid 3rd
Metoclopramide IV
AVOID triptans + ergo alkaloids
49
Q

Purpose of Migraine Prophylaxis therapy

A 
prevent headache
improve QOL
reduce severity, freq, disability associated w/ headache
educate and enable pts
reduce headache related distress
50
Q

How long to see effect of prophylaxis therapy?

A

about 2-6 months

51
Q

Indication for Migraine Prophylaxis therapy?

A 
Frequent attacks
Headaches in predictable pattern
cause significant disability 
profound disruption and/or risk of neurologic injury
acute meds ineffective, CI, ADE
52
Q

FDA approved for migraine prophylaxis

A

Propranolol
timolol

Valrproic acid
Divalproex sodium
Topiramate

53
Q

Valrproic acid, Divalproex sodium CI

A

Lamtorigine, estrogen contraceptives, warfarin

CI in liver disease, hx of pancreatitis, preg

54
Q

Topiramate CI

A

hx of nephroithiasis
renal/hepatic dysfunction
oral contraceptives

55
Q

Gepants for Prevention of migraine FDA approved

A

Rimegepant (Nurtec)

Atogepant (Quilpta)

56
Q

Anti-CGRP antibodies

A

FDA approved for migraine prevention

all 18+, given Q3 months except emagility which is monthly

57
Q

Botox DDI

A

aminoglcosides or other agents impacting nmt, muscle relaxants

58
Q

When to use Botox?

A

when other things have failed

59
Q

If co-morbid obestity/fat

A

Topiramate

60
Q

If com-morbid seizure or bipolar

A

AED

61
Q

If co-morbid depressed or cant sleep

A

TCA or SNRI

62
Q

If co-morbid HTN/angina/anxiety or healthy

A

BB or verapamil

63
Q

If menstrual related migraine

A

Frovatriptan
naratriptan
zolmitriptan

64
Q

If HA recurring in predictable pattern

A

NSAID or triptan at time of vulnerability

65
Q

Menstrual related migraines

A

-2 to +3 days of menstruation, at least 2 of 3 cycles

start 6 days before menstruation and continue for 5-7das after

CDM 2 Exam 2 (16 decks)

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