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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
Triptans ADE
``` Fatigue Dizziness flushing warm sensations somnolence paresthesia medication overuse headache ```
26
Triptan sensations
can go away by switching to another one
27
Triptan place in therapy
mod-seer migraine with no CI | severe migraine which responded poorly to NSAIDs or combo analgesics
28
If triptans ineffective then....
``` inc dose try another one try another formulation combine with other agents try different type of therapy ```
29
Ergot-Alkaloids MOA
Non-selective 5-HT1 receptors agonists, a1/2 receptors, DA2 receptors
30
Dihydroergotamine DDI
CI w/ CYP3A4 strong inhib
31
Ergot-Alkaloids CI
Renal/hepatic failure women preg/nursing (class X) vascular disease
32
Ergot-Alkaloids Side effects
Nausea + Vomiting super common, pretreat w/ antiemetic
33
Ergot-Alkaloids DDI
dont use within 24hrs of triptans
34
Ditans MOA
selective 5-HT1F agonist
35
Lasmiditan DDI
Serotonergic agents | PGP substrates
36
Lasmiditan precaution
impaired driving CNS oppression risk of med overuse headache risk of SS
37
Ditans place of therapy
pts who are CI to or unable to tolerate triptans or failed 2+ therapies mod-severe headache
38
Gepants moa
CGRP receptor antagonists
39
Ubrogepant DDI
CI w/ strong CYP3A4 avoid grapefruit dose
40
Rimegepant DDI
avoid w/in 48hr mod CYP3A4 inhib avoid continent admin w/ strong CYP3A4 inhib or mod CYP3A4 induce think about hepatic/renal disease
41
Ditans and Gepants criteria for initiation
18+ licensed clinician ICHD-3 Dx migraine CI/cant tolerate triptan/2+ failed
42
Lamiditain patient ed
avoid driving or operating heavy machinery 8hrs after
43
Ergotamine patient ed
med can cause sensitivity to cold temp
44
NSAIDs with best efficacy
Excedrin ASA Ibuprofen Naproxen
45
Antiemetics Agents Side effects
QTc prolongation
46
Antiemetics place in therapy
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
Pediatrics w/ migraines
``` Management: APAP Ibuprofen Rizatriptan Zolmitriptan nasal spray ```
48
Pregnancy w/ migraines
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
Purpose of Migraine Prophylaxis therapy
``` prevent headache improve QOL reduce severity, freq, disability associated w/ headache educate and enable pts reduce headache related distress ```
50
How long to see effect of prophylaxis therapy?
about 2-6 months
51
Indication for Migraine Prophylaxis therapy?
``` Frequent attacks Headaches in predictable pattern cause significant disability profound disruption and/or risk of neurologic injury acute meds ineffective, CI, ADE ```
52
FDA approved for migraine prophylaxis
Propranolol timolol Valrproic acid Divalproex sodium Topiramate
53
Valrproic acid, Divalproex sodium CI
Lamtorigine, estrogen contraceptives, warfarin CI in liver disease, hx of pancreatitis, preg
54
Topiramate CI
hx of nephroithiasis renal/hepatic dysfunction oral contraceptives
55
Gepants for Prevention of migraine FDA approved
Rimegepant (Nurtec) | Atogepant (Quilpta)
56
Anti-CGRP antibodies
FDA approved for migraine prevention all 18+, given Q3 months except emagility which is monthly
57
Botox DDI
aminoglcosides or other agents impacting nmt, muscle relaxants
58
When to use Botox?
when other things have failed
59
If co-morbid obestity/fat
Topiramate
60
If com-morbid seizure or bipolar
AED
61
If co-morbid depressed or cant sleep
TCA or SNRI
62
If co-morbid HTN/angina/anxiety or healthy
BB or verapamil
63
If menstrual related migraine
Frovatriptan naratriptan zolmitriptan
64
If HA recurring in predictable pattern
NSAID or triptan at time of vulnerability
65
Menstrual related migraines
-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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