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Therapeutics Y2 Sem 2 > Migraine > Flashcards

Migraine Flashcards

1
Q

What is thought to be the three patho points of migraines?

A

Sensitized Neurons
Vasodilation
Triggers (That trigger inflammation)

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2
Q

What are triptans?

A

Selective serotonin agonists that cause vasoconstriction

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3
Q

WHat are NSAIDs?

A

Help with the inflammation

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4
Q

What is the role of anti-CGRP medicaitons?

A

Prevent/reduce vasodilation

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5
Q

What is the central role of migraine therapy?

A

Early treatement to nip it in the bud leading to better efficacy

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6
Q

What generally occurs in about 30% of migraine patients?

A

Aura

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7
Q

What are the three types of aura?

A

Visual
Sensory
Speech

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8
Q

What is a visual Aura?

A

Flicker bright lines, blind spots, lightning bolts

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9
Q

What is a sensory disturbance?

A

Tingling numbness pins and needles

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10
Q

What is speech disturbances?

A

Difficulty finding the words

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11
Q

What are some migraine triggers?

A

Stress
Foods
Alcohol
Caffeine withdrawal
Dehydration

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12
Q

What is the POUND acronym>

A
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13
Q

What does the P stand for in Pound?

A

Pulsatile quality of headache

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14
Q

What does the O stand for in pound?

A

One day duration

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15
Q

What does the U stand for in pound?

A

Unilateral headache

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16
Q

What is generally the first step in Acute migraine management?

A

NSAID

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17
Q

What are the NSAIDs we generally go for in acute migraine management?

A

Ibuprofen liquid gels
Naproxen Sodium
Diclofenac Potassium (Not common because it is expensive)

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18
Q

What is an important point to taking NSAIDs for management of migraine?

A

Need to take on an empty stomach

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19
Q

What is the second step for management of a migraine?

A

Generally we lean towards triptans as they have better response in patents as compared to NSAIDs alone

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20
Q

What are the slow acting triptans?

A

Naratriptans, frovatriptan

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21
Q

When should triptans be taken for migraines?

A

WE want to start is at the earliest onset

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22
Q

How many trials of triptans should we try?

A

We should try a triptan for 3 separate migraines and if it doesn’t do the trick we can switch (Generally 3 different triptans thoug)

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23
Q

What are triptans?

A

Potent vasoconstrictors and serotonin agonist

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24
Q

What can be added to triptans to possible help with migraines?

A

Could try acetaminophen. NSAID or metoclopramide

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25
Q

What is metoclopramide?

A

This is a dopamine antagonist which will increase GI motility

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26
Q

What is the fastest acting triptan therapy?

A

Sumatriptan

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27
Q

What are the other effects of metoclopramide other then increased GI motility?

A

Decreased Nausea

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28
Q

Why might someone switch from a faster acting triptan to a slower acting one?

A

Tolerability

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29
Q

What may be combined with Triptans/NSAIDs to helP/

A

Caffeine, metoclopramide, or caffeine

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30
Q

Wat is generally avoided in migraines?

A

Opioids and barbiturates

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31
Q

Who should be ocnsidered for migraine prophylaxis?

A

Anyone who is refractory

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32
Q

What is another alternative that patients may start prior to all the other therapies?

A

DHE nasal spray

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33
Q

Why are tylenol #3 no recommended for migraines?

A

Generally because the caffeine and acetaminophen dose are not high enough to be therapeutic

Too we have unpredictable metabolism of codeine

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34
Q

What are the contraindications of triptans?

A

Cardiovascular Disease

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35
Q

What medications are contraindicated with triptans?

A

24 hours within DHE due to additive coronary vasospasm, DO NOT COMBINE with triptans

MAOIs

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36
Q

What is a side effect of triptans?

A

Nausea

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37
Q

Why cant we use odansetron with triptans?

A

Because they work the opposite where Odnasetron is a serotonin antagonist and tripatns area serotonin agonsit

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38
Q

What are the routes of administration for triptans?

A

Oral, injeciton, nasal, dissolve

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39
Q

What is the fastest onset triptan?

A

Subcut (10), Nasal (10-15)

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40
Q

What are the two Nasal route of administration triptans

A

Suma, zolmi

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41
Q

What are the two long acting onset triptans?

A

Nara, Frova

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42
Q

What is the general onset of oral triptans?

A

30-60 minutes

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43
Q

When is the best efficacy of tripans achieved?

A

2 hours

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44
Q

What is another antiemetic agent that could be used?

A

DOmperidone

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45
Q

What is the issue with Domperidone?

A

Lots of side effects with respect to QT prolongation and Torsades de pointes possibly

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46
Q

What are the side effects of metoclopramide?

A

May cause shaking of hands because it is a dopamine blocker`

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47
Q

What are the max days per month that you can use Triptans?

A

9

48
Q

What are the max days per month that you should use opioids?

A

9

49
Q

What are the max days per month that you should use NSAIDS or acetaminophen?

A

14

50
Q

What may be a fix for menstrual migraine?

A

continuous combined contraceptives therapy, but this may lead to increased risk of stroke/ VTE

51
Q

How else may be choose to treat menstrual migraine?

A

Naproxen, Naratriptan, Frovatripan of estradiaiol gel 1 week prior

52
Q

What are the two CGRP receptor antagonists we should know?

A

Ubrogepants and Atogepant

53
Q

What is Ubrogepant?

A

Used for the TREATMENT of Migraine 50-100mg stat

54
Q

What is the usage of Atogepant?

A

Used for the prevention dose of migraine 10-60mg

55
Q

What is the dosage of ubrogepant?

A

50-100mg

56
Q

What is special about the CGRP receptor antagonists?

A

They are not contraindicated in CV disease, and low risk of medicaiton overuse headache

57
Q

What are the AE of CGRP receptor antagonists?

A

Nausea, somnolence

58
Q

What are the side effects of triptans?

A

Nausea, S-syndrome, chest tightness, poor tase

59
Q

Who should think about getting migraine prophylaxis?

A

Depends on severity
Whether they are disabling
Difficult to treat attacks

60
Q

What migraine prophylaxis numbers should we know?

A

6 migraine days for minor migraines
3 migraine days for severe disabling attack

61
Q

How should we setup an adequate trial of Migraine prophylaxis?

A

Headache Diary
Start migraine prevention nat low dose
Dose increase gradually over 1-2 weeks
Remain at dose for 8-12 weeks
Assess and decide to whether to continue increase the dose or taper

62
Q

What are reasonable goal of therapy with migraine prophylaxis?

A

50% decrease in frequency or severity (Helps us to assess to help patients assess the expectations of migraines)

63
Q

If we do not achieve a 50% reduction of less severe headache what might we do;

A

Increase therapy

64
Q

What is important to educate patients with respect to prophylaxis?

A

Effectiveness takes time and tolerability

65
Q

How do we advise on side effects?

A

OTC saliva subs for example for TCA usage

66
Q

Which drugs have the best efficacy data for migraines?

A

Amitrptyline
Propranolol
Metoprolol
Topiramte

67
Q

Which drugs have the fewest adverse reactions?

A

Candesartan
Magnesium
Riboflavin

68
Q

What co-morbidities may we also tailor treatment for migraines?

A

Smoking, insomnia, chronic pain, hypertension, depression/anxiety

69
Q

What is the target dose of propranolol?

A

80mg BID or 160mg LA daily

70
Q

What is the target dose of metoprolol?

A

100mg BID or 200mg

71
Q

What are the three Beta blocker medications used for migraine proph?

A

Propranolol, metoprolol, timolol

72
Q

What is the working theory for how beta blockers help with migraines?

A

If we have a bit of vasodilation already occurring a bit, when we have inflammation wave go through we wont have as much dilation occurring. Little less room for vasodilation

73
Q

What are the adverse reactions with beta blockers?

A

Decreased heart rate, dizziness, exercise fatique

74
Q

What are the 2 TCAs that we are focused on?

A

Amitriptyline and Nortriptyline

75
Q

What are the theories of TCAs for migraines

A

May decrease serotonin receptors around which may decrease migraines from occuring

May be numbing the pain of the migraine a bit more

76
Q

Which of the TCAs are more likely to cause drowsiness?

A

Amitriptyline because it is a tertiary amine and is more sedating.

77
Q

Which of the TCAs have the smoking cessation indications?

A

Nortriptyline

78
Q

What is the target dose of amitriptyline for migraine prophylaxis?

A

75mg HS

79
Q

What are the two antoconvulsants?

A

Topiramate and divalproex

80
Q

What is the issue with the anticonvulsants?

A

Lots of drowsiness occurs with them

81
Q

What is the target dose of topiramate?

A

50mg BID

82
Q

What are the Ace/ARb medications indicated for migraines?

A

Lisinopril and candesartan

83
Q

What is the target dose of candesartan?

A

16mg

84
Q

What should we counsel with Ace/Arb medications?

A

Orthostatic hypotension, dizziness, cough, renal function, and electrolytes

85
Q

Do ace/arb cause increase or decrease in potassium?

A

increases

86
Q

When on an ace/arb therapy what percentage of patients experience dizzines?

A

1/3

87
Q

What are the SNRIs that are used for prophylaxis?

A

Venlafaxine, duloxetine

88
Q

What are the side effects of SNRIs?

A

Increase agitation, headache prevalence, insomnia, sexual dysfunction

89
Q

What is the issue with SNRIs and stopping them?

A

FINISH

90
Q

What is the FINISH acronym stand for?

A

Flu like symptoms
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyper arousal

91
Q

What can happen if you miss a dose of venlafaxine?

A

You may have more issues with throwing up

92
Q

Which SNRIs may not have as bad as the other

A

Duloxetine

93
Q

What are the non-DHPCCB medications used?

A

Flunarizien, verapamil

94
Q

What are the side effects of verapamil?

A

Constipation and decreased heart rate

95
Q

What is pizotifen?

A

Serotonin antagonist, but may help with prophylaxis by blocking serotonin receptors for the attack to propigate

96
Q

What is the target dosing of magnesium oxide?

A

500mg po daily (elemental)

97
Q

What is the magnesium citrate target dose?

A

300mg PO BID

98
Q

What is the riboflavin target dose?

A

400mg po daily

99
Q

What is the issue with magnesium excess?

A

diarrhea

100
Q

What is the riboflavin DRI?

A

1mg

101
Q

What are the side effects of riboflavin?

A

None really, just peeing alot out of it and turing urine neon yellow

102
Q

What is CGRP?

A

Inflammatory mediator that increases propigation of migraines

103
Q

What is memantine?

A

Alzheimers treatment, isnt that well studied

104
Q

What is a major drug interaction with rizatriptan?

A

Propranolol which increases rizatriptan metabolism

105
Q

Why do we worry about rizatriptan and propranolol?

A

Too much vasoconstriction?

106
Q

What is the downside with giving MAB every 4 months

A

May have resistance issues in the trough levels

107
Q

What is the onset of the prophylaxis options with respect to the biologics?

A

Days

108
Q

What are the adverse effects of the MAB?

A

Hypertension

109
Q

What are the red flags for acute headache requiring emergency

A
110
Q

What are tension headaches?

A

Pressing or tightening pain mild to moderate intensity

111
Q

Take some time to review cluster headaches

A
112
Q

Take some time to review tension type headaches

A
113
Q

What are cluster headaches?

A

Stabbing, nonpulsating pain severe to excruciating

114
Q

What is the onset of frenumizamab?

A

Days to 6 months

115
Q

What is the definition of medication overuse headache?

A

> 15 days per month

116
Q
A

Therapeutics Y2 Sem 2 (17 decks)

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