Migraine Flashcards
MOA of Triptans
5HT1(serotonin) receptor agonist and cause vasoconstriction of the cranial blood vessels. inhibits neuropeptide release and decreasing pain transmission
non-pharmacologic interventions for migraines
avoiding triggers, non-stress, relaxation, applying a cold compress to the head
common migraine triggers
Hormone changes in women: fluctuations in estrogen, used (POP) Food: alcohol (beer and red wine) aged cheese, chocolate, MSG, salty and processed foods, stress, bright lights, loud noises, scents, change in weather, not enough or too much sleep
Natural products used for migraines
feverfew, willowbark, CoQ10, fish oils, mg2+, riboflavin, butterbur, and guarana
Migraine Prophylaxis
if pt has >1x/month or sever sx, prophylaxis should be tried for 2- 6 mos
Acute trxt of migraines
Triptans and some pts prefer OTC NSAIDS or excedrin migraine or using them together
Naratriptan
Amerge 1 and 2.5mg, can repeat x 1 after 4 hrs
Almotriptan
Axert 6.25 and 12.5mg, can repeat x1 after 2 hrs
Frovatriptan
Frova 2.5mg, can repeat x 1 after 2 hr
Sumatriptan PO KNOW DOSING
Imitrex PO 25, 50, 100mg can repeat x1 after 2 hrs
Sumatripatan injection dose
Needless sumatriptain injection (Sumavel Dosepro-6mg) injection by air pressure.
Imitrex STATdose
Imitrex STATdose SC; 4,6mg can repeat x1 after 1 hr
Nasal spray sumatriptan dose
NS: 5,20mg can repeat after 2 hr
Treximet dosing
Sumatriptan + Ibuprofen (Treximet) 85-500mg
Rizatriptan
Maxalt, Maxalt- MLT: 5, 10mg can repeat x1 after 2 hr
Maxalt MLT disint grating tablets, water needed? Dose?
Maxalt 5mg no water needed
Eletriptan brand and dosing
Relpax 20mg and 40mg, can repeat after 2 hr**
Zolmitriptan
Zomig, Zomig-ZLT, NS PO 2.5 and 5md can repeat after 2hr
zolmitriptan nasal spray, dose ?
NS 5mg can repeat after 2 hr
zolmitriptan disintegrating tablets brand? Water needed?
Zomig-ZMT 2.5 and 5 no water needed
S/E of triptans KNOW
somnolence**, dizziness, nausea, paresthesias (numbness/tingling) throat/neck presssure, hot/cold sensation, chest pain/tightness
What triptans have ODT
sumpatiptan, rizatriptan , zolmitriptan
Triptan sensations
pressure in the chest or heavnees pressure in the neck region that usually dissipate after administration
Contraindications
Cerebrovascular dz and uncontrolled BP
What are the longest acting triptans?
Frovatriptan (Frova) and naratriptan (Amerge): longer acting but slower onset
What are the triptans with the shorter half-lifes?
almotriptan (axert) zolmitriptan, eletriptan (relpax) rizatriptan, sumatriptan
Study of eletriptan vs Sumatriptan
eletriptan (Relpax) 40mg was more effective than Sumatriptan 100mg
What triptans are C.I. with MAO-Is?
Maxalt, zomig, and imitrex. all the rest are not
What triptan is C.I. with 3A4 inhibitors?
Eletriptan (Relpax)
what formulations provide the fastest relief?
SC injection and nasal spray
ODT and PKU
Do not use Maxalt-MLT and Zomig-ZLT in pts with Phenylketonuria due to the sweetner
imitrex injection counseling
includes a carrying case and two prefilled SC syringes. Clean the area of the skin with an alcohol pad in the upper outside arm. Load the STATdose pen by inserting it into the cartridge and turning it clockwise. inject the dose and hold the pen till for 5 seconds
Zomig nasal counseling
Blow your nose gently before using. There is only one dose in the nasal sprayer so do not try to prime or you will lose the dose. Do not press the plunger into you have put the tip into your nostril
less commonly used agents for migraines
Fiorcet CIII- APAP, butalbital, caffiene: must taper off or will get worsening sx of tremors, HA, and risk for delirium and seizures. Fiornal, Vicodin, Butorphanol NS CIV- onset is 15 mins
Ergotamine products, pregnancy category? CI and what? names of brands
Preg Cat X, do not use with strong 3A4 inhibitors due to risk of cerebral ischemia. Ergoloid mesylates (Ergomar, Ergostat) ergotamine/caffeine (Cafergot) DHE Dihydoergotamine (DHE-45, migranal NS)
Ergotamine side effects
N/V, muscle pain, tingling in the periphery, angina-like pain, weakness in legs, tachycardia, bradycardia
What is 1st line therapy for migraine prophylaxis?
propanolol (inderal) timolol (blocadren) amitriptyline (Elavil) divalproex (sodium valproate) and topiramate (Topamax)
What is 2nd line therapy for migraine prophylaxis?
other beta blockers, ACEIs, antidepressants, natural products, birth control for menstrual associated and botulism type A (botox)
Do not use propanolol and timolol in what dz states?
Asthma, COPD, emphysema because they are non-selective b-blockers
What is the result of overuse of medications?
medication overuse (rebound) headaches. limit acute medication trxt to 2 or 3 times weekly
longer duration of action naproxen or ibuprofen??
NAPROXEN 12 hours
triptans are CI
CEREBROVASCULAR dz and uncontrolled HTN!!! b/c hey have found cardiac and cerebrovascular issues w/ the drug
migrain with aura choose what kind of birth control
migrian with aura has a higher risk for clots- so we want a NO ESTROGEN birth control hence mini pills- hence NOR- QB, NOR Be, and camilla
what is the mechanism of action of Tryptans
the are serotonin receptor agonists, that cause vasoconstriction
what can you treat menstrual assocated migraines with?
treat with oral contraceptoves , can use NSAIDs, triptans
when do you start the tx for menstrual migraines?
2 days beforehte mensies and continue fo 5-7 days
when children get migraines , what to recommend?
Rec OTC, usually ibuprofen first. can use triptan in children
what are some non pharm tx for migrains?
avoid triggers
mental relaxation,
apply cold compresses to the head
manage sress
OTC recommendations for migraines?
NSAIDS , or excedrine which is ASA, APAP, caffeinee
when do u start medication therapy for mgraines?
if patient is getting them twice per week or sigficant decrease in the quality of life
what are some common triggers for migraines?
changes in hormones during menstruation food: etoh, cheexe, chocolate, caffeine, stess bright lighs irregular sleep pattern
imitrex
sumatriptan
alsuma
sumatriptan
po dose for sumatriptan for acute attack of migraine
25, 50 or 100mg dose x1 and can repeat dose in 2 hours
SC dose for sumatriptan
5, 20 mg and can repeat x1 in 2 hours if not releive
maxalt
rizatriptan
maxalt dosing
5 or 10mg x 1 and repeat 2 hours later if neessary
relpax
eletriptan
eletriptan dose
20 or 40mg and can repeat in 2 hours
which patients are contraindicated form ahving triptans?
patietns with cerebrovasucalr diseas or uncontrolled hypertension
some are contrindicated with MAOIs
what are the maind side effects of the tirptans?
somonolence , nausea,
tingling or numbness
hotcold sensations
pressure in the chest or neck region but thesese usually dissipate
when to use rizatriptan and zolmitrpatan?
have disintegratin tablets that dissolve and good vor nausea vomitng or if patient cant swallow
signs and symptoms of serotonin syndrome?
restlessness, sweating, poor coordination, confusion and hallucinations
what agent is a good choice for migraine prophylaxis for young women ? which is worst and why?
good: topiramate cuz good side effect profile and causes weight loss. Bad is valproate because can cause Polycistic ovary syndrome by increasing testosterone levels
topiramate dose for migraines?
start 25mg qhs then titrate to 50mg bid
