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Pharm Test 2 > Migraine > Flashcards

Migraine Flashcards

1
Q

Migraine

Rx list

A
  • Propranolol
  • Valproate
  • Topiramate
  • Onabotulinum toxin
  • Ergotamine + Dihydroergotamine
  • Sumatriptan
  • Metaclopromide
  • Caffeine
  • NSAIDs
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2
Q

Migraine

Mech

A

*vascular headache = vasodilation

2 versions :

  • classic = aura
  • common = w/o aura
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3
Q

Classic migraine

A
  • 20%
  • visual/sensory aura
  • aphasia, vertigo, pallor, chills, tremor, unilateral weakness
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4
Q

Migraine

Who?

A
  • women
  • genetic
  • start in adolescence
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5
Q

Migraine

s/s

A

*Onset w/ waking
*4 hour - 3 days
*from trigger
*n/v
*photophobia
*scalp tenderness
*lightheadedness
*vertigo
MORE THAN PAIN

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6
Q

Migraine triggers

A
  • mental
  • endogenous
  • exogenous - food, ETOH, allergens, MSG, etc.
  • other - lights, smells, temp, altitude
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7
Q

Dx

A

Repeated headache attacks, lasting 4 hours - 3 days

2 of these:

  • unilateral pain
  • throbbing pain
  • aggravation w/ movement
  • moderate/severe intensity

+1 of these:
N/V
Photophobia/phonophobia

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8
Q

CGRP calcitonin g related peptide

A

From trigeminal ganglian neuron

*Sterile inflammation / sensitization of blood vessels AND affect brain

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9
Q

Serotonin

role in migraine

A
  • 5HT + metabolites change (increase) during migraine
  • triggers pain afferents
  • 5HT constricts cerebral vessels
  • Migraine - other serotonin behaviors = sleep, appetite,depression
  • DON’T REALLY KNOW
  • best Rxs address serotonin
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10
Q

Serotonin

Periphery - hemostasis

A

*hemostasis. = platelet aggregation, vasoconstriction (spasm = too much)

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11
Q

Serotonin
Periphery

GI

A
  • Motility
  • Malignant carcinoid tumors secrete
  • emesis, nausea
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12
Q

Prophylactic Tx

A
  • frequent occurence (>3-5/month)
  • mild-moderate therapy
  • classic>
  • over 1/2 success rate
  • > 6 weeks tx to work
  • may need tolerance break after 6 months
  • UP CSD threshold (supress)
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13
Q

Prophylactic Tx

Rx 1st line

A

1st line =
*B-blocker
Propranolol
Timolol

*Anticonvulsants
Valproate
Topiramate

+others REVIEW SLIDE

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14
Q

Beta blockers

Migraine prophylaxis

A

*mech unknown
*many S.E
Fatigue, GI disturbance
Depression, insomnia,nightmare
*NO IN ASTHMA, DEPRESSION, HF
*NO w/ CCB
*withdrawal = CV distress

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15
Q

Anticonvulsants

Topiramate

A
  • block sodium + calcium channel
  • block glutamate receptors
  • UP gaba
  • stop TNC
  • SE - paresthesia, fatigue, cognitive impairment, weight loss
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16
Q

Onabotulinum Toxin (BoTox)

A
  • Chronic 15< per month
  • Every 12 weeks
  • Cleaves snares in release of CGRP
    1) lowers peripheral sensitization
    2) lowers central sensitization
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17
Q

Onabotulinum toxin

SE

A
  • Neck pain
  • Muscular weakness (Ach)
  • eyelid/eyebrow ptosis (improper technique)
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18
Q

Acute Tx

Mild ot moderate

A
  • Naproxen
  • Caffeine
  • vasoconstriction
  • aids in absorption of analgesics
  • adjuvant
  • Metoclopramide REGLAN
  • 5ht3 + D2 receptors
  • anti-emetic, up gastric emptying
  • adjuvant
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19
Q

Severe Migraine Tx

Rx

A

Ergots

Triptans

20
Q

Ergots

Mech

A
  • oldest
  • Dx and Treatment
  • Vasoconstrictor CNS
  • non- selective 5ht ags
21
Q

Ergots

Routes

A
  • Dihydroergotamine (DHE) - parenteral/nasal
  • eratic w/ oral response
  • PR - nausea

*combos = caffeine, sedatives

22
Q

Ergot

Therapy

A
  • Must take Early - not rescue drugs
  • S.E. w/ ergotamine may be limiting
  • dependence
23
Q

Ergots

S.E.

A

Dihydroergotamine = parenteral admin faster
Less S.E.

Drug interactions = triptans, b blocker, nicotines

24
Q

Triptans

A

Sumatriptan IMITREX

25
Q

Triptans

A

1st line

  • selective 5HT1 ags (b/d/f)
  • multiple routes
  • rapid
  • good response
26
Q

Triptans

S.E.

A
  • Minimal effects - receptor selectivity
  • Re-emergent migraine
  • Coronary disease (watch) - vasoconstriction
27
Q

Triptans

Rx interaction

A

MAOIs (break down??)

28
Q

Triptans

“Stratified care”

A
  • mix = oral/nasal/injectable as needed
  • injectible (5 mins)- rescue
  • nasal (15mins) - fast
  • NSAID (naproxen)= adjuvant
29
Q

New migraine therapies

A

*-Ditans = 5-H1F receptor ag, only TG path,no vessels, good with CV dz

  • CGRP antags (gepants)
  • CGRP antibodies
30
Q

Triptans

A
  • onset

* duration

31
Q

Sumatriptan

Mech

A
  • serotonin derivative

* Selective ags = 5HT 1b/1d

32
Q

Other mild/moderate migraine Tx

A
  • opiods
  • phenothiazines (don’t use - S.E.)
  • Combos - vasoconstrict + analgesic + sedative. (Acetaminophen+Aspirin+caffeine)
33
Q

CSD = cortical spreading depression

A
  • Spread from back to front
  • Decrease (depole) in Blood flow, Then Increase (hyperpole) in blood flow
  • aura
  • dilation = pain
34
Q

TG system activatoin

A

Input from meningial vessels
Trigem afferents –> Trigem ganglion –> trigem nucleus caudalis –> thalamus –> cortex

Input from Locus ceruleus + Periaqueductal gray + raphe nucleus (serotonin) =. (bstem)

=CSD activates this

35
Q

CSD =

TG system =

A

CSD = aura

TG system = pain

36
Q

Serotonin targets for Migraine

A

5HT1 = B/D/F

37
Q

Migraine Prophylaxis

Anti-convulsants

Valproate

A
  • up GABA-mediated transmission (down inflammation)

* S.E. = N/V, weight, NO PREGGER

38
Q

Migraine prophylaxis

Anti-convulsants

Topiramate

A
  • Block Na+/Ca2+ channel
  • Down Glutamate, UP Gaba, STOP TNC

*S.E. = topiramate = paresthesias

39
Q

Migraine prophylaxis

Anti depressants

A

TCAs

  • amitriptyline
  • nortriptyline
40
Q

Migraine prophylaxis

CCB

A

Verapamil
*block 5-HT

*S.E. - hypoTN

41
Q

Migraine prophylaxis

NSAIDs

A

Naproxen

*frequent use - withdrawal, s/s worse

42
Q

Triptans vs. ergots

Later in migraine

A

Triptans effective!

43
Q

Which give rebound headache

A

Triptans

Don’t take too close together

44
Q

Migraine = main tx ideas

Directly constrict blood vessels

Rx

A

Caffeine

Triptans

45
Q

Migraine = main tx ideas

Inhibit vasodilation

A

Shut off inflammatory mediators = CGRP

Inhibit leakage with vasodilation

46
Q

Migraine = main tx ideas

Work centrally

A

TNC

Pharm Test 2 (13 decks)

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