Migraine

Question 1

What are the delivery options for sumatriptan

Answer 1

Injectable, nasal spray, oral tablet

Question 2

Which form of the migraine is treated with administration of ergot alkaloids

Answer 2

Severe or refractory migraines

Question 3

What is the theory behind the cause of a migraine

Answer 3

1) Electrical activity causes hydrogen/potassium through the nerve cells
2) Release of neuropeptides and inflammatory mediators
3) Dilation of cranial blood vessel sensitizes nerves to pain
4) Sensitization spreads to the brain

Question 4

What are the anticonvulsives that can be given to prevent a migraine attacks

Answer 4

• Topirimate

- Valproate

Question 5

Which chronic conditions are contraindicated for triptan use

Answer 5

• Vasospastic heart conditions
• Uncontrolled hypertension

*Because Triptans cause vasoconstriction of coronary and renal vessels

Question 6

What are the pros and cons of taking oral forms of Triptans

Answer 6

Pro: easy to take
Con: ineffective if vomiting

Question 7

What are the delivery options for zolmitriptan

Answer 7

-Oral disintegrating tablets, nasal spray, and tables

Question 8

How effective are propranolol or timolol for the prevention of migraines

Answer 8

60-80% effective

Question 9

What is the mechanism of action for Triptans

Answer 9

Selective 5HT-1B/1D agonist

Question 10

What is the mechanism of action for dihydroergotamine poisoning

Answer 10

Non-selectively binds to serotonin receptors, and at high amounts, binds to adrenergic and dopamine receptors.

*Especially alpha 1 receptors on smooth muscle causing vasoconstriction

Question 11

What is the result of neurokinin A release

Answer 11

Increased Dural vessel permeability

Question 12

What is the pathophysiology of migraines

Answer 12

Neural event that results in dilation of blood vessels that result in pain and nerve aggregation

Question 13

What is the mechanism of actio for dihydroergotamine (DHE)

Answer 13

Binds to serotonin receptors non-selectively

Question 14

What are the clinical presentations of patients overdosing on ergot alkaloids

Answer 14

• Cerebral and coronary ischemia
• Headaches, nausea, vomiting
• angina
• gangrene
• MI

Question 15

Which treatments for migraines are contraindicated for pregnant mothers

Answer 15

• Ergot alkaloids (DHE)
• Triptans
• Valproic acid

Question 16

Which triptan should be administered for long duration of migraine pain relief

Answer 16

Frovatriptan

Question 17

Where is substance P and neurokinin A released from

Answer 17

Trigeminal C fibers

Question 18

Serotonin binds to which receptor on vasculature and what is the result

Answer 18

Binds to 5HT-1B and causes vasoconstriction

Question 19

Where is calcitonin gene released peptide (CGRP) released from

Answer 19

Trigeminal alpha delta fibers

Question 20

Which triptan drugs specifically are contraindicated with use of MAO inhibitors

Answer 20

• Sumatriptan
• Rizatriptan
• Zolmitriptan

Question 21

Serotonin binds to which receptor in synapses and what is the response.

Answer 21

Binds to 5HT-1D and causes reduction in pain

Question 22

What are the pros and cons of the nasal spray form of Triptans

Answer 22

Pros: effective if vomiting or nausea
Cons: Few formulated as nasal spray

Question 23

What is the frequency of administration for preventative agents of migraines

Answer 23

Daily

Question 24

What are the side effects of beta blockers for migraines and where is it contraindicated

Answer 24

• Fatigue, CNS depression, and bronchoconstriction

* Contraindicated in asthma patients

Question 25

Which treatment for migraines in pregnant females allowed in first and second trimesters only

Answer 25

- Aspirin | - Ibuprofen

Question 26

What is the result of Calcitonin-gene related peptide (CGRP) release

Answer 26

Increases the Dural vessel vasodilation

Question 27

What is the mechanism of action of Triptans with regards to how it affects migranes

Answer 27

- 5HT-1B: vasoconstriction of vessels - 5HT-1D Presynaptic: inhibits CGRP release - 5HT-1D: inhibits passage of signal to the higher brain centers

Question 28

What are the two beta blockers that can be given for prevention of migraine attacks

Answer 28

- Propranolol | - Timolol

Question 29

Which class of drugs will make administering Triptans contraindicated

Answer 29

- MAO inhibitors | - Selective serotonin reuptake inhibators (SSRIs)

Question 30

Central neurons express which subset of serotonin receptors

Answer 30

1B/1D

Question 31

What are the two tricyclics antidepressants that can be given for prevention of migraine attacks

Answer 31

- Amitriptylene | - Imipramine

Question 32

What might be a side affect of using organic nitrates to treat coronary artery disease

Answer 32

Can provoke a migraine via the release of NO, which causes the release of CGRP and subsequent migraine pain

Question 33

What is the result of substance P release

Answer 33

Increased Dural vessel permeability

Question 34

What is the process of Cortical spreading depression (CSD)

Answer 34

1) CSD leads to vasoconstriction 2) Vasoconstriction leads to discharge of hydrogen, potassium, nitric oxide 3) These cause vasodilation and migraine pain

Question 35

Which treatment for migraines is acceptable for pregnancies in all trimesters

Answer 35

Acetaminophen and codeine

Question 36

Which condition are patients on Triptans and SSRIs at risk for

Answer 36

Serotonin Syndrome

Question 37

When is verapamil commonly used

Answer 37

Calcium channel blocker commonly used for migraine prevention, and is usually the first choice

Question 38

Cranial vessels/vasculature express which subset of serotonin receptors

Answer 38

1B

Question 39

What is the prototype triptan

Answer 39

Sumatriptan

Question 40

Peripheral nerves express which subset of serotonin receptors

Answer 40

1D

Question 41

What calcium channel blocker can be given for prevention of migraine attacks

Answer 41

Verapamil

Question 42

What is the relationship between CGRP and nitric oxide

Answer 42

They interact together, sometimes causing a postive feedback loop on the release of each other

Question 43

What is the criteria to receive preventative therapy for migraines

Answer 43

- More than 2 per month with disability - disability lasting more than 3 days a month - Rescue medication used more than 2 times per week

Question 44

When is valproate used and when is it contraindicated

Answer 44

Used in those who fail to respond to triptan but contraindicated in pregnant women

Question 45

What is a popular combination for migraine treatment that involves Triptans

Answer 45

Triptans and an analgesic, such as acetaminophen, ibuprofen, or naproxen