Migraine Flashcards
What are the delivery options for sumatriptan
Injectable, nasal spray, oral tablet
Which form of the migraine is treated with administration of ergot alkaloids
Severe or refractory migraines
What is the theory behind the cause of a migraine
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
What are the anticonvulsives that can be given to prevent a migraine attacks
- Topirimate
- Valproate
Which chronic conditions are contraindicated for triptan use
- Vasospastic heart conditions
- Uncontrolled hypertension
*Because Triptans cause vasoconstriction of coronary and renal vessels
What are the pros and cons of taking oral forms of Triptans
Pro: easy to take
Con: ineffective if vomiting
What are the delivery options for zolmitriptan
-Oral disintegrating tablets, nasal spray, and tables
How effective are propranolol or timolol for the prevention of migraines
60-80% effective
What is the mechanism of action for Triptans
Selective 5HT-1B/1D agonist
What is the mechanism of action for dihydroergotamine poisoning
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
What is the result of neurokinin A release
Increased Dural vessel permeability
What is the pathophysiology of migraines
Neural event that results in dilation of blood vessels that result in pain and nerve aggregation
What is the mechanism of actio for dihydroergotamine (DHE)
Binds to serotonin receptors non-selectively
What are the clinical presentations of patients overdosing on ergot alkaloids
- Cerebral and coronary ischemia
- Headaches, nausea, vomiting
- angina
- gangrene
- MI
Which treatments for migraines are contraindicated for pregnant mothers
- Ergot alkaloids (DHE)
- Triptans
- Valproic acid
Which triptan should be administered for long duration of migraine pain relief
Frovatriptan
Where is substance P and neurokinin A released from
Trigeminal C fibers
Serotonin binds to which receptor on vasculature and what is the result
Binds to 5HT-1B and causes vasoconstriction
Where is calcitonin gene released peptide (CGRP) released from
Trigeminal alpha delta fibers
Which triptan drugs specifically are contraindicated with use of MAO inhibitors
- Sumatriptan
- Rizatriptan
- Zolmitriptan
Serotonin binds to which receptor in synapses and what is the response.
Binds to 5HT-1D and causes reduction in pain
What are the pros and cons of the nasal spray form of Triptans
Pros: effective if vomiting or nausea
Cons: Few formulated as nasal spray
What is the frequency of administration for preventative agents of migraines
Daily
What are the side effects of beta blockers for migraines and where is it contraindicated
- Fatigue, CNS depression, and bronchoconstriction
* Contraindicated in asthma patients
Which treatment for migraines in pregnant females allowed in first and second trimesters only
- Aspirin
- Ibuprofen
What is the result of Calcitonin-gene related peptide (CGRP) release
Increases the Dural vessel vasodilation
What is the mechanism of action of Triptans with regards to how it affects migranes
- 5HT-1B: vasoconstriction of vessels
- 5HT-1D Presynaptic: inhibits CGRP release
- 5HT-1D: inhibits passage of signal to the higher brain centers
What are the two beta blockers that can be given for prevention of migraine attacks
- Propranolol
- Timolol
Which class of drugs will make administering Triptans contraindicated
- MAO inhibitors
- Selective serotonin reuptake inhibators (SSRIs)
Central neurons express which subset of serotonin receptors
1B/1D
What are the two tricyclics antidepressants that can be given for prevention of migraine attacks
- Amitriptylene
- Imipramine
What might be a side affect of using organic nitrates to treat coronary artery disease
Can provoke a migraine via the release of NO, which causes the release of CGRP and subsequent migraine pain
What is the result of substance P release
Increased Dural vessel permeability
What is the process of Cortical spreading depression (CSD)
1) CSD leads to vasoconstriction
2) Vasoconstriction leads to discharge of hydrogen, potassium, nitric oxide
3) These cause vasodilation and migraine pain
Which treatment for migraines is acceptable for pregnancies in all trimesters
Acetaminophen and codeine
Which condition are patients on Triptans and SSRIs at risk for
Serotonin Syndrome
When is verapamil commonly used
Calcium channel blocker commonly used for migraine prevention, and is usually the first choice
Cranial vessels/vasculature express which subset of serotonin receptors
1B
What is the prototype triptan
Sumatriptan
Peripheral nerves express which subset of serotonin receptors
1D
What calcium channel blocker can be given for prevention of migraine attacks
Verapamil
What is the relationship between CGRP and nitric oxide
They interact together, sometimes causing a postive feedback loop on the release of each other
What is the criteria to receive preventative therapy for migraines
- More than 2 per month with disability
- disability lasting more than 3 days a month
- Rescue medication used more than 2 times per week
When is valproate used and when is it contraindicated
Used in those who fail to respond to triptan but contraindicated in pregnant women
What is a popular combination for migraine treatment that involves Triptans
Triptans and an analgesic, such as acetaminophen, ibuprofen, or naproxen
