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Neurology 2 > Migraine Drugs - Fitzpatrick > Flashcards

Migraine Drugs - Fitzpatrick Flashcards

1
Q

CGRP
CSD
DHE

A

Calcitonin gene related peptide - neurotransmitter
Cortical-spreading depression
Dihydroergotamine

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2
Q

Typical prodrome symptoms before a migraine

When?

A

Yawning, depression, lethargy, excitability, craving, distaste

12-36 hours before

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3
Q

Typical acute migraine symptoms

A

Headache, Photophobia, Phobophobia, Nausea, Vomiting

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4
Q

Typical postdrome symptoms after a migraine

A

Exhaustion, fatigue

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5
Q

When does the aura come in (if present)?

Symptoms?

A

Between prodrome and headache

Flashing lights, deja vu, weird neurologic symptoms

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6
Q

3 groups of therapeutic migraine drugs (+ when they are administered)

A

Triptans - during prodrome phase
Ergot alkaloids - during prodrome phase
NSAIDs/acetaminophen - during headache phase

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7
Q

Other name for serotonin

Why is this useful to know?

A

5-HT = hydroxyTRIPTAmine

TRIPTANs = serotonin receptor 1B/1D agonists

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8
Q

4 groups of preventative migraine drugs (w/ drug names)

Given when?

A

Beta-blockers (propranolol, timolol)
Antidepressants (Tri-cyclic, SSRIs)
Anticonvulsants (valproate, topirimate)
Ca++ channel blockers (verapamil)

Asymptomatic phase (between attacks)

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9
Q

Describe the pathophysiology of a migraine

A
  1. Neural electric wave from periphery to TRIGEMINAL GANGLION/NERVE to brain causes CEREBRAL vessel vasoconstriction and release of CGRP, NO, Histamine, PGs release.
  2. Released NTs diffuse across and dilate CRANIAL blood vessels, and CGRP sensitizes nerves to pain.
  3. Neurogenic inflammation travels back to the Trigeminal ganglion to the Trigeminal nucleus, causing PAIN
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10
Q

A patient has coronary artery disease and is prescribed organic nitrates for treatment to dilate the vessels. What is a potential side effect of taking this drug?

A

MIGRAINES - N.O. is heavily involved in the pathophysiology

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11
Q

Where does serotonin come into play regarding migraines?

A

Cranial vessels possess 5HT-1B receptors.
Neurons possess 5HT-1D receptors (pre-synaptic).
The TG nucleus (CNS) has 5HT-1D receptor also.

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12
Q

Function of serotonin on vessels, nerves, and TG nucleus?

A

Vessels - causes vasoconstriction (opposses vasodilation)
Neuron terminals - inhibits CGRP release
TG nucleus - inhibits incoming pain sensations from reaching thalamus and higher brain, where pain is perceived

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13
Q

Sumatriptan benefit?
Half-life?
Clearance?

A

Sub-Q or Nasal Spray options (quicker and longer than oral)
Half-life = 1-2 hours
Metabolized by MOA

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14
Q

Contrast different Triptans (compare to Sumatriptan)

A

Naratriptan - Longer half-life, higher bioavailability
Zolmitriptan - has active metabolite
Frovatriptan - MUCH longer half-life (1 day)

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15
Q

Pro and Con of oral Triptan

A

Easy to take, but ineffective w/ vomiting

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16
Q

Pro and Con of nasal spray Triptan

A

Good, easy, and quick with nausea/vomiting, but few options available

17
Q

Pro and Con of injection Triptan

A

Works quickly, but inconvenient to give shot every time

18
Q

2 Triptans with most delivery options

Compare and contrast delivery options

A

Sumatriptan, Zolmitriptan

BOTH = Tablets and nasal spray
Suma = Sub-Q injection
Zolm = Orally-disintegrating tablets
19
Q

If one Triptan does not work, should you quit them all?

A

NO

20
Q

A patient needs a Triptan for migraines, and wants one that works the longest to prevent risk of overuse. Best option?

A

Frovatriptan

21
Q

A patient needs a Triptan for migraines, and needs them to work fast. Best options?

A

Nasal spray (Suma, Zolm) or Sub-Q injection (Suma)

22
Q

Contraindications to Triptan use

A

Ischemic/vasospastic coronary disease or other CV disorders

23
Q

A patient needs a Triptan for migraines. She is currently taking a MAO inhibitor for depression. Which drugs should be AVOIDED?

A

Sumatriptan, Zolmitriptan, Rizatriptan

24
Q

Why should MAO inhibitors and certain Triptans not be used together?

A

The Triptans (previous card) can be converted into an active metabolite that is then broken down by MAO. Inhibiting MAO will cause prolonged and toxic effects of the Triptan.

25
Q

2 Ergot alkaloids

A

DHE, Ergotamine

26
Q

Caution regarding ergot alkaloids?

A

Interact with serotonin receptors AND dopamine receptors AND alpha-adrenergic receptors. THUS –> can lead to a variety of side effects

27
Q

DHE vs. Ergotamine/caffeine (Cafergot)

A

DHE - sub-lingual, intranasal, IV, IM, SC

Cafergot - oral, rectal

28
Q

Contrast DHE vs. Triptans

A

Triptans - FASTER

DHE - LONGER

29
Q

A patient is on a Triptan for migraines, but it doesn’t seem to be working well enough. What should you try?

What should you NOT do?
Why?

A

DHE instead

Do NOT use DHE + Triptan together
Both cause vasoconstriction

30
Q

Side effects of ergot alkaloids (DHE)

A

Emesis (major), BAD vasoconstriction

31
Q

Patient needs treatment for migraines. She has a present history of coronary artery disease. What should especially be avoided?

A

DHE

32
Q

A pregnant woman presents with migraines. What are your treatment options?

What is especially contraindicated? Why?

A

Acetaminophen +/- codeine
Aspirin/Ibuprofen - 1st and 2nd trimesters
Triptans - CAUTIOUSLY

DHE/ergot alkaloids (vasoconstriction –> abortion)

33
Q

Good drug COMBOS for migraine treatment

A

Triptan + NSAIDs/acetaminophen
- Sumatriptan + Naproxen (especially good)
Triptan + anti-emetic
DHE + anti-emetic

34
Q

Function of BOTOX for migraines

Used when?

A

Inhibits ACh release at motor synapses

CHRONIC migraines, or nothing else works

35
Q

Migraine prevention agent groups

Taken when?

A

Beta-blockers
TC antidepressants
Anticonvulsants
Ca++ channel blockers

Daily, when bad or chronic, when asymptomatic

36
Q

1st choice for migraine prevention

Mechanism?

A

Verapamil (Ca++ channel blocker)

Prevents cerebral vasoconstriction and NT release –> prevent cranial vasodilation

37
Q

A patient needs preventative treatment for migraines. She has a history of asthma. What is contraindicated?

A

Beta-blockers (due to bronchoconstriction)

38
Q

Other side effects of beta-blockers

A

Typical anti-sympathetic stuff (fatigue, change of sexual function, lost exercise tolerance, hypotension/bradycardia)

39
Q

Anti-epilepsy drugs used for migraine prevention

Mechanism?

Caution?

A

Topirimate, Valproate

Prevents that spread of electrical activity during seizure

SUICIDE RISK when not used for epilepsy/seizures

Neurology 2 (22 decks)

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