Migraine/Gout Flashcards
What other symptoms accompanied by a headache should a patient seek medical attention?
Fever Stiff neck Rash Confusion Seizures Double vision Weakness Numbness Chest pain SOB Aphasia (trouble speaking)
What is a common type of migraine in women? How is it treated?
Menstrual-associated migraine (MAM)
Tx: oral contraceptives or estradiol patch to decrease the frequency
women who experiences migraine with aura are at a higher risk for stroke; estrogen-containing contraceptives should be avoided
Common migraine triggers
- Hormonal changes in women
- Foods (alcohol, aged cheeses, overuse of caffeine, salty & processed foods)
- Sensory stimuli (bright lights, sun glares, loud sounds, certain scents)
- Changes in Wake-Sleep Pattern
- Changes in the Environment
Diagnosis in adults
At least 5 attacks:
- Headaches lasting 4-72 hours
- Unilateral location, pulsating
- N/V, photophobia (sensitivity to light), phonophobia (sensitivity to sound)
Natural products used for migraines
Caffeine Butterbur Feverfew Magnesium Riboflavin
Acute (abortive) treatment used for headache that is already present.
OTC:
- acetaminophen
- Advil Migraine (only ibuprofen)
- Excedrin Migraine (ASA + ibu + Naproxen)
- Aleve (Naproxen)
Prescription options for acute treatment
Serotonin receptor agonists (Triptans)
What types of drugs are not recommended due to abuse/dependence issues for migraines?
Opioids, butalbital-containing products, tramadol and tapentadol
Triptans MOA
selective agonists for the 5-HT1 receptor and can cause vasoconstriction of cranial blood vessels
Triptans agents (generic/brand)
rizatriptan (Maxalt-MLT)
sumatriptan (Imitrex)
zolmitriptan (Zomig ZMT)
Which triptan has the longest half life? What is the half life?
frovatriptan (Frova) - 26 hours
Triptans that have a shorter half life have a faster onset. Which are?
almotriptan eletriptan rizatriptan sumatriptan zolmitriptan
What are the formulations available for triptans?
sumatriptan (nasal spray, powder, prefilled syringe & auto-injector)
zolmitriptan (nasal spray & ODT)
rizatriptan (ODT)
All Triptans are available as tablets
Triptan drug interactions
Sumatriptan, rizatriptan & zolmitriptan are contraindicated with MAOIs (or w/in 2 weeks of stopping)
Ergotamine MOA
nonselective agonist of serotonin receptors
*used if patients do not benefit triptans**
Ergotamine agent
generic/brand; formulation, Boxed warnings, contraindications
dihydroergotamine (D.H.E. 45, Migranal)
Formulations: IM/SC/IV, nasal spray
Boxed warnings: CI with potent CYP3A4 inhibitors due to peripheral ischemia
Contraindications: uncontrolled HTN, pregnancy, ischemic heart disease
Name the oral CGRP receptor antagonists approved to treat acute migraine attacks.
(generic/brand)
rimegepant (Nurtec ODT)
ubrogepant (Ubrelvy)
What drug is a first-in-class serotonin agonist that is selective for the 5-HT1F receptor subtype?
(generic/brand)
lasmiditan (Reyvow)
C-V
Fioricet generic
acetaminophen + butalbital + caffeine
Fiorinal generic
aspirin + butalbital + caffeine
C-III
Prophylactic drug treatment is considered when?
acute treatments > 2 days/week or > 3 Xs/month, if the migraine decrease their QOL
Oral prophylactic therapies include
Antihypertensives: beta-blockers - propranolol
Antiepileptics: topiramate* (popular = weight loss) and valproic acid
Antidepressants: amitriptyline or venlafaxine
MAM: monophasic and extended-cycle OCs if not aura
Monoclonal antibodies typical dosing range
eptinezumab-jjmr (Vyapti)
IV Q3 months
Monoclonal antibodies typical dosing range
erenumab-aoor (Aimovig)
SC monthly
Monoclonal antibodies typical dosing range
fremanezumab-vfrm (Ajovy)
SC month or SC Q3 months
Monoclonal antibodies typical dosing range
galcanezumab-gnlm (Emgality)
SC monthly
What agent is used for chronic migraines ONLY? What is considered as chronic?
Botox
> 15 headache days per month
Why are migraine medications limited to acute treatment to 2-3 times per week, at most?
Medication overuse headaches (MOH) aka rebound headaches
Counseling point for sumatriptan nasal powder
Brand?
Brand: Onzetra Xsail
CP: place mouthpiece into your mouth; blow into the device with your mouth for 2-3 seconds to deliver medication into your nose
Define gout
build up of uric acid (UA) crystals primarily in the joints
What is the medical name of the joint for the big toe?
metatarsophalangeal joint
**most common joint where gout occurs*
Risk Factors for Gout
Male gender
Obesity
Excessive alcohol
Drugs that increase uric acid
Aspirin, lower doses Calcineurin inhibitors (tacrolimus and cyclosporine) Diuretics (loops and thiazides) Niacin Pyrazinamide Select chemotherapy (with TLS) Select pancreatic enzyme products
Foods to avoid to prevent gout attacks
Organ meats
High-fructose corn syrup
Alcohol
Prophylactic drugs are used to do what?
lower UA levels (goal: < 6 mg/dL)
Gout Treatment Basics
- Treat acute pain w/ anti-inflammatory drugs
- Colchine
- Steroids
- NSAIDs (often starting in high doses)
- Once gout has struck, treat chronically to prevent future attacks
- Xanthine oxidase inhibitor (XOI): allopurinol** or febuxostat
- *an acute gout flare can occur when an XOI is started, so give initially with colchicine or an NSAID
- if XOI didn’t work well enough and UA remains > 6 mg/dL
- Add probenecid or lesinurad to daily XOI
- replace the XOI with IV pegloticase (Krystexxa)
Steroids used in gout
prednisone/prednisolone
methylprednisolone (Medrol, Solu-Medrol)
NSAIDs used in gout
indomethacin (Indocin)
naproxen (Aleve)
celecoxib (Celebrex)
What drug is a urate-oxidase enzyme used in the treatment of tumor lysis syndrome (TLS) and is contraindicated with G6PD deficiency?
rasburicase (Elitek)
What is the MOA of pegloticase (Krystexxa)?
Recombinant uricase: converts uric acid to allantoin
IV formulation - must be premedicated with antihistamines and steroids due to anaphylactic reactions
Reserved for refractory disease
Patients at risk risk of a severe Allopurinol hypersensitivity reaction should be screened what prior to drug use?
HLA-B*5801 allele
if positive - (esp. Asians) do not use drug
