migraine headache treatment Flashcards
how would you treat cluster headaches?
nasal or subq triptans or ergots + “burst & taper” steroid, like prednisone
how do you treat mild-moderate or menstrual migraines?
non-narcotics analgesics (NSAIDs)
how do you treat moderate-severe migraines?
short acting triptan
- oral or faster acting nasal spray
- naratriptan & frovatriptan (longer action but slower onset)
- Subq sumatriptan is most effective & fastest onset
which triptan is the most effective and fastest onset drug to treat migraines?
Subq sumatriptan
what are the 5 drugs that are used for prophylactic treatment of migraines?
topiramate valproate propanolol timolol metoprolol
what can happen with too frequent use of anti-migraine drugs?
this can lead to a paradoxical worsening of the migraines (analgesic overuse syndrome)
how do you try to fix the problem of analgesic overuse syndrome in migraine therapy?
start transition program
how are the NSAIDs effective drugs for treating migraines?
block PG production, and so reduce the production of inflamm. signals that trigger MAPK upregulation & the increased neuronal production of CGRP & substance P for release from nerve endings
how are triptans effective agents in treating migraines?
produce selective carotid vasoconstriction (via 5-HT1B receptors) & presynaptic inhibition of trigeminovascular inflamm. responses implicated in migraine (via 5-HT1D/5-HT1F receptors)
when is the best time to take NSAIDs for treating migraines?
SOONER
what are some of the adverse effects of NSAIDs in the elderly?
additive nephrotoxicity
- fluid retention, HTN, edema
- potentiation of migraine-associated nausea
name the NSAIDs that are commonly used to treat migraines?
Ibuprofen Ketoprofen Fenoprofen Nabumetone Naproxen
which type of NSAIDs are less likely to cause problems with analgesic overuse?
long acting NSAIDs
why are NSAIDs contraindicated in late pregnancy?
- effects upon patency of ductus arteriosus
2. prolonging labor and delivery
what kind of metabolic deficiency may be important with chronic doses of acetaminophen?
G6PD deficiency
which drug represents a class of drugs that are strongly linked to analgesic overuse syndrome?
butalbital-barbiturate
what are the adverse effects of barbituates?
CYP inducers & CNS/resp. depressant
barbituates are contraindicated with what other substances and conditions?
porphyria, ethanol, sedative contraindications
MOA of triptans?
- selective intracranial/extracerebral vasoconstriction
- inhibition of trigeminal nerve activation by vasoactive peptides
- inibition of trigeminal cervical complex activation
the triptans are agonists at which 2 serotonin receptors in the CNS?
5-HT1B & 5-HT1D
which 2 triptans are available as nasal sprays which speed up the onset of action?
sumatriptan
zolmitriptan
which triptan can be administered subq, which provides the quickest onset of drug action and is considered the most effective drug and delivery route?
sumatriptan
which two triptans both produce a more durable effect but at the expense of a longer onset time?
naratriptan
frovatriptan
adverse effects are most prominent with which triptan?
sumatriptan Subq
what are the adverse effects of triptans?
Side Effects may limit utility:
-CNS effects, like dizziness, drowsiness & fatigue may reflect aspects of migraine remaining after successful pain relief
-heaviness of tightness of chest
May cause coronary and peripheral vasospasm
triptans are contraindicated in what conditions?
heart dz, uncontrolled HTN, or ischemic bowel dz (use w/ caution w/ other vascular risk factors like DM)
triptans are contraindicated how long following ergot or triptan treatment?
<24 hrs
which triptans are affected with MAO inhibitors that prevent the breakdown?
Riza-, Suma-, Zolmitriptan
which beta blocker increases the serum levels of Eli-, Riza-, & Zolmitriptan?
propanolol
which triptan has interactions with CYP3A inhibitors that would result in an increase in the serum drug level?
Eletriptan
using SSRIs or SNRIs with triptans may precipitate what adverse effect?
SEROTONIN SYNDROME
what are the two ergots?
ergotamine
dihydroergotamine
what are the clinical symptoms/signs of acute and chronic ergotism?
characterized by mental disorientation, convulsions, muscle cramps, & dry gangrene of the extremities
what effect does ergotamine have in moderate doses?
causes contraction of smooth muscle fibers
which antimigraine drug has also been used to promote uterine contraction in childbirth?
ergotamine
what effect does ergotamine have in large doses?
paralyzes motor nerve endings of sympathetic nervous system
how can people get ergotism?
by eating contamina`ted baked goods
what pregnancy category are the ergots?
category x (also contraindicated in lactation)
which class of drugs has complex agonist effects on multiple receptors for example central (5-HT) + peripheral (alpha) vasoconstriction & decreased amine reuptake?
ergots
ergots are contraindicated w/ vasospastic predisposing conditions such as what?
peripheral vascular or CAD, sepsis, MI, uncontrolled HTN
what is the consequence of ergots interacting with beta blockers and dopamine?
potentiate vasoconstrictive action
what is the consequence of ergots interacting with strong CYP3A4 inhibitors?
increased ergot persistence
what is the consequence of triptans interacting with the ergots?
24 HOUR RULE
migraines are a common problem in which trimester of pregnancy?
1st trimester (when fetus is at greatest risk of toxicity)
what is the mainstay treatment for migraines in 1st trimester of pregnancy?
acetaminophen
what class of drugs can be added to treat migraines in pregnancy if the condition persists into later trimesters?
opioids
__________are contraindicated in treating migraines in pregnancy and other classes should be used ONLY when unavoidable
ergots
what may be the indication for using ergots to treat migraines?
can be appropriate in pts who are unresponsive to triptan therapy
what are the most frequently used drugs to treat menstrual migraine?
NSAIDs
when should you start taking NSAIDs to treat menstrual migraines?
2-3 days before menstrual period starts and continue until the period ends
for severe menstrual migraines or when taking oral contraceptivese, begin NSAID on ______ day of cycle and continue through the second day of the next cycle
19
the combo of what two risk factors produces a multiplicative increase in risk of ischemic stroke?
- low dose combo of oral contraceptives
2. migraine with aura
combo oral contraceptives are ok to treat what kind of migraines?
migraines w/o aura
triptans are ineffective for treating what kind of migraines?
migraines that produce allodynia
if you didn’t want to give narcotics to a pt suffering from migraines with allodynia, what could you give them instead?
Keratolac
name the 3 antiemetic drugs used to treat vomiting in migraines that work via D2 blockade centrally?
metoclopramide
Prochlorperazine
Chlorpromazine
explain the MOA of the antiemetic effect of promethazine?
cholinergic blockade, H1 & Weak D2 blockade
name the drug: prokinetic by increasing ACh effects and has AEs of increasing prolactin levels leading to gynecomastia, used to treat emesis in migraines
metoclopramide
name the 2 drugs that block D2 receptors centrally and have other effects including cholinergic + alpha-adrenergic blockade, used to treat emesis in migraines
prochlorperazine
Chlorpromazine
what are the AEs of prochlorperazine and chlorpromazine?
dyskinesia, hypotension, glaucoma, urinary retention, BPH
when would prophylactic treatment migraine be a good idea?
- recurrent migraine, interfering with daily routine despite acute treatment
- contraindication to or troublesome side effects from acute meds
- overuse of acute meds
- hemiplegic migraine; risk of neurologic injury
which 4 classes of drugs are used for prophylactic treatment of migraines?
antiepileptic drugs, antidepressant drugs, beta-blockers, Ca2+ blockers
what are the 1st line prophylactic treatments for migraines?
amitriptyline
Divalproex or Valproic acid
Propanolol or timolol
Topiramate
if 2-3 months of prophylactic treatment of migraines still doesn’t work, what do you do next?
combine 2 first line agents
MOA of amitriptyline
decrease reuptake of NE & serotonin + strong anticholinergic action
what are the AEs of amitriptyline?
aggressiveness, increase weight, dry mouth sedation
MOA of divalproex & valproic acid
Na+ channel blocker, increases GABA activity
what are the adverse effects of divalproex & valproic acid?
Cat. X, hepatotoxic, sedation, nausea, increase weight, highly protein bound
what is the MOA of propanolol & timolol in prophylactic migraine treatment?
decreased arterial dilation
decreased NE-induced lipolysis
what are the AEs of propanolol & timolol in prophylactic migraine treatment?
fatigue exercise intolerance asthma probz DM AV block
MOA for topiramate
blocks Na & glutamate, increases GABA activity
what are the AEs of topiramate?
paresthesias
fatigue
nausea
narrow therapeutic range
what is the only drug that has proven to be effective for migraine prophylaxis in children?
propanolol
how is botox administered to treat migraines prophylactically?
symmetrical injection into glabellar frontalis & temporalis muscles
botox injection is not recommended for what kind of migraines?
episodic migraines
what are the 4 analgesic overuse syndrome criteria?
- headaches for > 15 days/month that also fulfill criteria #3 & #4
- regular med overuse > 3 months
- headaches began or progressed in severity while taking meds
- headache resolves or reverts to previous pattern w/i 2 months after discontinuing chronic drug administration
what is the mechanism behind analgesic overuse syndrome?
cellular adaptation in teh already aberrant signaling processes
trigeminovascular system sensitization is due to what?
incomplete initial drug treatment
which 3 categories of drugs have a high risk for developing analgesic overuse syndrome?
- aspirin/acetaminophen/caffeine
- butalbital-containing combos
- opioids
which 3 types of drugs have a low risk for developing analgesic overuse syndrome?
- long acting NSAIDs
- Tramadol
- Dihydroergotamine
which types of drugs have a moderate risk of development of analgesic overuse syndrome?
triptans
short acting NSAIDs
what is the 3 faceted approach to treating analgesic overuse syndrome?
- transition or bridging program: control w/ ergotamine, prophylaxis w/ propanolol
- biofeedback
- prophylaxis: TCA, SSRI, beta-bockers, antiepileptics, NSAIDs
the american academy of neurology supports what 3 techniques of mind-body therapy to reduce migraine incidence?
- biofeedback
- cognitive behavior therapy
- relaxation training
which two alternative therapies has clinical evidence to show symptomatic relief of headache?
riboflavin
coenzyme Q10
which two alternative therapies have demonstrated an ability to reduce the frequency of migraine attacks?
feverfew & butterbur
which alternative therapy med used to treat migraines has an inssue with pyrrolizidine alkaloids?
butterbur (look for products that are alkaloid-free)
what three alternative migraine therapies are not to be used in pregnancy?
feverfew, butterbur, riboflavin
