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migraine headache treatment Flashcards

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1
Q

how would you treat cluster headaches?

A

nasal or subq triptans or ergots + “burst & taper” steroid, like prednisone

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2
Q

how do you treat mild-moderate or menstrual migraines?

A

non-narcotics analgesics (NSAIDs)

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3
Q

how do you treat moderate-severe migraines?

A

short acting triptan

  • oral or faster acting nasal spray
  • naratriptan & frovatriptan (longer action but slower onset)
  • Subq sumatriptan is most effective & fastest onset
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4
Q

which triptan is the most effective and fastest onset drug to treat migraines?

A

Subq sumatriptan

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5
Q

what are the 5 drugs that are used for prophylactic treatment of migraines?

A 
topiramate
valproate
propanolol
timolol
metoprolol
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6
Q

what can happen with too frequent use of anti-migraine drugs?

A

this can lead to a paradoxical worsening of the migraines (analgesic overuse syndrome)

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7
Q

how do you try to fix the problem of analgesic overuse syndrome in migraine therapy?

A

start transition program

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8
Q

how are the NSAIDs effective drugs for treating migraines?

A

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

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9
Q

how are triptans effective agents in treating migraines?

A

produce selective carotid vasoconstriction (via 5-HT1B receptors) & presynaptic inhibition of trigeminovascular inflamm. responses implicated in migraine (via 5-HT1D/5-HT1F receptors)

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10
Q

when is the best time to take NSAIDs for treating migraines?

A

SOONER

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11
Q

what are some of the adverse effects of NSAIDs in the elderly?

A

additive nephrotoxicity

  • fluid retention, HTN, edema
  • potentiation of migraine-associated nausea
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12
Q

name the NSAIDs that are commonly used to treat migraines?

A 
Ibuprofen
Ketoprofen
Fenoprofen
Nabumetone
Naproxen
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13
Q

which type of NSAIDs are less likely to cause problems with analgesic overuse?

A

long acting NSAIDs

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14
Q

why are NSAIDs contraindicated in late pregnancy?

A
  1. effects upon patency of ductus arteriosus

2. prolonging labor and delivery

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15
Q

what kind of metabolic deficiency may be important with chronic doses of acetaminophen?

A

G6PD deficiency

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16
Q

which drug represents a class of drugs that are strongly linked to analgesic overuse syndrome?

A

butalbital-barbiturate

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17
Q

what are the adverse effects of barbituates?

A

CYP inducers & CNS/resp. depressant

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18
Q

barbituates are contraindicated with what other substances and conditions?

A

porphyria, ethanol, sedative contraindications

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19
Q

MOA of triptans?

A
  • selective intracranial/extracerebral vasoconstriction
  • inhibition of trigeminal nerve activation by vasoactive peptides
  • inibition of trigeminal cervical complex activation
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20
Q

the triptans are agonists at which 2 serotonin receptors in the CNS?

A

5-HT1B & 5-HT1D

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21
Q

which 2 triptans are available as nasal sprays which speed up the onset of action?

A

sumatriptan

zolmitriptan

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22
Q

which triptan can be administered subq, which provides the quickest onset of drug action and is considered the most effective drug and delivery route?

A

sumatriptan

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23
Q

which two triptans both produce a more durable effect but at the expense of a longer onset time?

A

naratriptan

frovatriptan

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24
Q

adverse effects are most prominent with which triptan?

A

sumatriptan Subq

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25
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
26
triptans are contraindicated in what conditions?
heart dz, uncontrolled HTN, or ischemic bowel dz (use w/ caution w/ other vascular risk factors like DM)
27
triptans are contraindicated how long following ergot or triptan treatment?
<24 hrs
28
which triptans are affected with MAO inhibitors that prevent the breakdown?
Riza-, Suma-, Zolmitriptan
29
which beta blocker increases the serum levels of Eli-, Riza-, & Zolmitriptan?
propanolol
30
which triptan has interactions with CYP3A inhibitors that would result in an increase in the serum drug level?
Eletriptan
31
using SSRIs or SNRIs with triptans may precipitate what adverse effect?
SEROTONIN SYNDROME
32
what are the two ergots?
ergotamine | dihydroergotamine
33
what are the clinical symptoms/signs of acute and chronic ergotism?
characterized by mental disorientation, convulsions, muscle cramps, & dry gangrene of the extremities
34
what effect does ergotamine have in moderate doses?
causes contraction of smooth muscle fibers
35
which antimigraine drug has also been used to promote uterine contraction in childbirth?
ergotamine
36
what effect does ergotamine have in large doses?
paralyzes motor nerve endings of sympathetic nervous system
37
how can people get ergotism?
by eating contamina`ted baked goods
38
what pregnancy category are the ergots?
category x (also contraindicated in lactation)
39
which class of drugs has complex agonist effects on multiple receptors for example central (5-HT) + peripheral (alpha) vasoconstriction & decreased amine reuptake?
ergots
40
ergots are contraindicated w/ vasospastic predisposing conditions such as what?
peripheral vascular or CAD, sepsis, MI, uncontrolled HTN
41
what is the consequence of ergots interacting with beta blockers and dopamine?
potentiate vasoconstrictive action
42
what is the consequence of ergots interacting with strong CYP3A4 inhibitors?
increased ergot persistence
43
what is the consequence of triptans interacting with the ergots?
24 HOUR RULE
44
migraines are a common problem in which trimester of pregnancy?
1st trimester (when fetus is at greatest risk of toxicity)
45
what is the mainstay treatment for migraines in 1st trimester of pregnancy?
acetaminophen
46
what class of drugs can be added to treat migraines in pregnancy if the condition persists into later trimesters?
opioids
47
__________are contraindicated in treating migraines in pregnancy and other classes should be used ONLY when unavoidable
ergots
48
what may be the indication for using ergots to treat migraines?
can be appropriate in pts who are unresponsive to triptan therapy
49
what are the most frequently used drugs to treat menstrual migraine?
NSAIDs
50
when should you start taking NSAIDs to treat menstrual migraines?
2-3 days before menstrual period starts and continue until the period ends
51
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
52
the combo of what two risk factors produces a multiplicative increase in risk of ischemic stroke?
1. low dose combo of oral contraceptives | 2. migraine with aura
53
combo oral contraceptives are ok to treat what kind of migraines?
migraines w/o aura
54
triptans are ineffective for treating what kind of migraines?
migraines that produce allodynia
55
if you didn't want to give narcotics to a pt suffering from migraines with allodynia, what could you give them instead?
Keratolac
56
name the 3 antiemetic drugs used to treat vomiting in migraines that work via D2 blockade centrally?
metoclopramide Prochlorperazine Chlorpromazine
57
explain the MOA of the antiemetic effect of promethazine?
cholinergic blockade, H1 & Weak D2 blockade
58
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
59
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
60
what are the AEs of prochlorperazine and chlorpromazine?
dyskinesia, hypotension, glaucoma, urinary retention, BPH
61
when would prophylactic treatment migraine be a good idea?
1. recurrent migraine, interfering with daily routine despite acute treatment 2. contraindication to or troublesome side effects from acute meds 3. overuse of acute meds 4. hemiplegic migraine; risk of neurologic injury
62
which 4 classes of drugs are used for prophylactic treatment of migraines?
antiepileptic drugs, antidepressant drugs, beta-blockers, Ca2+ blockers
63
what are the 1st line prophylactic treatments for migraines?
amitriptyline Divalproex or Valproic acid Propanolol or timolol Topiramate
64
if 2-3 months of prophylactic treatment of migraines still doesn't work, what do you do next?
combine 2 first line agents
65
MOA of amitriptyline
decrease reuptake of NE & serotonin + strong anticholinergic action
66
what are the AEs of amitriptyline?
aggressiveness, increase weight, dry mouth sedation
67
MOA of divalproex & valproic acid
Na+ channel blocker, increases GABA activity
68
what are the adverse effects of divalproex & valproic acid?
Cat. X, hepatotoxic, sedation, nausea, increase weight, highly protein bound
69
what is the MOA of propanolol & timolol in prophylactic migraine treatment?
decreased arterial dilation | decreased NE-induced lipolysis
70
what are the AEs of propanolol & timolol in prophylactic migraine treatment?
``` fatigue exercise intolerance asthma probz DM AV block ```
71
MOA for topiramate
blocks Na & glutamate, increases GABA activity
72
what are the AEs of topiramate?
paresthesias fatigue nausea narrow therapeutic range
73
what is the only drug that has proven to be effective for migraine prophylaxis in children?
propanolol
74
how is botox administered to treat migraines prophylactically?
symmetrical injection into glabellar frontalis & temporalis muscles
75
botox injection is not recommended for what kind of migraines?
episodic migraines
76
what are the 4 analgesic overuse syndrome criteria?
1. headaches for > 15 days/month that also fulfill criteria #3 & #4 2. regular med overuse > 3 months 3. headaches began or progressed in severity while taking meds 4. headache resolves or reverts to previous pattern w/i 2 months after discontinuing chronic drug administration
77
what is the mechanism behind analgesic overuse syndrome?
cellular adaptation in teh already aberrant signaling processes
78
trigeminovascular system sensitization is due to what?
incomplete initial drug treatment
79
which 3 categories of drugs have a high risk for developing analgesic overuse syndrome?
1. aspirin/acetaminophen/caffeine 2. butalbital-containing combos 3. opioids
80
which 3 types of drugs have a low risk for developing analgesic overuse syndrome?
1. long acting NSAIDs 2. Tramadol 3. Dihydroergotamine
81
which types of drugs have a moderate risk of development of analgesic overuse syndrome?
triptans | short acting NSAIDs
82
what is the 3 faceted approach to treating analgesic overuse syndrome?
1. transition or bridging program: control w/ ergotamine, prophylaxis w/ propanolol 2. biofeedback 3. prophylaxis: TCA, SSRI, beta-bockers, antiepileptics, NSAIDs
83
the american academy of neurology supports what 3 techniques of mind-body therapy to reduce migraine incidence?
1. biofeedback 2. cognitive behavior therapy 3. relaxation training
84
which two alternative therapies has clinical evidence to show symptomatic relief of headache?
riboflavin | coenzyme Q10
85
which two alternative therapies have demonstrated an ability to reduce the frequency of migraine attacks?
feverfew & butterbur
86
which alternative therapy med used to treat migraines has an inssue with pyrrolizidine alkaloids?
butterbur (look for products that are alkaloid-free)
87
what three alternative migraine therapies are not to be used in pregnancy?
feverfew, butterbur, riboflavin

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