Migraine Meds Flashcards
3 categories of H/As?
tension
cluster
migraine
majority of H/As are caused by what state of vessels?
vasodilation
what hormone appears to play a vital role in migraines and how so?
serotonin
receptors appear to account for potential of either vasoconstriction or dilation being elicited by serotonin
serotonin 1 receptors elicit constriction
serotonin 2 receptors elicit dilation
also has been found that higher levels of serotonin cause constriction whereas lower levels cause dilation
serotonin may also alter the threshold of pain perception
prophylactic migraine med options?
beta-blockers (propanolol/inderal or metoprolol/lopressor)
CCBs (verapamil/isoptin)
methysergide
tricyclic antidepressants (nortyptylene/aventyl)
erogtamine
anti-seizure meds
prodromal phase migraine tx option?
triptans
actual migraine H/A phase meds?
analgesics
anti-emetics
class of propranolol/inderal? indications? MOA? how to rx propranolol? problem that can occur dt non-selectivity?
class: non-selective BB
indications: HTN, angina, AMI, panic attacks, migraines
MOA: blocks adrenergic stimulation which serves to decrease HR and myocardial O2 demand and also decreases renin release
rx: PO 10-100 mg/d
SE: non-selective means it might cause bronchoconstriction via antagonism of B2 nerves
SEs of propranolol/inderal? abrupt discont can cause what?
bronchoconstriction, hypotension, bradycardia, fatigue, impotence
abrupt discont can cause rebound HTN, tachycardia w/subsequent increase in myocardial O2 demand, increases risk of arrhythmias, stroke, angina and MI
class of amitriptyline/elavil? indications? MOA? how to rx?
class: tricyclic antidepressant
indications: migraine/tension H/A, chronic pn, bipolar d/o, depression
MOA: CNS modulation of both serotonin and NE (inhibits reuptake)
rx: PO or IM, usu taken at bedtime to minimize SEs of drowsiness and dizziness
SEs of amitriptyline/elavil? do not use in combo with what?
SEs: dizziness, marked drowsiness, Ach effects such as anti-SLUD + blurred vision
do not use with monoamine oxidase inhibitors!
class of topiramate/topamax? indications? MOA?
class: anticonvulsant
indications: anticonvulsant approved in use of epilepsy and prophylaxis of migraines, off-label use for bipolar d/o
MOA: block voltage dependent Na channels in CNS, augmenting the activity of GABA at some subtypes of GABA-A receptor
how to rx topiramate/topamax? SEs?
rx: PO tablets, also available capsules or sprinkle form for peds
SEs: fatigue, dizziness, vision changes, acute angle glaucoma, nausea, constipation
class of methysergide/sansert? indications? MOA?
class: ergot derivative, serotonin 2 receptor antagonist
indications: prophylaxis migraine and cluster H/A
MOA not fully understood but appears to be serotonin receptor 2 antagonist which = vasoconstriction
how to rx methysergide/sansert? do not use w/in 24 hrs of what other drug?
give PO, should never use beyond 6 mos w/o a drug free interval; dosage must be tapered to avoid rebound
do not use w/in 24 hrs of triptan b/c of increased risk of vasoconstrictive spasm
SEs of methysergide/sansert? use is usu reserved for tx’ing what?
HTN
thrombophlebitis
N/V
pulmonary fibrosis and retroperitoneal fibrosis (potentially life-threatening)
heart valve thickening
C/I in PG and in pts w/peripheral vascular dz
all these potential SEs make its use a less attractive choice
use is reserved for cases refractive to other meds and tx modalities
class of sumatriptan/imitrex? indications? MOA? how to rx?
class: serotonin agonist
indication: migraines and cluster H/As
MOA: serotonin agonist at 5-HT 1D and 1B receptors, found in small, peripheral nerves that innervate the intracranial vasculature; acts to reduce the vascular inflammation assoc w/migraines
take PO/SQ/nasal spray
onset of action of sumatriptan/imitrex? max dose in 24 hrs? SEs? what category?
onset of action: 10-60 misn, max 2 doses in 24 hrs
SEs: dizziness, tingling, facial flushing, weakness, chest tightness or pn, arrythmias, HTN, use w/caution in pts w/HTN and in pts w/angina
category C drug that is well controlled, should probably not be used in PG
what is serotonin syndrome?
uncommon potential SE of all triptans
ssxs: agitation, tremor, ataxia, fever, chills, diarrhea
frequent use can cause rebound H/As
nonsteroidal analgesics that can be used during migraine?
NSAIDs: aspirin, ibuprofen, naproxen, acetaminophen
caffeine often added to analgesic and increases effectiveness in tx’ing H/A
MOA of NSAIDs?
inhibit synth of prostaglandins
what do prostaglandins promote?
inflammation, pain, fever, support clotting fxn of platelets and protect lining of the stomach from damaging effects of stomach acid
what enzyme is primarily involved in the production of prostaglandins?
COX-1, which NSAIDs prevent the formation of
class of ibuprofen/motrin, advil? indications? MOA? how to rx?
class: NSAID
indications: inflammation, pn, fever
MOA: reversible inhibition of COX-1, COX-2 enzymes; anti-inflam, analgesic effect largely dt blockade of prostaglandin synth at target tissues
rx: PO, PR, no increased risk for Reye’s syndrome noted
class of codeine? indications? MOA? how to rx? SEs? DOA?
class: opioid analgesic
indications: pain relief, antitussive
MOA: opioid agonist, much weaker analgesic than morphine
rx PO, IV, IM, SQ- lower abuse potential- effective antitussive
SEs: sedation, constipation
DOA: 4-6 hrs
class of butorphanol/stadol? indications? MOA?
class: opioid analgesic
indications: migraine that is refractory to triptans and to other agents as well as less potent analgesics
MOA: mixed agonist-antagonist of opioid receptors
how to rx butorphanol/stadol? SEs?
rx nasal spray or IM, usu dosed as 1 spray in nostrils every 3-5 hrs as needed for control of severe pn, marked dependency exists
SEs: nasal irritation, drowsiness, dysphoria, N/V, withdrawal sxs can be precipitated in pts w/underlying addiction to opiates
5 main anti-emetics used to tx migraines? given how?
diphenhydramine (benadryl), prochlorperazine (compazine), promethazine (phenergan), hydroxyzine (vistaril), these antihistamines are very effective in alleviating nausea
all give PO, PR, IV
when are cannabinoids used?
pts w/cachexia, cytotoxic nausea, vomiting or those who are unresponsive to other agents
how to 5-HT3 receptor antagonists work to alleviate nausea?
block serotonin receptors in the CNS and GI which prevents nausea
class of prochlorperazine/compazine? indications? MOA?
class: typical neuroleptic
indications: anti-emetic particularly when assoc w/migraine, vertigo, anti-psychotic
MOA: primarily H1 histamine receptor antagonist, also D2 dopaminergic receptor antagonist and alpha-adrenergic receptor antagonist
how to rx prochlorperazine/compazine? SEs?
give PO, PR, IM, IV
SEs: drowsiness, dry mouth, constipation, urinary retention, lowers seizure threshold, extrapyramidal SEs genearly seen when given in higher doses after a longer period of time (tardive dyskinesia, pseudoparkinsonism, dystonic rxns, akathisia)
category of ondansetron/zofran? indications? MOA? how to rx? SEs?
category: antiemetic
indication: severe nausea
MOA: block serotonin (5HT3) receptor sites resulting in significant anti-nausea effects
give PO, IV
SEs: dizziness, H/A, generally well tolerated
additional non-pharm tx options?
B2, riboflabin 400 mg/d Mg 600-2000 mg/d biofeedback acupuncture botulinum toxin (botox) injxn has shown promise
