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PT2 Neuro 10-11 and Pain 1-4 > migraine pharmacology and therapeutics > Flashcards

migraine pharmacology and therapeutics Flashcards

1
Q

four factors thought to be involved in the cause of migraines

A
  1. serotonin system dysregulation
  2. trigeminal nerve
  3. vasodilation
  4. release of vasoactive and inflammatory peptides
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2
Q

main vasoactive and inflammatory peptide

A

calcitonin gene related peptide

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3
Q

what indicates trigeminal nerve in migraines

A

unilateral feature of migraines

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4
Q

neuron pathway of the trigeminovascular system

A
  1. 1st order nociceptive fibers transmit signals from blood vessels in the dura
  2. 1st order neurons synapse with 2nd order in the trigeminocervical complex
  3. 2nd order neurons extend to the thalamus
  4. 3rd order neurons take the signal from the thalamus to the cortex
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5
Q

peptides are released from where

A

nerve terminals

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6
Q

neuropeptides cause

A

vasoconstriction

inflammation

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7
Q

what activates pain receptors

A

sterile perivascular inflammation (in the dura)

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8
Q

unified neural generator theory

A

in people with migraine headaches 2nd order neurons are hyperexcitable which increases perception of pain

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9
Q

when migraine triggers occur what area of the brain appears to start the attack

A

hypothalamus

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10
Q

pain processing center

A

periaqueductal gray

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11
Q

Trigeminocervical complex excitability increases proportionally with

A

time to the next attack

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12
Q

acute treatment for migraines concept

A

inhibit COX activity to decrease prostaglandin formation

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13
Q

decreased prostaglandin activity does what

A
  • decreased nociception
  • decreased inflammation
  • reduced vasodilation
  • reduced transmission between 1st and 2nd order neurons
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14
Q

benefits of caffeine in migraine treatments

A
  • has intrinsic analgesic properties

- may promote uptake of drugs in the GI tract

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15
Q

acute treatment combo drugs

A
  • excedrin
  • fiorinal
  • fioricet
  • midrin
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16
Q

Midrin MoA

A
  • Isometheptene vasoconstricts
  • Dichloralphenazone is hypnotic and antipyretic
  • acetaminophen
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17
Q

Midrin adverse effects

A
  • hepatotoxicity
  • hypertension
  • sedation
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18
Q

Midrin contraindications

A
  • glaucoma
  • severe uncontrolled hypertension
  • heart disease
  • MAO-I
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19
Q

triptan’s MoA

A

5-HT 1b/1d agonists (serotonin agonists)

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20
Q

where is 5-HT1d serotonin receptor

A
  • peripheral nociceptive fiber

- TCC

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21
Q

where is 5-HT1b serotonin receptor

A
  • cerebral and dural blood vessels

- TCC

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22
Q

5-HT1b serotonin receptors cause

A

vasoconstriction

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23
Q

5-HT1d serotonin receptors cause

A

decreased excitability of nociceptors by:

  • reducing Ca influx
  • increasing K conductance
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24
Q

contraindications of triptans (5-HT1b/1d agonists)

A
  • heart disease
  • peripheral vascular disease
  • uncontrolled hypertension
  • ergot alkaloids w/i past 24 hr
  • MAOI in last 2 weeks
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25
Q

when to use ergot alkaloids

A

in acute settings inside a hospital after other options have failed

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26
Q

ergot MoA

A

vasoconstriction

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27
Q

ergot basic adverse effects

A
  • N/V
  • abdominal pain
  • weakness/fatigue
  • muscle pain
  • chest tightness
  • peripheral ischema
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28
Q

ergot serious adverse effects

A
  • gangrenous extremities
  • myocardial infarction
  • hepatic necrosis
  • bowl/brain ischemia
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29
Q

what kind of migraine headaches can we treat prophylactically?

A

cyclical headaches, such as those tied with menstruation or seasons

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30
Q

generator location of cluster headache

A

hypothalamus

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31
Q

other symptoms of cluster headache

A

parasympathetic signs on the side of the face with pain

  • lacrimation
  • nasal congestion
  • rhinorrhea
  • sweating
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32
Q

pterygopalatine ganglion

A

reflex arch thought to be involved with the parasympathetic symptoms of cluster headaches

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33
Q

primary headache types

A

tension
migraine
cluster

34
Q

secondary headache types

A

symptomatic of organic disease (ie drug induced)

35
Q

pain description of migraines

A
  • throbbing
  • pulsating
  • moderate to severe
  • worsens with exertion
36
Q

associated symptoms of migraine

A
  • nausea
  • vomiting
  • photophobia
  • phonophobia
  • sometimes aura
37
Q

pain description of tension headache

A
  • dull
  • non-pulsatile
  • tightness
  • pressure
  • moderate
38
Q

associated symptoms of tension headache

A
  • mild photophobia
  • mild phonophobia
  • sometimes none
39
Q

pain description of cluster headache

A
  • occurs suddenly
  • excruciating
  • penetrating
  • boring intensity
  • severe
40
Q

associated symptoms of cluster headache

A
  • lacrimation
  • nasal stuffiness
  • rhinorrhea
  • facial sweating
  • eyelid edema
  • miosis
  • restlessness
  • agitation
41
Q

features of migraine

A
  • unilateral

- 4-72 hours long

42
Q

features of tension headache

A
  • bilateral, can extend down neck

- variable length

43
Q

features of cluster headache

A
  • unilateral in the orbit

- 15-120 mins, multiple times per day

44
Q

migraine diagnosis

A
  1. > = 5 attacks total
  2. must last 4-72 hours
  3. unilateral, pulsating, moderate/severe pain, activity avoidance (must have 2)
  4. N/V, photophobia, phonophobia (must have 1)
45
Q

migraine with aura diagnosis

A
  1. > = 2 attacks
  2. visual, sensory, and/or speech/language symtpoms
  3. symptoms spread over 5 mins, last 5-60 mins, unilateral, headache within 60 mins
46
Q

goals of acute migraine therapy

A
  • treat rapidly and consistently
  • restore ability to function
  • minimize use of backup meds
47
Q

goals of prophylactic migraine therapy

A
  • reduce frequency, severity, disability
  • reduce acute treatment
  • improve QOL
48
Q

nonpharm acute migraine therapy

A
  • ice to the head
  • rest or sleep
  • dark quiet room
  • avoid triggers
49
Q

nonpharm prophylactic therapy

A
  • regular sleep
  • exercise
  • smoking cessation
  • reduce caffeine
  • good eating habits
  • relaxation therapy
50
Q

food triggers for migraines

A
  • alcohol
  • caffeine
  • chocolate
  • aspartame
51
Q

environmental triggers for migraines

A
  • glare/flickering
  • high altitude
  • loud noises
  • tobacco smoke
  • weather changes
52
Q

behavioral triggers of migraines

A
  • excess/insufficient sleep
  • fatigue
  • menstruation/menopause
  • sexual activity
  • skipped meals
  • strenuous physical activity
  • stress
53
Q

treatment of migraines with mild to moderate symptoms

A
  1. NSAID
  2. OTC combination (APAP, aspirin, caffeine)
  3. triptan
54
Q

NSAID side effect

A

nausea

55
Q

longer half life, slower onset triptans

A

frovatriptan

naratriptan

56
Q

unique instruction of naratriptan use

A

repeat dose every 4 hours

57
Q

triptan with fastest onset

A

sumatriptan SQ

58
Q

triptan with interaction with propranolol

A

rizatriptan

59
Q

repeating triptan doses

A
  • after 2 hours for oral, nasal, ODT
  • after 1 hour for SQ
  • no more than 2-3 days per week
60
Q

acute side effects of triptans

A
  • flushing
  • dizziness
  • drowsiness
  • paresthesias
61
Q

precautions when using triptans

A
  • ischemic heart disease
  • stroke
  • CAD
  • pregnancy
  • ergots
  • serotonin syndrome
62
Q

precautions in ergot use

A
  • CAD or CVD
  • uncontrolled hypertension
  • renal/hepatic failure
  • elderly
  • pregnancy/lactating
63
Q

ergots acute side effects

A
  • N/V
  • abdominal pain
  • weakness/fatigue
  • muscle pain
  • peripheral ischemia
64
Q

ergots serious side effects

A
  • gangrenous extremities
  • MI
  • hepatic necrosis
65
Q

opioid use in migraines

A
  • last line

- for moderate to severe migraine after other treatments fail

66
Q

antiemetics for use in migraine

A
  • metoclopramide

- prochllorperazine

67
Q

medication-overuse headache

A
  • self-sustaining headache with prolonged use of medication
  • daily or near daily
  • discontinue offending agent by tapering
68
Q

indications for migraine prophylaxis

A
  • > 2 migraines per week
  • symptomatic therapy doesn’t work
  • symptomatic therapy causes AEs
  • risk of permanent neurologic injury
  • patient preference to limit attacks
69
Q

prophylactic treatment strategy for predictable pattern headaches

A

nsaid or triptan at time of vulnerability

70
Q

prophylactic treatment strategy for unpredictable pattern and healthy, has HTN, or angina

A
  • beta-blocker

- Ca channel blocker if beta-blocker contraindicated

71
Q

FDA approved beta blockers for prophylaxis

A

propranolol

timolol

72
Q

side effects of beta-blockers

A
  • fatigue
  • dizziness
  • bradycardia
  • depression
  • hypotension
73
Q

precautions in beta-blocker use

A
  • CHF
  • peripheral vascular disease
  • asthma
  • hypoglycemic awareness
  • depression
74
Q

prophylactic treatment with comorbid depression or insomnia

A

TCA (amitriptyline)

SNRI (venlafaxine)

75
Q

prophylactic treatment with comorbid seizures or bipolar

A

topiramate

valproic acid

76
Q

time to see benefit with prophylactic medications

A

3-6 months

77
Q

botulinum toxin in prophylaxis

A
  • FDA approved for chronic migraine

- injections into 31 sites every 12 weeks

78
Q

first line therapy for tension headaches

A

OTC analgesics, limited to 2-3 days per week

79
Q

acute therapy for cluster headache

A
  • oxygen
  • triptans
  • ergots
80
Q

prophylactic therapy for cluster headache

A
  • suboccipital corticosteroid injection
  • verapamil
  • lithium

PT2 Neuro 10-11 and Pain 1-4 (5 decks)

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