Migraines Flashcards
Which triptan has the longest DOA and may be useful in a pt with recurrent migraine?
a. Sumatriptan
b. Eletriptan
c. Almotriptan
d. Frovatriptan
e. Rizatriptan
d
Frovatriptan has the longest half-life (~26 hours), but the onset of action is slower.
CM was recently diagnosed from the hospital for liver failure. His Dr is aware that he has a long hx of migraine headaches that occur once per week, but he doesn’t want to exacerbate CM’s liver condition. What drug is the most reasonable option for daily migraine prophylaxis in CM?
a. Divalproex
b. Felbamate
c. Topiramate
d. Excedrin Migraine
e. Tylenol
c
-Valproic acid is associated with liver toxicity
-Acetaminophen might be safe as an occasional abortive tx, but the case describes weekly migraines, so a prophylactic agent is warranted.
-Felbamate isn’t used for migraine prophylaxis. It’s a drug reserved only for refractory epilepsy d/t the risk of hepatotoxicity.
Which of the following is characteristic of a migraine headache?
a. Lasts < 1 hr
b. Pain is bilateral
c. Associated with stiff neck, confusion, and trouble speaking
d. Associated with N/V, photophobia, or phonophobia
e. Pain always responds to OTC pain relievers
d
Migraine can be diagnosed when an adults has 5 or more attacks meeting these criteria:
-Headaches last 4-72 hours
-Meet 2 or more of the following: Pulsatile, unilateral, cause avoidance of routine physical activity
-Associated with N/V, photophobia, or phonophobia
HP has 1 or 2 migraine headaches per month. She can usually predict when she’ll get a migraine because her headaches are triggered by lack of sleep and too much processed food. She has an Rx for Imitrex STATdose, and a single dose always terminates her migraine quickly. She’s not taking any chronic meds. Choose the correct statement:
a. She should start daily therapy with Treximet.
b. She should start daily therapy with frovatriptan.
c. She should begin prophylactic therapy with propranolol.
d. She should begin daily therapy with Fiorinal.
e. She doesn’t need daily prophylactic therapy.
e
Prophylactic (or preventative) therapy is appropriate if acute tx is needed for migraines >/= 2 days/week or >/= 3x per month if the pt’s QOL is decreased of if acute treatments are ineffective or contraindicated.
SA has 3-4 migraines monthly. Each one reduces her ability to function for 3-4 days, which is negatively impacting her job performance. Her daily meds include fosinopril, a daily MVI, and sumatriptan PRN for migraines. She states that she’s been taking her sumatriptan “2 or 3 days per week.” Which of the following options is best to optimize the management of SA’s migraines?
a. Take sumatriptan daily instead of an as-needed basis.
b. D/c sumatriptan and start daily therapy with rizatriptan.
c. Begin prophylactic therapy.
d. Make no changes to her current regimen.
e. Begin daily therapy with Fiorinal.
c
-Prophylactic (or preventative) therapy is appropriate if acute tx is needed for migraines >/= 2 days/week or >/= 3x per month if the pt’s QOL is decreased of if acute treatments are ineffective or contraindicated.
-Sumatriptan, rizatriptan, and Fiorinal are for acute attacks only, not for migraine prophylaxis.
A pt reports to his Dr that he has occasional migraines. He self-treats with OTC ibuprofen, which is effective for him. When the pt left the appt, he found that the Dr had written an Rx for sumatriptan for him at the front desk. Choose the correct statement regarding the tx of acute migraine headaches.
a. OTC tx (e.g., NSAIDs or acetaminophen-aspirin-caffeine) can be effective and acceptable for some pts.
b. Aspirin-butalbital-caffeine is considered the 1st line drug for the tx of severe acute migraines.
c. Rx drugs are considered 1st line for all pts with mild-mod migraines.
d. Ibuprofen is preferred for acute tx of migraine over naproxen d/t the longer DOA of ibuprofen.
e. Beta-blockers are preferred for acute tx of migraines, assuming there are no contraindications to their use.
a
-Ibuprofen has a shorter DOA than naproxen (Q4-6H dosing for ibuprofen vs. Q12H for naproxen).
-Beta-blockers are a good option for prophylaxis, not abortive tx.
JW comes into the pharmacy to drop off an Rx for an antibiotic to treat bronchitis. The pt mentions that he has occasional migraines and that his Dr suggested trying an OTC pain reliever. The pt reports having a severe reaction to acetaminophen. Which of the following OTC products would be most appropriate for him?
a. Tylenol
b. Advil Migraine
c. Excedrin Migraine
d. Butterbur
e. Sumatriptan
b
Butterbur is a natural product used to prevent migraines, not treat them.
IP presents to the pharmacy with an Rx for phenelzine (Nardil) to treat her depression. She wants to refill an old Rx on file for her migraines. She can’t recall the name of the migraine med, but she knows that it’s a “triptan.” Which med can she safely take with phenelzine?
a. Imitrex
b. Rizatriptan
c. Eletriptan
d. Zolmitriptan
e. Treximet
c
Sumatriptan, rizatriptan, and zolmitriptan are contraindicated with MAO inhibitors. The other triptans aren’t, though the warning about combining them with serotonergic drugs still applies.
SG is a 45 y/o female who presents to the pharmacy with a new RX for Migranal nasal spray. Which of SG’s meds would cause a major DDI with this new med?
Meds:
Alprazolam 0.5 mg BID
Bupropion SR 150 mg BID
Erythromycin 500 mg BID
Lamotrigine 100 mg daily
Metformin 1 g BID
Omeprazole 20 mg daily
Pravastatin 40 mg HS
a. Bupropion
b. Erythromycin
c. Lamotrigine
d. Omeprazole
e. Pravastatin
b
The ergot products contain a BBW not to use with mod-strong CYP3A4 inhibitors (e.g., erythromycin) d/t the risk of cerebral ischemia and/or peripheral ischemia because CYP3A4 inhibition elevates drug levels of ergot products.
Which of the following are common “triggers” for migraine attacks?
a. Changes in hormone levels
b. Brown rice
c. Stress
d. Alcohol
e. Bright lights
a, c, d, e
Triggers:
-Menstrual-associated migraine (MAM) - most common
-Alcohol (esp. beer and red wine), aged cheeses, chocolate, aspartame, overuse of caffeine, monosodium glutamate, salty foods, and processed foods
-Stress
-Sensory stimuli
-Changes in Wake-Sleep Pattern
-Changes in environment (weather)
Which of the following drugs used for migraine prophylaxis should be avoided in a female of childbearing age?
a. Propranolol
b. Timolol
c. Valproic acid
d. Topiramate
e. Lisinopril
c, d, e
Topiramate has a warning, and valproic acid and lisinopril have BBWs against their use in pregnancy d/t fetal harm.
Which of the following contraceptive options is recommended to treat menstrual-associated migraine (MAM) with aura in a female pt?
a. Norethindrone and ethinyl estradiol
b. Drospirenone and ethinyl estradiol
c. Estrogen transdermal patch
d. Estrogen vaginal ring
e. Progestin-only pill
e
Migraine with aura has a higher risk of stroke, and estrogen should be avoided.
AP is hospitalized for a diabetic foot infection. Her current meds include Glucophage XR 1000 mg daily, sertraline 100 mg daily, Zyban 150 mg BID, and Zyvox 600 mg BID. She’s been told that she may require an amputation of her left foot. The stress has induced a migraine. The Dr orders sumatriptan 50 mg x 1 now. Choose the correct statement:
a. Don’t fill the Rx for sumatriptan; suggest eletriptan instead.
b. Fill as written; this is the safest triptan to use and is considered 1st line.
c. Don’t fill any triptan at present.
d. Switch Glucophage XR to insulin and fill the sumatriptan Rx as written.
e. Don’t fill the Rx for sumatriptan; suggest duloxetine instead.
c
Labeling for triptans contains a warning about combining them with serotonergic drugs. This pt is on multiple.
A pt presents to the pharmacy with an Rx for Fiorinal. Choose the correct statement:
a. It contains an opioid.
b. It’s a C-III drug.
c. Risk of physiological dependence is low.
d. It’s a C-II drug.
e. It’s the preferred tx for migraine prophylaxis.
b
Butalbital is a barbiturate with a risk of physiological dependence. All butalbital-containing products, with the exception of Fioricet (acetaminophen/butalbital/caffeine), are federal schedule III controlled substances.
A pharmacist has an Rx for sumatriptan for a pt with the following active meds:
Avapro 150 mg daily
Plavix 75 mg daily
Crestor 10 mg daily
Lopressor 100 mg BID
NTG SL PRN
Aspirin 81 mg daily
The pt just checked his BP on the store’s machine. It’s currently 178/102. Should the pharmacist dispense the sumatriptan?
a. Yes, the pt’s high BP is likely caused by the migraine.
b. No, the pt can’t use sumatriptan with Lopressor.
c. No, the pt can’t use sumatriptan with Crestor.
d. No, the pt can’t use sumatriptan with Avapro.
e. No, the pt can’t use sumatriptan with this degree of HTN.
e
Triptans are contraindicated in pts with cerebrovascular disease (stroke, TIA), uncontrolled HTN, and ischemic heart disease (MI, angina).
