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SHPCPJEN3 > Migraines > Flashcards

Migraines Flashcards

1
Q

Migraine prophylaxis if > 3 migraine per month

Prevention of migraine NOT for tx

A

• BB - Metoprolol, propranolol , timolol - ( FDA approved for migraines propranolol and timolol )
• Verapamil
•amitriptyline, Venlafaxine ext release ( Effexor XR )
•divalproex sodium ( depakote ) - teratogenic, N/V , weight gain, alopecia, hepatotoxicity, pancreatitis
• topamax - teratogenic
• amitriptyline

•botulinum toxin
•dietary supplements : butterbur, feverfew

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2
Q

Tx for acute attacks

A

• asa
• Asa or apap with caffeine ( all 3 : excedrin migraine )
•NSAIDs : ketoralac, naproxen, indomethacin , diclofenac, ibuprofen
• Nodolor : isomethaptene + dichloralphenazone + apap
•butalbital compounds - tension or muscle contraction HA
• triptans — INCREASES serotonin and are Vasoconstrictors
• ergot alkaloids

•for nausea : metoclopramide ( reglan )- decreases dopamine ( cant use for parkinsons patients ) , prochloperazine, chlorpromazine

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3
Q

Treximet

A

Sumatriptan - naproxen

Oral formulation that works well

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4
Q

Naratriptan

A

Amerge

Oral tabs

The only triptan the patient has to wait 4 hours between doses. ( other triptans you only have to wait 2 )

Also it takes 1 to 3 hours to work. Slow onset

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5
Q

Rizatriptan

A

Maxalt / Maxalt -MLT

Oral and odt

2 hours between each dose.
Onset 30 mins.

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6
Q

Sumatriptan

A

Imitrex
Alsuma- subq initial dose 6 mg
Sumavel - subq initial dose 6mg
Zembrace - subq initial dose 3 mg
Onzetra - nasal formulation ( second quickest after sub q form)

Tabs subQ nasal

Only Triptan that comes subq

2 hours between doses. ( for subq only have to wait one hour between doses )
Onset 30-60 min
Max dose of 200 mg in 24 hours

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7
Q

Zolmitriptan

A

Zomig; zomig zmt

Oral, odt, nasal

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8
Q

Almotriptan

A

Axert

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9
Q

Frovatriptan

A

For a

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10
Q

Eletriptan

A

Relpax

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11
Q

TRIPTANS MOA
SE
Contraindications

A

MOA: 5HT receptor agonists

SE: N headache recurrence, chest tightness, dizziness, sleepiness, parathesias ( numbness or tingling )

Contraindications: uncontrolled HTN, vasospastic angina ( prinzmetal), ischemic stroke, ischemic heart disease
Pregnancy category C

Kids 6- 11 recommend Maxalt tabs or imitrex nasal

Contraindicated with ergots and MAOI’s ( linezolid , tedizolid )

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12
Q

DDI with TRIPTANS

A

Triptans increase 5HT ( watch for additive ): ssri, SNRI,

Watch for MAOI: selegiline : EMSAM MAOI watch for high doses.

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13
Q

Almotriptan

A

Axert

All triptans pregnancy category C

Only tabs
2 hours between dose
Onset 30-60 mins

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14
Q

Frovatriptan

A

Frova

Only comes in 2.5 mg tabs

2 hrs between doses.

Longest elimination half life 24 hours
But slow onset about 2 hours

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15
Q

Eletriptan

A

Relpax
Only tabs

Max 80mg/day
Works in 30 to 60 mins

DDI: cyp3a4 substrate. Do not use withing 72 hours of strong inhibitors ( keto, itra, voriconazole, posconazole, erythromycin, clarithromycin, verapamil, diltiazem, any protease inhibitor, strongest is Ritonavir ) and grapefruit juice too ( 3a4 inhibitor )

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16
Q

SubQ formulation works faster than other formulations

A

T and sumatriptan is the only fast formulation.

17
Q

ODT formulations of triptans

A

Maxalt and zomig

18
Q

Trexemet

A

Sumatriptan and naproxen

19
Q

Ergot alkaloids

A

Major vasoconstrictors ( much more than triptans). They increase 5HT, increase NE, dopamine.
Pregnancy category X.

Indication: Migraine / one for cluster headache

• dihydroergotamine mesylate
Migranal - nasal spray
D.H.E. 45 : IV IM SQ

• ergotamine Tartrate
( ergomar ) SL Tabs

•ergotamine + caffeine
Cafergot ( Tabs ) and Migergot( suppository )

20
Q

Butalbutal / Caffeine / APAP

A

Fioricet - cet for apap

Fiorinal - ASA instead of apap. C3 bc it has increased CNS effects

21
Q

Nodolor

A

Isomethptene + Dichloralphenazone + acetaminophen

Isometheptene is a vasoconstrictor
Dichloralphenazone : sedating analgesic effect
Apap :

Max 5 caps in 12 hours

DDI : maoi’s

22
Q

Excedrin migraine

A

OTC

Apap + ASA + Caffeine

Pregnancy category D: aspiring component

23
Q

New migraine medications

A

Prevention: monoclonal abs ( mabs) : all refrigerated. Dont shake them.
• Erenumab ( Aimovig ) SQ
• Fremanezumab ( Ajovy ) SQ
•Galcanezumab ( Emgality ) SQ
•Eptinezumab ( Vyepti ) IV

Treatment:
Calcitonin gene related peptide ( CGRP ) antagonists
( Gepant’s ) - all are cyp3a4 substrates

Remegepant ( Nurtec ODT ) - cyp3a4 substrate
Uborgepant ( Ubrelvy ) -cryp3a4 substrate

Selective serotonin 5-HT1 F agonists : Lasmiditan ( Reyvow)

24
Q

Rimegepant

A

Nurtec ODT

CGRP antagonist for the tx of migraine

Max 75 mg /24 hours

Dose : 75 mg odt as a single dose

Wait 48 hours if on a moderate cyp3a4. Avoid if on strong cyp3a4

Inhibitors will increase it. And inducers will decrease it.

25
Q

Strong cyp3a4 inhibitors

A

GPAC

Grapefruit juice
Protease Inhibitors - strongest is Ritonavir
Azoles and amiodarone
Clarithromycin and erythromycin and CCB ( verapamil and diltiazem )

26
Q

Strong Cyp3a4 inducers

A

SRCOP

St. John’s wort
Rifampin ( major inducer )
Carbamazepine,
oxcarbazepine,
phenytoin, phenobarbital

27
Q

Ubrogepant

A

Ubrelvy

1 hour onset ( Nurtec was 2 )

28
Q

Lasmiditan

A

reyVow: this is CV C5

SE: major sedation. Hullicinations euphoria. Dont drive or operate ( at least 8 hours)

Benefit: unlike triptans this does not cause vasoconstriction.

DDI : watch for serotonin syndrome

29
Q

What drugs increase seratonin?

A

SSRIs, SNRIs
MAOIs linezolid ( zyvox) tedizolid ( Sivextro ) , phenelzine
Pain: tramadol, nucenta ( tapendatol ) , fentanyl, methadone, meperidine
TCAs
Cyclobenzaprine ( structurally like TCA and carabamazepine )

30
Q

Cluster headaches

A

Very painful. Usually on one side of the face for patient.

Need tx that works fast. ( SQ sumatriptan is fastest)

Prophylaxis : verapamil 240 mg /day in divided doses

SHPCPJEN3 (13 decks)

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