MIGRAINES

Question 1

*Mild-Mod HA - treatments

Answer 1

ASA or NSAIDS
ASA/APAP/Caffeine (Excedrin)
APAP + isometheptene +dichloralphenazone (Midrin)

Question 2

When are anti-emetics given for HA?

Answer 2

when N/V from HA or med used

• -> give 15-30 min prior
• ->can cause sedation
• ->Reglan, Chlorpromazine, Phenergan

Question 3

Cabergoline, dihydroergotamine, ergonovine, ergotamine, ergotamine + caffeine, methylergonovine - class?

Answer 3

Non-Selective 5-HT1 Receptor Agonist

Question 4

When are Non-selective 5-HT1 Receptor Agonists best use?

Answer 4

pre-headache/prodromal
–>no longer used in most patients for severe migraines due to SE
(“Ergos”)

Question 5

Non-selective 5-HT1 Receptor Agonist pregnancy?

Answer 5

No, X…except Methergine (C)

Question 6

*Acute Migraines - Treatment

Answer 6

NSAIDS/APAP
Selective 5-HT1 Receptor Agonists “Triptans”
best if used pre-HA

Question 7

Sumatriptan (Imitrex), Zolmitriptan (Zomig), Eletriptan, etc - Class?

Answer 7

Selective 5-HT1 Receptor Agonists

Question 8

Which triptan has the longest t1/2 (25 hrs)?

Answer 8

Frovatriptan (Frova)

Question 9

If using a triptan, can you redose if HA comes back?

Answer 9

Yes, second dose OK but don’t keep giving.

Question 10

DDI - most Triptans

Answer 10

MAO (do not take within 2 weeks)

Not frovatriptan and eletriptan

Question 11

Triptans - clinical issues

Answer 11

chest pain/pressure - ?may look like cardiac emergency

Tablets are best tolerated with least SEs

Question 12

Triptans - pregnancy?

Answer 12

Yes, C (safer than non-selective 5-HT1 receptor agonists)

Question 13

NSAIDS for HA

Answer 13

Ketorolac (Toradol) IV,IM
Naproxen PO
Ketorolac (Spirix) Nasal

Question 14

Opioids for HA

Answer 14

rarely used
reserved for severe, retractable
*addiction possibility

Question 15

Which opioid for HA?

Answer 15

Stadol (Butorphanol) NS

Question 16

When is Metoclopramide (Reglan) used for HA?

Answer 16

when N+V

OK for preg

Question 17

Treatment options refractory HA

Answer 17

MgSO4

Valproic acid

Question 18

Which blocks can be used for abortive treatment of HA?

Answer 18

lower cervical IM injection
Occipital nerve block (not if hx craniotomy)
Sphenopalatine ganglion block

Question 19

Migraine prophylaxis

Answer 19

avoid precipitants

TCAs, propranolol, topiramate, varapamil, valproic acid, NSAIDS

Question 20

Tension HA - treatment

Answer 20

treat underlying depression or anxiety disorder

NSAIDs/APAP/ASA

Question 21

Cluster HA - treatment

Answer 21

Acute: sumatriptan (or other)
100% O2 (8-10L/min) x 10-15 min
or Sumatriptan + O2

Question 22

Cluster HA - prophylaxis

Answer 22

Verapamil DOC

ergotamines, lithium, corticosteroids

Question 23

Botox for migraines - MOA

Answer 23

prevents release of acetylcholine which binds to nicotinic receptors and causes contraction –> relaxes muscle

Question 24

Methylergonovine AKA

Answer 24

Methergine

Question 25

Sumatriptan AKA

Answer 25

Imitrex

Question 26

All selective 5-HT1 receptor agonists (triptans) have MAO DDI except 2…

Answer 26

Eletriptan

Frovatriptan

Question 27

Migraine prophylaxis (5) - if want to avoid pharmaceuticals

Answer 27

Magnesium
Riboflavin (b2)
Coenzyme q10
Feverfew
Petasites (butterbur root)

Question 28

Which Selective 5HT1 Receptor Agonist is parenteral –> fast acting?

Answer 28

Sumatriptan (Imitrex) NS

Question 29

Ketorolac cautions

Answer 29

use <5 days
hydrate
Avoid if active GIB, renal impairment or bleeding

Question 30

Which NSAID is a good option for migraines if N/V?

Answer 30

Ketorolac (Parenteral or NS)