Migraines

Question 1

Migraine pathophysiology

Answer 1

neurovascular, Trigeminal nucleus caudalis, serotonin neurotransmission, calcitonin gene related peptide

Question 2

5HT receptors

Answer 2

5HT1 agonists: migraine treatment, 5HT2 antagonists: migraine prevention, 5HT antagonists: treatment of N/V

Question 3

Phases of the migraine

Answer 3

irritable, depressed, neck stiffness, fluid retention, thirst, drowsiness

Question 4

Migraine aura

Answer 4

neurologic symptoms, visual and somatosensory most common, speech, language, sx evolve slowly, 20-60 min before migraine

Question 5

Migraine attack

Answer 5

moderate to severe intensity, unilateral, throbbing pain, N/V, photophobia, phonophobia; sleep will alleviate

Question 6

Primary vs secondary headaches

Answer 6

primary: 90%, migraine, tension, cluster; secondary: tumor, meningitis, alcohol-induced

Question 7

Red flags of headache history

Answer 7

age of onset, time form onset to peak, intensity, pain level, aggravating factors, associated sx

Question 8

Post headache sx

Answer 8

fatigue, mood changes, decreased appetite, muscle weakness

Question 9

Diagnosis of migraine

Answer 9

at least 5 attacks meeting criteria of +/- aura, lasts 4-72 hours, pain 2 of 4 (moderate to severe intensity, unilateral, pulsatile/throbbing, aggravated with activity, N/V, photo/phonophobia

Question 10

Diagnosis episodic tension-type headache

Answer 10

bilateral, 30 min-7 days, pain 2 of 4 (bilateral, pressing/tightening, intensity mild-moderate, not aggravated by activity), no nausea/vomiting, +/- photo/phonophobia

Question 11

variable headache presentations

Answer 11

migraine +/- aura, episodic/chronic tension-type headache, menstrual migraines, sinus headache

Question 12

migraine treatment strategies

Answer 12

all pts diagnosed w/ migraine follow similar med ladder, simple analgesics, combo treatment, specific migraine therapies

Question 13

Non-pharm treatment

Answer 13

hydration, biofeedback, relaxation training, behavioral therapy, cold compress, sleep, cool, dark and quiet room, ha diary,

Question 14

Complementary treatments

Answer 14

feverfew, magnesium oxide, vit B2, coenzyme Q-10, valerian root, Omega 3

Question 15

Migraine prophylaxis

Answer 15

BB, CCB, TCA, anticonvulsants

Question 16

Acute apisodes

Answer 16

Nonspecific treatment: NSAIDs, antiemetics, Specific treatments: triptans, dihydroergotamine

Question 17

Lower need options

Answer 17

low-end therapy, NSAIDs, analgesics, triptans

Question 18

Moderate need options

Answer 18

combo analgesic/NSAIDs, antiemetics, triptans, prophylactic therapy

Question 19

high end need options

Answer 19

opiods, ergots, triptans, prophylactic therapy, consultation

Question 20

Acute migraine meds

Answer 20

triptans, ergotamine/dihydroergotamine, NSAIDs, opiods, anti-emetics

Question 21

Triptans MOA

Answer 21

serotonin (5HT) agonists, inhibit CGRP gene transcription, prevent release of neuropeptides which cause vasodilation/pain

Question 22

Triptans

Answer 22

DOC for acute attacks, not best for tension HA, take as soon as possible to onset, not for prevention

Question 23

Triptans metabolism

Answer 23

hepatic CYP450, avoid in hepatic

Question 24

Triptan interactions

Answer 24

MAOI: avoid use within 2 weeks of discontinuing MAOI, oral contraceptive potentially increase in [triptan], avoid use of ergot within 24 hours of triptans

Question 25

Triptans contraindication and precautions

Answer 25

concern for developing serotonin syndrome, concurrent admin of MAOIs, SSRIs; concern with vasoconstriction, MI, angina, silent ischemia, CAD, uncontrolled HTN, pregnancy cat C

Question 26

Serotonin syndrome interaction

Answer 26

rare, potential w/ SSRIs, & SNRIs, S/SX: agitation, confusion, muscle spasms, tachy, BP changes, N/D, diaphoresis

Question 27

Triptans ADRs

Answer 27

tingling, warmth, flushing, dizziness, somnolence, abnormal taste, pain at injection site, CX pain, neck pressure or discomfort may be serious sx

Question 28

Triptan drugs

Answer 28

Sumatriptan (Imitrex), Rizatriptan (Maxalt), Zolmitriptan (Zomig), Naratriptan (Amerge), Almotriptan (Axert), Frovatriptan (Frova), eletriptan (Relpax)

Question 29

Triptan drug with fastest onset

Answer 29

Sumatriptan (Imitrex), injectable

Question 30

Triptan drug given nasal spray

Answer 30

Sumatriptan (Imitrex),, Zolmitriptan (Zomig)

Question 31

Triptan given orally disintegrating tabs

Answer 31

Rizatriptan (Maxalt), Zolmitriptan (Zomig)

Question 32

Triptan with best tolerability and duration

Answer 32

Naratriptan (Amerge), Frovatriptan (Frova)

Question 33

Ergot derivatives

Answer 33

Ergotamine and dihydroergotamine, most affective at first sign of a migraine, all are sedating

Question 34

Ergot derivatives MOA

Answer 34

high affinity for serotonin 1 receptors, also interact with alpha adrenergic, dopaminergic, and serotonin 3 receptors

Question 35

Ergot derivatives ADRs

Answer 35

Severe sx, nonoral route preferred, N/V/D, vasoconstriction of systemic and coronary arteries

Question 36

Ergot derivatives FDA Boxed warning

Answer 36

risk of stroke and/or gangrene when taken with certain antibiotics, antiviral and antifungal drugs

Question 37

Antiemetics

Answer 37

Chlorpromazine (Thorazine), Metoclopramide (Reglan), Prochlorperazine (Compazine)

Question 38

symptomatic migraine medication

Answer 38

acetaminophen, caffeine, isometheptene (Prodrin), Acetaminophen, isometheptene, dichloralphenazone (Midrin)

Question 39

Isometheptene

Answer 39

a sympatomimetic, vasoconstrictor

Question 40

Dichloralphenazone

Answer 40

a sedative, prodrug converted to chloral hydrate

Question 41

NSAIDs drugs

Answer 41

naproxen, ibuprofen, aspirin

Question 42

NSAIDs pearls

Answer 42

beneficial in menstrual migraines, use for pt with infrequent, mild-moderate severity migraines

Question 43

Rescue medication

Answer 43

Opioids, APAP w/ codeine/hydrocodone or butorphanol, meperidine and tramadol; risk of dependency

Question 44

Prophylactic treatment

Answer 44

BB, CCBs, anticonvulsants

Question 45

Indication for prophylaxis

Answer 45

rule of 2s, HA >2 days per week or 2-4 x per month, use of acute tx >2 days/week, use of rescue > 2 x/month

Question 46

Approved prophylactic drugs

Answer 46

propranolol, topiramate, divalproex sodium, botulinum toxin A, also TCA (amitriptyline, nortriptyline), verapamil, gabapentin

Question 47

BB for prophylaxis

Answer 47

first line for prevention, chronic daily HA, modulate vascular tone, also anti HTN, contraindicated in asthma and COPD, propranolol, Atenolol, metoprolol

Question 48

Anticonvulsants drugs

Answer 48

topiramate (Topamax), Gabapentin (Neurontin), Divalproic acid (Depakote, Depakote ER)

Question 49

Topiramate (Topamax)

Answer 49

blocks Na channels, potentiates GABA activity, dose titrate to response, risk of kidney stones, ADRs: somnolence, wt loss, psychomotor slowing, tingling in extremities, difficulty concentrating, avoid in preg

Question 50

Gabapentin (Neurontin)

Answer 50

possibly effective, beneficial in pt with neuralgia

Question 51

Divalproic acid (Depakote)

Answer 51

reduces frequency, not severity, reduces excitatory amino acids, increases GABA activity, nausea, weakness, somnolence, wt gain, hair loss, liver toxicity, avoid pregnancy

Question 52

Botulinum toxin A (Botox)

Answer 52

Neurotoxin, muscle relaxant, anti-spasmotic, small doses injected in to neck every 3 months, starts working in 1 month, $$$$, droopy eyelid, anaphylactic rxn

Question 53

TCA drugs

Answer 53

amitriptyline (Elavil), Nortriptyline (Pamelor)

Question 54

TCA MOA, ADR, cautions

Answer 54

inhibition of peripheral sensitization, 5HT2 antagonism, increase GABA, sedation, anticholinergic, wt gain, glaucoma, urinary retention, no use in suicidal pts

Question 55

CCB

Answer 55

verapamil, nifedipine, MOA unknown, nifedipine may worsen HA, CT in pt with CHF, hypotension, arrhythmias