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Clinical Pharmacy 4 > Migraines > Flashcards

Migraines Flashcards

1
Q

How far in advance of a migraine does the prodromal phase occur?

A
  • 24-48 hours in advance
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2
Q

Can MOH ever come before another type of headache?

A
  • no!

always presents after a tension type headache or a migraine

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3
Q

What are some of the factors that would lead you to think the person is experiencing a MOH?

A
  • > 15 headaches per month

- untreated headaches that last over 4 months

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4
Q

What is one characteristic of a MOH that distinguishes it from other headaches?

A
  • usually are present first thing in the morning - migraines sx typically develop throughout the day and they will have disappeared by the morning
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5
Q

What is considered to be a chronic migraine?

A
  • headache occurring on 15 or more days for more than 3 months
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6
Q

What are the typical s/s of a migraine headache?

A
  • unilateral (most often) - but not always on the same side
  • throbbing, pulsating
  • attack progressively worsens over hours
  • often n/v
  • photophobia/phonophobia
  • osmophobia and cutaneous allodynia
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7
Q

What are some of the main red flag symptoms associated with migraines?

A
  • age > 50 y/o
  • severe and abrupt
  • worsening over days-weeks
  • stiff neck, focal signs, reduced consciousness, abnormal speech, motor reflex, cognitive impairment
  • fever, rash, n/v
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8
Q

What are the risk factors associated with medication overuse headaches?

A
  • anxiety/depression
  • smoking
  • women ( <50 y/o)
  • high caffeine intake ( >2 cups of coffee/day)
  • physical inactivity
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9
Q

What ar the most typical signs and symptoms associated with a MOH?

A
  • am symptoms
  • poor acute tx response
  • > 15 headache days per month (often daily with a pre-existing migraine)
  • overuse of acute meds (>3 months)
  • neck pain
  • increased variability
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10
Q

What meds are considered to be “low risk” for MOH?

used >15 days/month

A
  • NSAIDS
  • acetaminophen
  • ASA
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11
Q

What meds are considered to be “moderate risk” for MOH?

used >10 days/month

A
  • triptans

- ergotamine

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12
Q

what meds are considered to be “high risk” for MOH?

used > 5-10 days/month

A
  • opioids
  • butalbital products (5 days)
  • ASA/acetaminophen
  • use of >1 acute medication
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13
Q

What is a type 1 (uncomplicated) type of MOH?

A
  • no hx of drug misuse
  • not using opioids, barbiturates
  • no significant and/or uncontrolled psychological concerns
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14
Q

What is a type 2 (complicated) MOH?

A
  • previous withdrawal failure
  • significant/uncontrolled psychological concerns
  • hx of drug misuse
  • using opioids and/or barbiturates
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15
Q

Who would benefit most from a slow taper of there migraine medications?

A
  • patients using opioids/barbiturates (caffeine?); previous unsuccessful abrupt weans, significant anxiety over medication removal
  • psychiatric co-morbidities
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16
Q

Who would benefit most from an abrupt wean of migraine medications?

A
  • patients using acute medications other than opioids/barbiturates, motivated and accepting of process
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17
Q

How long is bridge therapy typically for?

A
  • 5-10 days
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18
Q

What is bridge therapy?

A
  • purpose of it is to get the person over to their prophylactic therapy with the least amount of pain possible
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19
Q

What medications are typically used for bridge therapy?

A
  • NSAIDS
  • corticosteroids (dexamethasone, prednisone)
  • asa
  • triptans
  • DHE (nasal spray)
20
Q

Once back to episodic migraines, you can reintroduce what?

A
  • migraine specific prn medications (need to only be used <2 days a week)
21
Q

What are some possible withdrawal symptoms after medication removal for headaches?

A
  • increase in headaches
  • n/v
  • tachycardia
  • restlessness
  • insomnia
  • anxiety
22
Q

How long do withdrawal sx of medications typically last?

A

3-10 days (up to 4 weeks)

23
Q

What are the main principles of prophylactic migraine therapy?

A
  • start low and titrate slowly (for max dose, or to intolerable effects)
  • trial drug for adequate period of time (delayed response)
  • consider patient specific characteristics
  • discuss expected benefits with patients
  • in treatment failure, try drug from different therapeutic class
  • lifestyle measures are also important
24
Q

What is valproate CI’ed in?

A
  • pregnancy
  • nausea
  • weight gain
  • alopecia
  • transaminitis
  • pancreatitis
  • agranulocytosis
25
Q

What are the main SE associated with topiramate?

A
  • parasthesias
  • change in taste
  • cognitive SE
  • anorexia/weight loss
  • aggravates depression
  • category D in pregnancy
26
Q

What is the MOA of beta- blockers?

A
  • raises the migraine threshold by modulating the adrenergic system and 5HT transmission in cortical pathways of the brain
27
Q

When are beta-blockers first line?

A
  • especially in patients <60 years, hypertension or CVD
28
Q

Beta-blockers with ___________ may not be effective

A

intrinsic sympathomimetic activity

29
Q

What are the main SE associated with beta blockers?

A
  • fatigue
  • bradycardia
  • hypotension
  • coldness of extremities
  • vivid dreams
  • depression
  • impotence
  • bronchospasm
30
Q

In what illnesses are beta blockers CI’ed?

A
  • asthma
  • heart block
  • uncompensated heart failure
  • peripheral vascular disease
31
Q

What is the MOA with antidepressants in migraines?

A
  • down regulates central 5HT receptors, increases synaptic NE levels, enhances endogenous opioid receptor action
  • consider in those with comorbidities: depression, insomnia, neuropathic pain, tension-type headache
32
Q

What antidepressant is used first line?

A
  • tricyclic antidepressants (amitripyline, nortriptyline)
33
Q

What antidepressants are typically chosen second line?

A
  • venlafaxine, duloxetine
    (2nd line with less evidence)
  • once daily dosing, beneficial if co-morbid anxiety/mood disorders
34
Q

What ar the main SE associated with TCAs?

A
  • anticholinergics (avoid in BPH, glaucoma), sedation, increased appetite, weight gain, orthostatic hypotension, cardiac toxicity (slowed atrioventricular conduction)
35
Q

When should antidepressants NOT be used?

A
  • avoid in heart block
  • significant CVD
  • urinary retention
  • uncontrolled glaucoma
  • prostate disease
  • mania
36
Q

What are the main SE associated with venlafaxine?

A
  • n/v
  • drowsiness
  • sexual dysfunction
37
Q

When should venlafaxine not be used?

A
  • avoid in hypertension

- avoid in kidney failure

38
Q

What is a CGRP antagonist?

A
  • mABs for the preventative tx for migraine for target CGRP (calcitonin gene-related peptide)&raquo_space;> CGRP is a vasodilatory neuropeptide w/ NB role for migraines
39
Q

Do CGRP antagonists work much better with migraines than other prophylactic therapy?

A
  • no- do not appear to be more significantly effective than other prophylactic treatment
  • some patients had significantly better responses than others
40
Q

What is the main CGRP antagonist available?

A
  • erenumab
41
Q

What are the main SE associated with CGRP antagonists?

A
  • GI: constipation
  • immunologic: antibody development
  • local: injection site reaction
  • neuromuscular and skeletal: muscle cramps, muscle spasms
42
Q

Who should CGRP antagonists be considered for?

A
  • severe disability and lack of benefit from or unable to tolerate existing alternatives
  • difficulty adhering to daily medication regimens
  • polypharmacy (antibodies =low risk of DIs)
43
Q

Who should CGRP antagonists be avoided in?

A
  • infrequent h/a’s and/or h/a’s that respond to abortive treatment
  • pregnancy or possibility of becoming pregnant (long duration of action; levels of CGRP are lower in women with preeclampsia)
  • known cardiovascular disease or high risk (CGRP may have a cardioprotective effect during ischemic emergencies)
44
Q

CGRP antagonists - exercise caution with patients who are:

A
  • concomitantly, regularly exposed to vasoconstrictive drugs or substances (CGRP blockade may be risky)
45
Q

When should women not be using oral contraceptives when they have migraines?

A
  • when they have an aura- should be encouraged to try an alternative form of contraception (no estrogen)

Clinical Pharmacy 4 (7 decks)

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