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PHAR255 > Migraines & Headache > Flashcards

Migraines & Headache Flashcards

1
Q

Describe a simplified pathophysiology of migraines.

A
  1. some people have sensitized neurons (unclear)
  2. a migraine trigger comes along
  3. brain releases potent vasodilators (CGRP, NO) and inflammation reactions
  4. vasodilation=big pain; inflammation begets more inflammation
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2
Q

What is the MOA of triptans?

A

selective serotonin agonists = vasoconstrictors

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3
Q

What is the MOA of NSAIDs?

A

anti-inflammation

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4
Q

What is the MOA of anti-CGRP drugs?

A

prevent/reduce vasodilation

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5
Q

What is critical with migraine treatment in regards to the timing of treatment?

A

early treatment=nip it in the bud=better efficacy
-hitting inflammation early is critical

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6
Q

What is migraine aura?

A

early warning sign of migraine

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7
Q

What percentage of people with migraines experience aura?

A

30%

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8
Q

What are the symptoms of aura?

A

visual aura (90% of symptoms)
-lightning bolts, blind spots, flickering bright lines
sensory disturbances
-tingling, numbness, pins and needles
speech disturbances
-difficulty word-finding

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9
Q

What are some migraine triggers?

A

stress
meal skipping
foods
alcohol
caffeine withdrawal
dehydration
menstruation
lights/sunlight
erratic sleep/shift work
perfume/odour
obesity
change in barometric pressure

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10
Q

What is the mnemonic used to help in the diagnosis of a migraine?

A

POUND
-pulsatile
-one day duration(4-72h if untreated or poor treatment)
-unilateral headache
-nausea or vomiting
-disabling intensity
each one is worth 1 point

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11
Q

What is the likelihood of migraine based on points derived from the POUND mnemonic?

A

4-5 pts = 92%
3 pts = 64%
0-2 pts = 17%

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12
Q

Describe a simplified treatment approach to acute migraine.

A
  1. NSAID
    -cheap
    -response in 4-5/10 patients
  2. triptan
    -bit of a boost compared to NSAIDs
    -can start here
    -response in 5-6/10 patients
  3. NSAID + triptan
    -combining is better than one alone
    -response in 6-7/10 patients
  4. subcutaneous sumatriptan
    -can start here if really bad migraines
    -response in 8/10 patients
  5. refractory patients
    -manage agent failure
    -try alt combinations (acet, NSAIDs, triptans, metoclopramide, caffeine)
    -start migraine prophylaxis
    -possibly try DHE nasal spray
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13
Q

What is “response” defined as for acute migraines?

A

pain relief at 2 hours
-placebo response is 2-3/10 patients

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14
Q

Which agent has the fastest onset for acute migraine?

A

subcutaneous sumatriptan

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15
Q

Which drugs should be avoided in acute migraine?

A

opioids and barbiturates
-risk of MOH, AE, and overdose
-not doing anything for inflammation
-2x as likely to cause MOH

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16
Q

Which agent can be added anywhere along the treatment approach to acute migraine to improve efficacy and decrease nausea?

A

metoclopramide
-anti emetic by speeding up GIT motility
-faster absorption of other drugs

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17
Q

What is the DHE nasal spray?

A

dihydro ergotamine
-hits 5HT receptors but dirtier (more AE)
-almost never used

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18
Q

How can we manage NSAID failure for acute migraine?

A

ensure NSAID is taken at earliest onset of migraine pain and on an empty stomach (food delays onset)
try a faster-acting NSAID formulation (10-20 min faster than regular tabs)
-naproxen sodium, ibuprofen liquid gels, diclofenac potassium

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19
Q

Differentiate naproxen sodium and naproxen base.

A

naproxen sodium is 20-30min faster than naproxen base
-sodium of choice for migraine

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20
Q

What are the benefits of migraine prophylaxis?

A

decrease intensity of migraines and less migraines
decreasing intensity helps boost efficacy of other drugs

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21
Q

How can we manage triptan failure for acute migraine?

A

ensure triptan is taken at earliest onset of migraine pain
switch to a different triptan
-try for at least 3 different migraines (not a class response)
add acetaminophen, NSAID, or metoclopramide
ensure adequate absorption
-switch to injectable or nasal spray if vomiting dose
fast-acting triptan often preferred but if tolerability concerns then try slow-onset triptan

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22
Q

What are the slow-onset triptans?

A

naratriptan
frovatriptan

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23
Q

What are the fast-acting triptans?

A

eletriptan
almotriptan
rizatriptan
sumatriptan
zolmitriptan

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24
Q

Why should Tylenol #3 be avoided for migraines in almost every patient?

A

opioids have double the risk of MOH
caffeine dose is subtherapeutic
-~100mg needed for migraine efficacy, T3 has 15mg
acetaminophen dose is often subtherapeutic
-1000mg has best evidence, would need T3 x 3
codeine metabolism is unpredictable

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25
What are the side effects and contraindications of triptans?
triptans are potent vasoconstrictors -chest discomfort/tightness, palpitations, dizziness, flushing -CI in CV disease (uncontrolled HTN, previous stroke/MI, etc) -CI within 24h of ergots due to coronary vasospasm; do not combine triptans triptans are potent 5HT agonists -nausea -CI with MAOI (serotonin syndrome) and caution with other serotonergic drugs (increase monitoring)
26
What are some considerations when deciding which triptan is best for your patient?
fastest relief: 10-15min with SC or nasal best efficacy at 2hr: SC suma -lowest efficacy at 2hr: nara or frova best tolerability: slow onset or nara or frova decreases AE or nausea best if long-lasting attacks: nara or frova best for privacy: ODT (no H20) lower cost: almo po useful if vomiting: SC or nasal or add antiemetic
27
True or false: all triptans have similar safety in hepatic and renal disease
false
28
Which triptan has the highest efficacy?
SC sumatriptan -works in up to 80% of patients -useful if vomiting/severe nausea with oral agents -guarantee absorption
29
What are some tips and tricks for acute migraines?
try a triptan for at least 3 migraines before giving up and try at least 3 triptans before giving up on the class acetaminophen alone or in combo can be helpful -overall less powerful than NSAIDs N/V is common with migraines -ODT, antiemetic, intranasal, injectable = all useful
30
True or false: ODT triptans are faster than regular tabs
false they are not buccal, absorbed in the intestine useful if water causes nausea
31
What is the max days per month of acute meds to help avoid MOH?
opioids: 9 days triptans: 9 days NSAIDs or acet: 14 days multiple classes: 9 days
32
What is menstrual migraine?
for some, migraines increase during menstruation
33
What are the options for pre-treatment of menstrual migraine?
start ~2 days before treatment -naproxen 500mg BID x ~6 days -frovatriptan 2.5mg BID x ~6 days -naratriptan 1mg BID x ~6 days -estradiol gel 1.5mg daily x 7 days option for prevention with continuous CHC -but CHC + migraine with aura = CI
34
What are the available anti-CGRP drugs?
ubrogepant -treatment dose: 50-100mg stat rimegepant and zavegepant (USA) atogepant approved for prevention -10-60mg daily
35
What are the adverse effects of the anti-CGRP drugs?
nausea somnolence
36
What are the benefits of the anti-CGRP drugs?
not CI in CV disease very low risk of MOH
37
What is a con of the anti-CGRP drugs?
not as effective for acute migraine -although not compared head to head
38
Who should consider utilizing migraine prophylaxis?
patient preference -patient prefers prophylaxis for any reason frequent attacks -e.g. > 6 headache days/month severely disabling attacks -especially if > 3/month difficult-to-treat attacks -acute tx doesnt work well, is CI, or causes problems
39
Describe the steps in setting up an adequate trial for migraine prophylaxis.
1. initiate a headache diary 2. start a migraine prevention drug at a low dose 3. increase dose gradually q1-2wks guided by target dose range, patient response and tolerability 4. remain at that dose for ~8-12wks to assess effectiveness and tolerability 5. assess and decide whether to continue, increase the dose, or taper/dc
40
Which agents have the best efficacy data for migraine prophylaxis?
amitriptyline 50-75mg/d hs propranolol 80-160mg/d metoprolol 100-200mg/d topiramate 100mg/d
41
Which agents for migraine prophylaxis have the fewest adverse effects?
candesartan 16mg/d magnesium 500-600mg/d riboflavin 400mg/d
42
Which agent might be tried for migraine prophylaxis if the patient wants to pursue smoking cessation?
nortriptyline
43
Which agent might be tried for migraine prophylaxis if the patient experiences insomnia?
amitriptyline
44
Which agent might be tried for migraine prophylaxis if the patient has hypertension?
beta-blocker candesartan lisinopril verapamil
45
Which agent might be tried for migraine prophylaxis if the patient has chronic pain?
amitriptyline venlafaxine duloxetine topiramate possibly gabapentin
46
Which agent might be tried for migraine prophylaxis if the patient has depression or anxiety?
venlafaxine duloxetine amitriptyline
47
What are some tips and tricks for migraine prophylaxis?
set realistic expectations -decrease in migraine days/month by >50%; less severe headaches use a headache diary -watch for triggers & track medication effectiveness + tolerability be patient: allow time to stabilize on an effective dose -effectiveness increases with time -tolerability improves with time help manage side effects
48
What are the next steps if a trial of migraine prophylaxis fails?
consider: -another drug class -combo therapy -a CGRP antagonist if failure with 2 or more agents
49
How long should we treat at target dose before deciding if prophylaxis is helping?
8-12 weeks
50
Which beta-blockers are used for migraine prophylaxis and what are their target doses?
propranolol: 40-80mg BID, 80-160mg LA metoprolol: 50-100mg BID, 100-200mg SR timolol: 10-15mg BID
51
Which TCAs are used for migraine prophylaxis and what are their target doses?
amitriptyline: 50-75mg hs nortriptyline: 50-75mg hs
52
Which anticonvulsants are used for migraine prophylaxis and what are their target doses?
topiramate: 50mg BID divalproex: 500-750mg BID cc
53
What is a caution with anticonvulsants as migraine prophylaxis?
caution with women of child-bearing age
54
Which ACEI and ARBs are used for migraine prophylaxis and what are their target doses?
candesartan: 16mg daily lisinopril: 20mg daily
55
Which SNRIs are used for migraine prophylaxis and what are their target doses?
venlafaxine 150mg daily duloxetine: 60mg daily
56
What is the target dose of pizotifen for migraine prophylaxis?
1.5mg hs
57
What is the MOA of pizotifen?
serotonin antagonist
58
What is an adverse effect of pizotifen?
very sedating
59
Which CCBs are used for migraine prophylaxis and what are their target doses?
flunarazine: 10mg hs verapamil: 240mg daily with food
60
Which herbals are used for migraine prophylaxis and what are their target doses?
magnesium oxide: 500mg elemental daily magnesium citrate: 300mg BID riboflavin: 400mg daily
61
What is an adverse effect of high dose riboflavin?
neon-yellow urine
62
What are the anti-CGRPs used for migraine prophylaxis?
fremanezumab: 225mg SC q4wk or 675mg SC q12wk eptinezumab erenumab galcanezumab atogepant rimegepant
63
What are some "other" drugs used for migraine prophylaxis?
memantine: 10mg hs Botox: maybe if > 15 migraine days/month
64
What is a critical drug interaction of propranolol with respect to migraines?
slows metabolism of rizatriptan and thus levels increase 70%
65
How can we manage the propranolol-rizatriptan drug interaction?
use 5mg rizatriptan tabs instead of 10mg change triptans change beta-blockers
66
What is the MOA of the CGRP MABs?
MAB targeting calcitonin gene-related peptide
67
What is the response rate of the CGRP MABs?
40% of patients
68
Which CGRP MAB is covered by Sask and NIHB?
fremanezumab -failed two po prophylactic agents
69
How frequently is fremenazeumab dosed?
can be given q3mo but prefer monthly (better Css)
70
What are the adverse effects of CGRP MABs?
injection site rxn hypertension
71
What are the red flags of acute headache?
emergency (call for ambulance) -worst HA -impaired speech, strength, sensation, consciousness -neck stiffness or fever -thunderclap HA -head trauma -eye symptoms urgent (send for referral) -first ever headache -headache with exercise or sex -new headache if age >50 yrs -HIV, cancer, lyme dx, pregnancy -papilledema -older adult with cognitive changes
72
What are the different types of headaches?
migraine tension type cluster
73
Describe migraines based on the following: -duration -location -pain description -symptoms -acute tx -prophylaxis
duration: 4-72h location: typically unilateral (but 40% bilateral) pain: pulsating, mod-severe sx: N/V, photophobia, phonophobia, aura (5-60min), triggers acute tx: NSAIDs, acet, triptan, anti-emetic, DHE prophylaxis: BB, TCA, topiramate, candesartan, herbs, anti-CGRP, venlafaxine
74
Describe tension type headache based on the following: -duration -location -pain description -symptoms -acute tx -prophylaxis
duration: 30min-7d location: typically bilateral pain: photo or phonophobia, NO N/V, not usually triggered by routine activity acute tx: NSAIDs, acet prophylaxis: TCA
75
Differentiate frequent and infrequent TTH.
infrequent: < 1 day/month average frequent: 1-14 days/month average
76
Describe cluster headache based on the following: -duration -location -pain description -symptoms -acute tx -prophylaxis
duration: 15min-3h (untreated) location: unilateral, orbital, supraorbital, temporal, combo pain: stabbing, nonpulsating, severe to excruciating sx: clusters qod up to 8 HA/d, ipsilateral, nasal, eye, sweating, restlessness acute tx: SC sumatriptan prophylaxis: verapamil (240-960mg/d)
77
Differentiate episodic and chronic cluster headache.
episodic: 2 cluster periods lasting 7-365d, remissions of >1 month chronic: episodes recur for >1 year without remission or with remission lasting < 1 month
78
What is MOH?
chronic HA caused by the overuse of acute HA medication that often provides inadequate pain relief - > 15 HA days/month -common to wake up with a daily HA
79
What causes MOH?
> 9 days/month of triptans or opioids > 14 days/month of NSAIDs or acet > 9 days/month of combo
80
How can we break the cycle of MOH?
recognize MOH stop the overused med create a prevention and treatment plan to avoid relapse
81
How is MOH treated?
stopping the overused medication stop or taper the overused med while starting a prophylactic med start prophylactic med only
82
What is considered resolution of MOH?
return to episodic headaches ( < 15 days/month) -allow 3 months to establish new baseline
83
What are some tips and tricks for treating MOH?
educate all patients on risk of MOH prophylactic meds may become more effective once the overused med is stopped headache diaries non-drug approaches
84
What are the withdrawal symptoms of MOH?
HA will increase in pain and frequency before they improve anxiety, NV, sleep issues generally last 2-10 days but can be up to 2-4wks meaningful improvement in HA frequency usually 4-8wks

PHAR255 (24 decks)

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