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255B > Migraines & Headaches > Flashcards

Migraines & Headaches Flashcards

1
Q

List some migraine triggers

A

stress
meal-skipping (consider food insecurity)
foods (e.g. chocolate or soft cheese)
alcohol (especially red wine)
caffeine withdrawal
dehydration
menstruation
lights/sunlight
erratic sleep / shift work
perfume/odour
obesity
change in barometric pressure

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2
Q

Describe migraine aura

A

an aura occurs in around 30% pt. Most often it is a flickering bright line, blind spot or lightning bolts that warn pt they are about to have a migraine

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3
Q

MOA of Triptans

A

selective serotonin agonists –> vasoconstrictors

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4
Q

Contraindications of Triptans

A

CV disease
within 24 hours of ergots
MAOIs (risk of serotonin syndrome) and cautioned with other serotonin drugs

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5
Q

Why ergots and triptans should not be combined

A

due to additive coronary vasospasm (could cause MI)

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6
Q

List Triptan side effects

A

nausea, serotonin syndrome, chest tightness, poor taste with nasal sprays, injection site reactions with subcut injections

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7
Q

Which triptans are slow acting and which are fast acting?

A

Slow - nara / frova
Fast - suma/riza/zolmi/almo/ele

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8
Q

Why should opioids be avoided in migraines?

A

higher chance of medication overuse headache
subtherapeutic acet and caffeine
codeine metabolism is unpredictable

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9
Q

Tx option for Menstrual migraine

A

Option for pre-treatment (starting ~2 days before mensturation):
Naproxen 500mg BID x ~6 days ($5)
Naratriptan 1mg BID x ~6 days ($100)
Frovatriptan 2.5mg BID x ~6 days ($200)
Estradiol gel 1.5mg daily x ~7 days ($40)

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10
Q

What is the role of anti-emetics in migraines?

A

works to help reduce nausea and might get the GI tract moving faster getting the medication into body faster

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11
Q

What is the role of CGRP antagonists in acute migraines?

A

for people with CV disease or have failed on triptans

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12
Q

What is the role of CGRP antagonists in prophylaxis?

A

it is slower than needed for acute, work like a mop and clean up which is better for prophylaxis

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13
Q

What is the max days/month for triptans to avoid medication overuse headache?

A

9

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14
Q

What is the max days/month for opioids to avoid medication overuse headache?

A

9

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15
Q

What is the max days/month for NSAIDs to avoid medication overuse headache?

A

14

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16
Q

What is the max days/month for multiple classes to avoid medication overuse headache?

A

9

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17
Q

What is the max days/month for acetaminophen to avoid medication overuse headache?

A

14

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18
Q

What is the onset of action and target adult dosing for migraine prophylactic using propranolol

A

onset - 8-12 weeks
target doses - 40-80 mg BID

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19
Q

What is the onset of action and target adult dosing for migraine prophylactic using metoprolol

A

onset - 8-12 weeks
target doses - 50-100 mg BID

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20
Q

What is the onset of action and target adult dosing for migraine prophylactic using amitripyline

A

onset - 8-12 weeks
target doses - 50-75 mg HS

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21
Q

What is the onset of action and target adult dosing for migraine prophylactic using nortripyline

A

onset - 8-12 weeks
target doses - 50-75 mg HS

22
Q

What is the onset of action and target adult dosing for migraine prophylactic using topiramate

A

onset - 8-12 weeks
target doses - 50 mg BID

23
Q

What is the onset of action and target adult dosing for migraine prophylactic using candesartan

A

onset - 8-12 weeks
target doses - 16 mg daily

24
Q

What is the onset of action and target adult dosing for migraine prophylactic using fremanezumab

A

onset - within days but give 3-6 months for adequate trial
target doses - 225 mg SC q4wk

25
Q

What is the general three criteria for when to consider migraine prophylaxis

A

patient preference/request
frequent attacks - > 6 headache days/month
severly disabling
difficult to treat attacks

26
Q

How do you measure success for migraine prophylaxis

A

set realistic expection - decrease day/month by 50% or less severe headaches
use headache diary
be patient will help get to the proper dosage

27
Q

Explain some factors to consider when individualizing selection of a migraine prophylactic agent

A

There is a group for the best efficacy data, few adverse effects, presence of comorbidities (smoking, insomnia, hypertension, chronic pain, depression/anxiety)

28
Q

Know the MOA of CGRP antagonist

A

prevents/reduce vasodilation

29
Q

A/E of CGRP monoclonal antibodies

A

injection site reactions, hypertension. Patients with CV risk were excluded from trials

30
Q

What is the onset of action for CGRP antagonists in migraine prophylaxis

A

within a few days but need 3-6 months to be an adequate trial

31
Q

List a critical DDI with triptans

A
  1. Propranolol slows rizatriptan metabolism and this increases levels by ~70%
  2. For any pt on propranolol, use risa 5 mg tabs or switch to a different triptan or BB
32
Q

List all the flags for ER headache referral

A

worst headache
impairment of speech, sensation, strength or consciousness
fever or neck stiffness
thunderclap headache
ey sx
head trama

33
Q

List all the red flags for referring headaches to a walk in clinic or MD assessment

A

first ever headache
headache with exercise or sex
new headache if age > 50 yo
HIV, cancer, lyme dx or pregnancy
papilledema
older adult with cognitive changes

34
Q

What does POUND mnemonic

A

Pulsatile quality of headache
one day duration of headache
unilateral headache
nausea or vomiting
disabling intensity of headache

35
Q

List the duration, location, pain description for migraines

A

Duration - 4-72 hours
Location - typically unilateral
Pain Description - usually pulsating pain, moderate to severe intensity

36
Q

List the duration, location, pain description for tension type headaches

A

Duration - 30 minutes to 7 days
Location - typically bilateral
Pain Description - usually pressing or tightening pain; mild to moderate intensity

37
Q

List the duration, location, pain description for cluster headache

A

Duration - 15 min to 3 hours when untreated
Location - unilateral orbital, supraorbital, temporal or a combo
Pain Description - stabbing, non pulsating pain; severe to excruciating intensity

38
Q

Describe some common symptoms of migraines

A

During the headache patients experience at least one of: nausea, vomiting, photophobia, and/or phonophobia.

Can be aggravated by (or cause avoidance of) routine physical activity (e.g. walking or climbing stairs).

Aura (1 in 3 patients): may include reversible visual symptoms (e.g. flickering lights, spots, or lines; loss of vision), reversible sensory symptoms (e.g. pins & needles, numbness) or reversible dysphasic speech disturbance. Each aura symptom may last 5-60 minutes.

39
Q

Describe some common symptoms of tension type headaches

A

Either photophobia or phonophobia are present.

Nausea and vomiting are NOT present.

Usually not aggravated by routine physical activity such as walking or climbing stairs.

40
Q

Describe some common symptoms of cluster headaches

A

Occurs in clusters from every other day to up to 8 headaches per day.

May have the following ipsilateral symptoms: conjunctival injection or lacrimation, nasal congestion or rhinorrhea, eyelid edema, forehead and facial sweating, miosis or ptosis, restlessness or agitation

41
Q

List some acute and prophylaxis tx for migraine

A

acute - NSAID, triptan, acetam, anti-emetic, DHE, others
prophylaxis - TCA, BB, topiramate, candesartan, venlafaxine, anti-CGRP, some herbals, others

42
Q

List some acute and prophylaxis tx for tension type headache

A

acute - NSAIDs, acet, IV/IM ketorolac, metoclopramide, chlorpromazine
prophylaxis - TCA

43
Q

List some acute and prophylaxis tx for cluster headache

A

acute - subcutaneous sumatriptan (other triptans or O2)
prophylaxis - verapamil, lithium, galcanezumab

44
Q

Describe the difference between infrequent and frequent tension type headache

A

Infrequent - less than 1 day per month on average
Frequent - 1-14 days per month on average

45
Q

Describe episodic and chronic cluster headaches

A

Episodic - 2 cluster periods lasting 7-365 days and separated by pain free remission of > 1 month

Chronic - episodes recur for more than 1 year without remission or with remission lasting < 1 month

46
Q

Which triptan is the fastest relief

A

SC or nasal formulation

47
Q

Best efficacy at 2 hr for triptans

A

subcut suma

48
Q

Best tolerated triptans is

A

nara or frova from their slow onset

49
Q

Best triptan for long lasting attacks

A

nara or frova

50
Q

lowest costing triptan

A

almo po

51
Q

Which triptan should be used if vomiting

A

subcut or nasal
or can add antiemetic

255B (5 decks)

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