Neuro Flashcards

Question

When to use antipsychotics for RBD?

Answer 1

Reserve with severe responsive behaviors, particularly aggression that poses a risk to harm self or others, if Nonpharm is ineffective Nonpharm #1 Pharm #1 SGA (risperidone / olanzapine) DO NOT GIVE IF LBD , use quietiapine if antipsychotic required

Answer 2

Can sometimes be used for severe agitation when other agents fail and worsening condition Low dose LOT Lorazepam, oxazepam, temazepam In acute situation to mana severe agitation Ativan + haldol can be given IM

Answer 3

PHIL D Pregnancy HTN Immunizations Lyme disease Diabetes

Answer 4

acute onset Unilateral facial weakness (involving upper and lower face) Ear pain Altered taste

Answer 5

Exercise for early stages by physio (low evidence but not a bad thing to do)

Answer 6

Up to 48 hours after symptom onset Not a good benefit if treatment started 7 days after onset of symptoms Early treatment (initiated within 48–72 hours of symptom onset) provides maximal benefit; evidence of benefit is less clear for treatment initiated 4–7 days after onset.[16][17] Although several guidelines recommend treatment within 72 hours of onset, a 48-hour window appears to confer greater benefit.

Answer 7

No treatment Analgesics - ibuprofen Tylenol required for first 1-2 days to alleviate pain and edema Eye care - to prevent corneal abrasion in any eye that cannot close, lubricate with ophthalmic drops, gels or ointments BID up to Q1h while awake ** tape eyelid closed at night and protect with glasses during the day ** Early treatment (48-72 hours of symptom onset) provides maximal benefit, evidence of benefit is less clear for treatment initiated 4-7 days after onset. A 48 hour window is of greater benefit.

Answer 8

PO prednisone 60mg x 5 days Can discontinue without tapering if <2 weeks duration THINK palsy=5 = 5 days With complete paralysis, corticosteroids started within 7 days of onset of paralysis showed clinically and statistically improvement in recovery of function Analgesics - ibuprofen Tylenol required for first 1-2 days to alleviate pain and edema Eye care - to prevent corneal abrasion in any eye that cannot close, lubricate with ophthalmic drops, gels or ointments BID up to Q1h while awake ** tape eyelid closed at night and protect with glasses during the day **

Answer 9

No treatment (meds will not help) Urgent referral to neuro for opinion

Answer 10

No demonstrated benefit from corticosteroid therapy Risk of incomplete recovery is very small

Answer 11

Consider adding antivirals to corticosteroids for severe facial paralysis, suspect Ramsay hunt syndrome or immunocompromised Acyclovir 400mg daily x 10 d Famciclovir 500 mg TID x 1 week Valacyclovir 1000mg TID x 1 week

Answer 12

#1 supportive care Analgesics - Tylenol required for first 1-2 days to alleviate pain and edema Eye care - to prevent corneal abrasion in any eye that cannot close, lubricate with ophthalmic drops, gels or ointments BID up to Q1h while awake ** tape eyelid closed at night and protect with glasses during the day ** Effects of corticosteroids on fetus is unclear / will recover spontaneously To use antivirals VAC may be considered

Answer 13

Atonic: Loss of muscle tone Tonic: Muscle stiffness, rigidity Clonic: Repetitive, jerking movements Myoclonic: Sporadic (isolated), jerking movements Absence: brief loss of consciousness Grand Mal: Unconsciousness, convulsions, muscle rigidity if someone is having a seizure move all near objects out of the way and depending on seizure hold patient still.

Answer 14

Encourage good sleep Keep alcohol consumption to a minimum Decrease stress / anxiety Cocaine and amphetamines must be avoided due to proconvulsant properties Review herbal supplements some are proconvulsant Ketogenic diet, modified Atkins, low glycemic index = decreases seizures // RD should be involved discuss seizure precautions with family Referral for epilepsy surgery or neuromodualtion should be considered with medically refractory epilepsy or resistant to > 2 anti seizure meds (not include intolerant to s/e) Yoga, mindfulness, increase QOL Limited evidence in meditation, relaxation, acupuncture

Answer 15

First Investigate causes many pts will NOT require ASM Decision should be guided by history and other clinical indicators no role for ASMs in patients with acute symptomatic (provoked) seizures, such as those provoked by metabolic derangements (e.g., hypoglycemia, hyponatremia) or withdrawal from drugs or alcohol. in TBIs ASMs prevent seizures in the 7 days post seizure no effect on the development or later seizures -> could benefit from short term use <7 days of ASM but long term use does not prevent progression to epilepsy

Answer 16

start low, titrate up - minimize the risk of dose-dependent AEs *lamotigrine ALWAYS requires slow titration inform pt of risks - life-threatening hypersnesitivity reaction anyone of child-bearing age - 1mg of folic acid to prevent neural tube defects Make a small dosage reduction if dose-related adverse effects are problematic

Answer 17

Add a second ASM if the max tolerated dose of the first ASM has failed to achieve satisfactory seizure control. Gradually withdraw the first ASM after maintenance dose has been achieve with second drug

Answer 18

#1 Lamotrigine 25mg daily po After 2 week increase to 25mg BID then increase by 25-50 mg/day at 2 week intervals Maintenance: 100-400mg/ day BID Carbamazepine also an option

Answer 19

Rash which rarely can be very serious Insomnia

Answer 20

#1 ethosuximide (drug of choice) Valproic acid = equally effective

Answer 21

Valproic acid 250mg BID Increase by 250mg q3-4 days Maintenance: 750-1000mg/ day in 2 divided doses Should not be used in women of childbearing potential ****

Answer 22

Nausea, weight gain, tremor, hair loss, blood dyscrasias, hepatotoxicity (rare), edema (rare), menstrual irregularities, teratogenicity. V- vomiting A-alopecia (hair loss) L-liver toxicity P-pancreatitis / decrease platelets R- risk of neural tube defects O- obesity (weight gain) A-anorexia T-tremor/ teratogenic E-edema

Answer 23

GI upset ** absence seizure only / won’t work if you have multiple different kind of seizures**

Answer 24

Different categories dose-related skin rash - (more likely to happen w/ phenytoin, carbamazepine and lamotrigine/ PCL) more likely to occur within the first 6 weeks of tx -DC immediately *** titrate very slow to avoid*** Blood and/or hepatic dyscrasias Mild elevations (<2-3 times the upper limit of normal) in liver enzymes and/or modest reductions in blood counts (e.g., neutropenia with carbamazepine, thrombocytopenia with valproic acid) are relatively common. Enzyme-inducing ASMs increase the risk of hyperlidiemia -Obtain a baseline CBC and serum liver aminotransferases if treating with an ASM that may cause a hypersensitivity syndrome involving blood or liver; repeat in 4-6 wk. - do not need to be DC'd with minor changes, keep following and if enzymes remain stable then can he monitored yearly Osteoporosis Long-term use of valproic acid and enzyme-inducing ASMs ( CBZ, clobazam, phenytoin, phenobarbital) - monitor bone density carefully, supplement calcium and vitamin D

Answer 25

Consult with neuro Usually 2-5 years seizure freedom (adult) 18-24 months + normal EEG (child)

Answer 26

There is an increased risk of combined oral contraceptive (COC) failure in patients taking enzyme-inducing ASMs Ideally the COC should contain ≥50 mcg ethinyl estradiol - does not exist in canada Considering taking 2 COCs/ day *barrier methods also recommended (Condoms) Intrauterine devices (hormonal and nonhormonal) and progestin depot injection formulations may be reasonable alternatives for patients with epilepsy. Lamotrigine metabolism is profoundly affected by concomitant use of COCs - reduced levels by 50% - measure levels before and after initiation of COC - consider doubling Lamotrigine dose

Answer 27

Combined contraceptive patch Combined oral contraceptive Progestin implant Progestin-only oral contraceptive Vaginal ring

Answer 28

Pre pregnancy- assess if ASM still required, if >2 years free of seizures , consider d/c. If at risk = keep AVOID: Valproic acid + topiramate PREFERRED: Lamotrigine, levetiracetam and oxcarbazepine safe with low rates of teratogenicity. - Remember to take folic acid supplement** - Do not switch AEDs during pregnancy to avoid teratogenesis - Measure serum levels of AEDs q monthly during pregnancy as they can drop d/t increased clearance -May need dose adjustments -afte delivery , levels rise quickly 1-2 weeks dose Will need to be adjusted early after delivery to avoid toxicity // slowly titrate back to pre pregnancy dose // might be slight higher 3 months PP due to lack of sleep If taking Valproic acid = Take 4mg/ day folic acid

Answer 29

Continue BFing Infants whose mothers are taking barbiturates, benzos, ethosuximide or lamotrigine may be sedated. Infants exposed to barbiturates in utero and not BF may exhibit barbiturate withdrawal symptoms in first week after delivery

Answer 30

NO "treat the patient, not the serum level. Some patients have satisfactory seizure control at low levels

Answer 31

Lamotrigine 1-39 Valproic acid 350-700 Etho 283-708

Answer 32

CBC, LFT (q6-12 months), platelets, Valproic acid levels, albumin, mood changes, BMD

Answer 33

LFT, renal function, rash, mood changes

Answer 34

>5min likely suggest SE and should be treated aggressively Rescue meds be given at home with consult with neuro Diazepam PR or midazolam IM

Answer 35

Persistent (2-30 days) or intractable (>1 month) hiccups are unusual but distressing and occur predominantly in older males. They may cause insomnia, weight loss or depression and may be associated with metabolic causes and abnormalities of the CNS, ear, throat, diaphragm, thorax or abdomen

Answer 36

Continuous cervical epidural block has shown a high success rate when multiple sessions (usually 2-3) are utilized. Phrenic nerve disruption is reserved for cases where all other treatment modalities have failed. If gastric distention is identified as the cause, gastric aspiration is worth trying. No evidence to use: -posterior wall stimulation with finger -breath holding

Answer 37

dopamine antagonists Chlorpromazine 25-50mg TID-QID PO x 2-3 days Adverse effects: Anticholinergic effects, extrapyramidal effects, hypertension, sedation, seizure, weight gain, photosensitivity, QTc prolongation Drug interactions: additive sedative effects with CNS depressants, including alcohol Haloperidol (IM or PO) Parenteral 2-5mg IM; PO 2-10mg once daily x2-3 days Adverse effects: Sedation, extrapyramidal effects, seizures, QTc prolongation Drug interactions: additive sedative effects with CNS depressants, including alcohol Metoclopramide/Metonia (IM/IV or PO) Parenteral 10mg IM/IV; PO 5-10mg TID-QID x 2-3 days May act as dopamine antagonist or by enhancing gastric emptying Adverse effects: Diarrhea, abdominal cramps, hyperprolactinemia, sedation, extrapyramidal effects, headache Drug interactions: additive sedative effects with CNS depressants, including alcohol

Answer 38

Baclofen 5 mg BID increase Q3 days max 80mg/day Need to taper when d/c Med is excreted by kidneys need to decrease if renal impairment

Answer 39

Amantadine, amitriptyline, carbamazepine, gabapentin, nifedipine, valproic acid have been effective in some pts ***Avoid benzos → worsening hiccups****

Answer 40

When drug effective, taper down after 1-3 days. If ineffective, don't continue for more than 3 days If hiccups don't return, taper drug and stop it If hiccups return, find lowest dose that will suppress them Maintenance therapy may be required

Answer 41

Stress importance of staying active and having a regular exercise Encourage awareness of the important roles of allied health professionals such as speech, physical and occupational therapists, and home care as the disease becomes more advanced. Sleep therapy (CBT-insomnia, Bright light therapy) Some patients may benefit from surgery (lesioning procedures and DBS). (If <70 years and where meds can no longer control symptoms// helps functioning to their best “on time” Palliative care

Answer 42

Initial management: If no functional symptoms - no tx If mild symptoms, consider 1.resagiline, or 2. selegiline Monoamine oxidase B inhibitors Good for early stages as mono therapy or adjunct If more severe symptoms, and <50 years and willing to accept 50% risk of impulse control disorders: consider dopamine agonists (rotigotine (patch), pramipexole, ropinirole if not willing to accept: consider levodopa

Answer 43

Levodopa immediate release (gold standard) Levodopa/carbidopa (Sinemet = immediate release) Initial: 50/12.5mg BID PO Usual: 100/25mg-150/37.5mg TID-QID PO Levodopa/benserazide Initial: 50/12.5mg BID PO Usual: 100/25mg-150/37.5mg TID-QID PO levodopa is now combined with a dopa decarboxylase inhibitor (carbidopa or benserazide) to inhibit peripheral transformation to dopamine, thus enhancing distribution to the brain, reducing the amount of levodopa required for optimal therapeutic benefit and minimizing acute side effects such as nausea and vomiting

Answer 44

N/V , hallucinations, nightmares, orthostatic hypotension Think LEVODOPA Le= lethargy VO= vomiting D= dopamine O= orthostatic hypotension P= prazosin is for nightmares // (for ptsd but easy to remember) A= hallucinations L- lethargy E- V- vomit/ nausea O- orthostatic hypotension Hard - hallucinations Night -nightmare

Answer 45

Dopamine agonists Rotigotine Pramipexole Ropimirole ** less motor complications but increase hallucinations, daytime somnolence, GI upset, orthostatic hypotension CI- >70, ICD hx, pre existing cognitive impairment

Answer 46

Amantadine CI- cognitive deficits (med can increase confusion)

Answer 47

Levodopa #1 Good for all stages Dopamine agonist (rotigotine, pramipexole, ropinirole) -> good as mono therapy but less effective than levodopa /// can use adjunct with levodopa for “wearing off” Monoamine oxidase B inhibitors (resagiline, selegiline, safinamide) -> typically used in mild disease Best used in adjunct with levodopa in pt with wearing off (rasagiline and salfinamide only)

Answer 48

Amandine -> improves dyskinesia (could consider if not controlled with modifying existing therapy) Anticholinergics (benztropine, ethopropazine, trihexyphenidyl) -> may help with tremors in young patients Entacapone -> useful for pt with sudden and or unpredictable periods “wearing off”

Answer 49

Consider smaller and more frequent levodopa dose Add levodopa CR (Sinemet CR) QHS Combine DA with levo

Answer 50

Decrease Levo dose, increase frequency (increase dose CAUSES dyskinesia) Add amantadine Add or switch to DA or increase the dose of DA and decrease Levo

Answer 51

Add amantadine or ACh (if younger)

Answer 52

this syndrome occurs when dopaminergic drugs are abruptly reduced or stopped, and has similar symptoms to neuroleptic malignant syndrome Drug holidays not recommended

Answer 53

Depression -> SSRIs SNRI Rapid eye movement / sleep disorder -> non pharm, melatonin 3-12 mg, clonazepam 0.25-1mg Psychosis -> often d/t meds taking for PD. Only treat if not well tolerated by pt/caregiver. As disease progresses, need to reduce PD meds. Usually anticholinergics withdrawn 1st, then MAO-Bs, dopamine agonists and COMT inhibitors until only levodopa is left If you cannot balance PD meds 1. Quetiapine (trialed first / no monitoring) 2. Clozapine (needs blood monitoring) ** avoid all others*** Dementia -> cholinesterase inhibitors (Donepezil) Anatomic dysfunction//// Orthostatic hypotension: 1st increase salt intake and hydration, avoid alcohol, then add domperidone, midodrine and/or fludrocortisone Urinary urgency and incontinence: anticholinergics, mirabegron Erectile dysfunction: PDE-5 inhibitors (e.g. sildenafil) Constipation: limit drugs with anticholinergic effects, proper hydration with high fibre diet and exercise. 2nd line: PEG, lactulose or psyllium Sialorrhea (excessive salivation): onabotulinumtoxin A Nausea/ Vomiting -> domeperidone 30min before levodopa It is transient and disappears with time Have levodopa with food // no protein cause decreases absorption Nausea / vomiting

Answer 54

*not as effective as stimulants - behavioural txs -CBT (recommended as adjunct to meds) -Social skills, mindfulness and parent-management training - elimination of certain foods (high sugar), not enough evidence -exercise interventions (e.g., short-term aerobic exercise and yoga)

Answer 55

Nonpharm and pharm options

Answer 56

clear diagnosis of ADHD and who have demonstrated impairment in learning or academic/occupational performance due to their attention difficulties, or whose behaviours and social interactions are impaired by a lack of impulse control and/or hyperactivity.

Answer 57

Stimulants #1 long acting preferred

Answer 58

#1 is stimulants: dextroamphetamine (Dexedrine) lisdexamfetamine (vyvanse) methylphenidate (biogenetin, concerta, Ritalin, foquest) mixed salts amphetamine (adderall XR) Best are long acting stimulants Mixed salts amphetamines (adderall) Methylphenidate (biphentin and concerta) Lisdexamfetamine (vyvanse) -> Last 8-14 hours Can be opened and sprinkled in food or drank with water no preference over the agents as first-line >6 year olds long-acting > short-acting Short- and intermediate-acting stimulants are recommended for use when the patient requires more flexible dosing and minimal hours/day of medication or as add-on therapy to an extended-release formulation. 3-4 week trial - improvement typically seen in a week - if successful, continue tx for 6-12 months If does not tolerate after 3-4 weeks of therapy switch to alternative stimulant

Answer 59

-history of hypersensitivity to sympathomimetic amines -symptomatic cardiovascular disease (including moderate to severe hypertension, advanced atherosclerosis) -uncontrolled hyperthyroidism -history of drug abuse a -concurrent use with an MAOI Sudden cardiac death in those with underlying cardiac anomalies and with adverse psych symptoms such as hallucinations and agitation Rare = priapism in children

Answer 60

increased heart rate and blood pressure GI upset appetite suppression anxiety irritability and insomnia

Answer 61

Monitor for consistent appetite suppression and changes in weight Q 2 wk for the first 2 months, then Q 6 months. In children and adolescents, monitor height as well. Management Max nutrition before morning dose and evenings Consider nutrition supplements Reduce portions and increase snacks Consider drug holidays on weekends or during vacation

Answer 62

Monitor BP and HR in the first 2 wk of starting a stimulant medication, then Q 3 months. ECG not typically needed if no previous CV disorder If significant changes occur in BP, HR or ECG, discontinue and consider consulting a cardiologist. Stimulants cause increase HR/BP. Alpha 2 agonist causes a decrease in HR/BP if stopped abruptly can cause hypertensive crisis

Answer 63

Monitor for difficulties falling asleep, staying asleep and/or early morning awakenings at 1 wk, then monthly for the first 3 months, then Q 6 months Often resolves in 2 weeks May need to lower the stimulant dose, change the time to an earlier administration, add a more sedating medication at bedtime or discontinue the offending stimulant. -Minimize use of caffeine and other psychostimulants.

Answer 64

Symptoms may dissipate as patients enter adolescence. Weaning the medication for a 2-3-wk period once/year (summer months) may provide an opportunity to reassess ADHD-related behaviours and confirm if still required for the next school term. Extended drug holidays (months over the summer) = not recommended in children with moderate to severe ADHD symptoms who are doing well on the medication. Drug holidays may be useful when adverse effects (such as growth suppression or weight loss >10% of initial body weight) have occurred or when attempting to assess continued benefit. Abrupt discontinuation of stimulants may cause withdrawal symptoms in some individuals, especially if they have been treated for prolonged periods and/or at maximum doses; consider tapering over several weeks in patients who poorly tolerate discontinuation or have been on medication for longer than 3 months

Answer 65

Atomexetine (SNRI) Not classified as stimulant Nor a controlled substance Consider a comorbid substance abuse disorder and depression -takes 3-4 weeks to see effects -Used for those who have either not responded to or not tolerated an adequate trial of stimulant medications. Guanfacine XR (alpha 2 agonist) Reduce symptoms of aggression, impulsively, hyperactivity less profound effect on in attention Used as monotherapt or adjunct >6-17 yo

Answer 66

substance-use disorder and smoking dependence * however disproven in research that there is an association when taking stimulants// protective if on stimulants * If diversion of stimulant medication is suspected, consider switching to another agent w/ less abuse potential educate patients with ADHD about the dangers associated with misuse and diversion of these medications

Answer 67

Third line

Answer 68

Bupropion #1 Typically you'll see buproprion, venlafaxine or atomoxetine (NRI) used Can be considered as adjunct tx or third-line tx may benefit patients with comorbid conditions such as depression, anxiety, enuresis or tic disorders

Answer 69

Does NOT benefit this population Have very little effect on inattention Low-dose SGAs may be considered for the behavioural symptoms seen in hyperactive and impulsive children when stimulants alone are ineffective or not tolerated Often used in ODD, ASD, conduct disorders

Answer 70

Mild to moderate symptoms -> Nonpharm preferred AVOID: atomoxetine, methylphenidate, risperidone

Answer 71

Non pharm preferred Methylphenidate low transfer but neurological developments have not been well studied // monitor infant for agitation and poor weight gain Amphetamines = same as above Maintaining treatment with TCAs, bupropion or venlafaxine during breastfeeding for patients with a good response to one of these agents can be considered.

Answer 72

Consider adding immediate or intermediate release for coverage gaps If no response Rethink diagnosis or go to second line Atomoxetine or guanfacine

Answer 73

Daily, constant dull HA >15 days / months = Tylenol / NSAIDs >10 days / month = triptans, opioids Often associated with depression and in pt's that take abortive meds >3 days/week Chronic opioid use may also contribute to MOH

Answer 74

alleviate headache pain and associated symptoms within 2 hours of treatment and/or 24 hours of sustained headache relief

Answer 75

*Communicate to pt that their dx is real Advise patients to: o Maintain HA diary, which includes changes in sleep, stress, weather, or food ingested within 24 hrs prior to attack to identify triggers o avoid triggers, especially in migraine, e.g., too much or too little sleep, irregular meals, lack of regular exercise, extremes of stress or relaxation, known dietary triggers. o apply ice or heat; sleep or rest in a dark, noise-free room. - Try informal psychotherapy (family physician); refer to a psychologist or psychiatrist if psychiatric comorbidity is present or adverse childhood events. - Try biofeedback, relaxation therapy, cognitive behavioural therapy, psychotherapy, acupuncture and/or nerve blocks (neuromodulation with vagus nerves stimulation (nVNS)and external trigeminal nerve stimulation (eTNS)), individualized to each patient. - Refer to neurologist and/or specialized headache or pain management unit if problems too complex, such as chronic daily headache, or require multidisciplinary approach. Pr education / reassurance -Headache diary which includes changes in sleep, weather, food ingested within 24h of attack -apply ice, heat to head during headache, depending on what gives relief -sleep or rest in dark, noise free room -if hx or adverse childhood events present - may benefit from psych assessment -aerobic exercise may help some/ worsen others -refer to neurologist if too complex, chronic daily headache -vagus nerve stimulator = good if CI to pharm agents

Answer 76

Acetaminophen , ASA, and NSAIDs (e.g., diclofenac, ibuprofen, naproxen) first-line = ASA and NSAIDS Avoid MOH <15 days/month naproxen + antiemetic - * caution increased risk of GI irritation if using for a long period of time

Answer 77

#1 Triptans almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan To avoid MOH, triptans should be used less than 10 days per month

Answer 78

Ergotamine derivatives ** only use if no response to triptans**

Answer 79

CI= Cardiac disorders (ischemic heart disease) Sustained HTN Basilar and hemiplegic migraines *Second dose not likely to be effective if first dose provided no relief.

Answer 80

Ubrogepant (ubrelvy) approved April 2023

Answer 81

NSAID + sumatriptan = good efficacy Naproxen + sumatriptan = also good Offer combo if triptan monotherepy is inadequate

Answer 82

ALL triptans: do not use with ergotamine-containing products. Do not use a triptan within 24 h after another triptan. Caution with serotonergic medications (small increased risk of serotonin syndrome). Almotriptan: do not use with MAOIs. Inhibitors of CYP3A4 may increase bioavailability of almotriptan. Rizatriptan + propanolol = CI

Answer 83

ALL: chest discomfort, fatigue, dizziness, paresthesias, drowsiness, nausea, throat symptoms. T- tight chest / discomfort R- really fatigue I- P- parenthesis T- throat symptoms A- and 3 Ds ( drowsiness, dizziness, Dry mouth) N- nausea

Answer 84

Antinauseants (e.g., dimenhydrinate) and antiemetic/prokinetic agents (e.g., metoclopramide and domperidone) are useful as adjunctive therapy in headache disorders associated with nausea and vomiting or to facilitate absorption of medications in some patients. metoclopramide = best evidence

Answer 85

weeks, or occasionally in a few months, with the discontinuation of medications, especially combination analgesics

Answer 86

If withdrawal headache emerges, bridge therapy with triptans and NSAIDs prn Nerve blocks may be considered

Answer 87

Attacks significantly interfere with patient's daily routine despite acute treatment Frequent attacks (≥4 monthly headache days) Contraindication to, failure, or overuse of acute treatment Adverse reaction to acute treatment

Answer 88

First line : Beta blockers: 1st line-> (especially <60 or those with HTN or CVD) Propranolol, metoprolol and nadolol are good initial choices. - TCAs: 1st line-> (especially if associated with depression, chronic pain, insomnia, TTH) Amitriptyline and nortriptyline are effective for the prevention of migraine, especially in patients who also have tension-type headache. - SNRI: Venlafaxine reduces the number of headache days in patients with migraine and may be useful in some patients with comorbid depression or anxiety. - CCBs: Flunarizine has potential efficacy in migraine prophylaxis, but can precipitate weight gain and depression - ACE Inhibitors: Lisinopril (10mg daily) may be effective in reducing HA frequency - ARBs: Candesartan (8mg daily) in prevention of migraines - Antiepileptics: 1st line for severe migraines: Valproic acid and divalproex sodium (avoid in pregnancy). Or Topiramate. Gabapentin also an option, but may cause somnolence, helpful for pts with comorbid insomnia. - Serotonin Antagonists: Pizotifen (pizotyline) helpful in migraine prophylaxis. - Triptans: In the prevention of menstrually associated migraine, frovatriptan for short-term use. Perimenstrual use of naratriptan or zolmitriptan may also be effective. Need to have regular menstrual cycle and clearly documented HA pattern associated with cycle. Usually used for 5-7 days/cycle, starting 2 days before anticipated onset of HA. - Lithium is useful in the prophylactic management of chronic cluster headache. - Onabotulinum toxin A for chronic migraine prevention (expensive). - Natural health products: Butterbur, Magnesium citrate, riboflavin and coenzyme Q10, melatonin, feverfew (no longer recommended in Canada d/t SE) may be helpful

Answer 89

Anxiety/ depression/ chronic pain -> TCA (amitriptylline), venlafaxine Insomnia -> amitriptylline, gabapentin, HTN -> beta blockers, candasartan Wants weight loss -> topiramate Epilepsy -> Valproic acid, topiramate, gabapentin

Answer 90

For disabling chronic TTH prophylaxis may be considered TCA- amitriptylline SNRI - venlafaxine

Answer 91

Pt education / monitor for med overuse

Answer 92

Non-pharm = 1st line - For most women, whose migraine improves during pregnancy, nonpharmacologic measures supplemented with occasional use of acetaminophen may suffice. - Ibuprofen and naproxen can be used during the 1st or 2nd trimester but should be avoided in the later stages. - Severe nausea can be managed with metoclopramide or prochlorperazine. - Propanalol - preferred agent when considering prophylactic

Answer 93

Lactation may have positive effect on migraine activity, so encourage it Use Non-pharm as first line Acetaminophen = preferred agent Ibuprofen = safe NSAID AVOID ergot derivatives and opioids (including codeine) Sumatriptan = compatible with BF, use other triptans with caution as should avoid vasoconstricting agents in postpartum period If needing to use rescue meds, can "pump and dump" or delay feeding based on half-life of drug to clear meds Propranolol and metoprolol = beta-blockers of choice during BF Valproic acid/divalproex sodium and topiramate = compatible with BF

Answer 94

Decrease of > 50% severity = good response

Answer 95

Adaptive pain coping strategies CBT Relaxation Biofeedback Mindfulness Lifestyle mod : sleep hygiene, stress management, adequate hydration, regular exercise, protein rich meal, avoid skipping meals Discuss triggers

Answer 96

Tylenol , NSAIDs (No Asa due to Reye’s syndrome) Preventive useful if >4 times / month and significantly affecting ADL and school function 1) amitriptylline, nortriptylline (>12) Other options venlafaxine, mirtazipine

Answer 97

Nonpharm - same as TTH Pharm Analgesics (Tylenol / ibuprofen) Antiemetics (metoclopramide , prochlorperazine) // ondansetron Triptans >12 only Only approved = almotriptan (12-18 yo) ** only consider triptans when disabling, frequent, moderate to severe migraines are unresponsive to analgesics ***

Answer 98

In child reports >6 headaches of any severity per month or 3-4 severe headaches per month

Answer 99

Riboflavin Mg Melatonin Coq10

Answer 100

Promipexole CI- >70, ICD hx, pre existing cognitive impairment

Answer 101

Triptans >12 only Only approved = almotriptan (12-18 yo) ** only consider triptans when disabling, frequent, moderate to severe migraines are unresponsive to analgesics ***

Answer 102

Cognitive/ memory impairment Kidney stones Weight loss Headache Paresthesias

Answer 103

Sumatriptan 25-100mg at start of headache

Answer 104

DDDNF Drowsiness Dry mouth Dizziness Nausea vomiting Fatigue T- chest tightness/ discomfort R-really tired (fatigue) I- P-paresthesias T- throat symptoms A-all Ds (drowsiness, dizziness, diarrhea N-nausea S-serotonin syndrome

Answer 105

Butterbur-good effect / use with caution PA free (causes hepatoxicity) Magnesium (more definitive studies are needed) // effective in 2 large double blind controlled study Riboflavin (B2) found a reduction in frequency but more studies are needed Coq10( found a reduction in frequency) // more studies are needed Melatonin // more effective better than amitryptilline Feverfew// evidence for its efficacy is conflicting and it appears to be no better than placebo / not recommended