Neurology Flashcards
How many unprovoked seizures are required to make the diagnosis of epilepsy?
2 more than 24 hours apart
When would it be appropriate to consider discontinuing an AED?
Seizure free for 2-5 years with a normal EEG while receiving treatment
What black box warnings does carbamazepine carry?
-Increased risk of SJS/TEN with HLA-B*1502 allele (screen in patients of Asian and South Asian ancestry)
-Aplastic anemia
-Agranulocytosis
What are concerns with lacosamide therapy?
-DRESS
-Prolonged PR interval (ECG recommended for those with underlying proarrhythmic conditions)
-LFT elevations
What black box warnings does lamotrigine carry?
-Rash including SJS and TEN (increased risk if given w/ VPA or slow dose titration not followed)
What commonly used medication should not be administered with topramate?
Metformin (increased risk of lactic acidosis)
What black box warnings does valproic acid carry?
-Fetal risk including neural tube defects, other major malformations, and decreased IQ
-Pancreatitis
Which AEDs are preferred in those with hepatic impairment?
-Levetiracetam
-Gabapentin
-Pregabalin
-Topiramate
Which AEDs are preferred in those with renal impairment?
-Lamotrigine
-Valproic Acid
Which AEDs can be used for new-onset focal epilepsy?
-Lamotrigine (second-line)
-Levetiracetam
-Zonisamide
Which AEDs can be used for new-onset generalized epilepsy?
-Lamotrigine (second-line)
-Levetiracetam
-Valproic acid
Which class of medications should be used at home for treatment of seizure clusters?
Benzodiazepines
-Oral: clonazepam, diazepam, lorazepam
-Rectal: diazepam
-Nasal: midazolam, diazepam
How should allergic skin reactions due to AEDs be managed?
-Discontinue the medication
-Can use antihistamine or high-potency topical steroids for symptomatic relief of pruritus
What is the triad consistent with DRESS?
-Rash
-Fever
-Internal organ involvement
How should DRESS due to AEDs be managed?
-Discontinue the medication
-Oral corticosteroids for 2-3 months
Which AEDs can cause DRESS?
-Phenytoin
-Phenobarbital
-Carbamazepine
-Lamotrigine
What are the AEDs of choice during pregnancy?
-Levetiracetam
-Lamotrigine
What AEDs are enzyme inducers?
-Phenobarbital
-Phenytoin
-Carbamazepine
-Oxcarbazepine (at higher doses)
What is the definition of chronic migraine?
Headache either migraine-like or tension-like on 15+ days per month for more than 3 months, with the features of migraine headache on at least 8 days per month
What is first-line acute treatment for cluster headaches?
Triptans
-Sumatriptan nasal spray or injection
-Zolmitriptan nasal spray
What is first-line preventative treatment for cluster headaches?
Verapamil (high-doses - 360-960 mg/day)
What is second-line preventative treatment for cluster headaches?
Lithium (target level 0.4-0.8)
What is first-line acute treatment for tension-like headaches?
-APAP
-NSAIDs (naproxen, ibuprofen)
-Combination analgesics with/without caffeine
What are preventative treatment options for tension-like headaches?
-Amitriptyline
-Mirtazapine
-Tizanidine
-Botox (refractory cases)
What is recommended abortive/acute treatment of mild-to-moderate episodic migraines?
OTC analgesics
What is recommended abortive/acute treatment of moderate-to-severe episodic migraines?
-Triptans
-Ergotamines
-Antiemetics
-Ditans
-Gepants
What are contraindications to triptans?
-Uncontrolled HTN
-CAD
-PVD
-Stroke
Which antiemetics are preferred for treatment of episodic migraines?
-Metoclopramide
-Prochlorperazine
-Promethazine
What two gepants are approved for acute episodic migraine treatment?
-Ubrogepant
-Rimegepant
Which patients may benefit from gepant therapy?
Those at high cardiovascular risk or with a history of CV/cerebrovascular event
Which triptans have the fastest onset of action?
-Sumatriptan (nasal & SQ available)
-Almotriptan
-Rizatriptan (ODT available)
-Eletriptan
-Zolmitriptan (nasal available)
What gepants are approved for migraine prevention?
-Rimegepant
-Atogepant
What CGRP mAbs are approved for migraine prevention?
-Erenumab
-Fremanezsumab
-Galcanezumab
-Eptinezumab
When should a CGRP mAb be consider for migraine prevention?
Inadequate response or inability to tolerate (due to side effects) at least two oral migraine preventative drugs
What are some Level A medications used for migraine prevention?
-Metoprolol
-Propranolol
-Topiramate
-Valproic acid
-Botox
-Gepants
What enzyme modification can effect the metabolism of certain opioids?
CYP2D6 polymorphism
What are first-line treatment options for painful peripheral neuropathies?
-Duloxetine
-Venlafaxine
-Gabapentin
-Pregabalin
-Amitriptyline/Nortriptyline
What are second-line treatment options for painful peripheral neuropathies?
-Carbamazepine
What are third- and fourth-line treatment options for painful peripheral neuropathies?
-SSRIs (citalopram, paroxetine, escitalopram)
-Lamotrigine
-Opioids
-Lacosmide
-Milnacipran
-Oxcarbazepine
-Topiramate
-Valproic acid
-Tramadol
What is a counseling point for levodopa-carbidopa?
Avoid taking with high-protein meals (can delay absorption)
Which Parkinson’s medication should not be used as monotherapy?
Entacapone (COMT inhibitor) - must be used with levodopa
Which medications can be added to levodopa if symptoms are not well-controlled on monotherapy?
-MAO-B inhibitor (selegiline, rasagiline)
-COMT inhibitor (entacapone, opicapone)
-Dopamine agonist (pramipexole, ropinirole)
*consider decreasing levodopa dose when another agent is added
What is a long-term concern with levodopa?
Movement disorder/dyskinesias
Which medications can be used for treatment of hallucinations in patients with Parkinson’s?
-Clozapine
-Quetiapine
-Pimavanserin
Which class of medications is recommended to be initiated early of Alzheimer’s diagnosis?
Cholinesterase inhibitors
-Donepezil
-Rivastigmine
-Galantamine
What is memantine’s place in therapy for Alzheimer’s?
-Add-on to cholinesterase inhibitor when patient’s condition progresses to moderate disease or continues to decline
-Monotherapy for those who cannot tolerate cholinesterase inhibitors
What medications are recommended for treatment of essential tremor?
-Propranolol
-Primidone
Why is carbamazepine typically initiated at a low dose?
Reduce incidence of dizziness
Which triptans have the longest half-life?
-Frovatriptan (26 hours)
-Naratriptan (6 hours)
Which triptan is not metabolized by MAO?
Eletriptan
What co-morbid condition may warrant avoiding interferon B therapy?
Untreated depression
Which AED is not eliminated through the kidneys?
Lamotrigine (metabolized through glucuronidation)
Which AED is not metabolized through the liver?
Levetiracetam
Which triptan has the fastest onset of action?
SubQ Sumatriptan
What is a class side effect of cholinesterase inhibitors (i.e. donepezil, rivastigmine, galantamine)?
Bradycardia and syncope
What medications are recommended as second-line treatment for essential tremors?
-Gabapentin (“probably effective”)
-Nimodipine (“possibly effective”)
