TEST-4 STUDY GUIDE Flashcards
What is a migraine headache?
The typical migraine headache is “POUND”: Pulsatile, One-day duration, Unilateral, Nausea, Disabling intensity.
headaches are the second most common type of headache with high prevalence and socioeconomic impacts.
Migraine
Racial differences in migraine prevalence are striking in
Migraine headaches
Prevalence of migraine is highest in adults younger than age ?
40
____ lowest in those older than age 60.
Migraine headaches
True or False?
It is not unusual for migraine headaches to begin during childhood.
True
Sarah is a 30-year-old woman who presents to your family nurse practitioner clinic with complaints of recurring headaches. She reports experiencing these headaches about twice a month. Sarah describes the headache pain as a throbbing sensation on the right side of her head that lasts anywhere from 6 to 24 hours. She also experiences nausea and increased sensitivity to light and noise during her headaches.
- Question: Based on Sarah’s symptoms and the provided information, what type of headache is she likely experiencing?
Answer: Sarah is likely experiencing migraine headaches. Her symptoms, including the unilateral throbbing pain, nausea, and photophobia (sensitivity to light) are characteristic of migraines.
Sarah is a 30-year-old woman who presents to your family nurse practitioner clinic with complaints of recurring headaches. She reports experiencing these headaches about twice a month. Sarah describes the headache pain as a throbbing sensation on the right side of her head that lasts anywhere from 6 to 24 hours. She also experiences nausea and increased sensitivity to light and noise during her headaches.
What potential triggers for Sarah’s migraines should you inquire about?
You should inquire about common migraine triggers such as alcohol consumption, stress levels, menstruation (if applicable), and dietary habits.
Tom is a 45-year-old man who presents to the clinic because he has started experiencing headaches about once a month. He notes that about 30 minutes before the headache starts, he sees flashing lights and zigzag patterns in his vision. These headaches are severe and pulsing, predominantly on one side of his head, and are accompanied by nausea.
- Question: What specific type of migraine is Tom likely experiencing, and what is the defining feature?
Answer:** Tom is likely experiencing a migraine with aura. The defining feature is the sensory phenomena that occur before the headache, such as the visual disturbances he describes.
Tom is a 45-year-old man who presents to the clinic because he has started experiencing headaches about once a month. He notes that about 30 minutes before the headache starts, he sees flashing lights and zigzag patterns in his vision. These headaches are severe and pulsing, predominantly on one side of his head, and are accompanied by nausea.
Why might Tom’s perception of flashing lights and zigzag patterns occur prior to his headache?
These visual disturbances, known as an aura, occur due to neural or vascular changes in the brain during the initial phase of a migraine with aura. These changes can lead to temporary alterations in perception before the pain phase of the migraine starts.
Anna is a 28-year-old who presents with recurrent migraines that occur around the same time each month. She experiences a throbbing headache along with nausea and sensitivity to sounds. Upon further questioning, you find this typically coincides with the start of her menstrual cycle.
What is the likely trigger for Anna’s migraines?
The likely trigger for Anna’s migraines is hormonal changes associated with her menstrual cycle. This is sometimes referred to as menstrual migraines
What strategies could you suggest to Anna to help manage or prevent her migraines?
Strategies could include maintaining a headache diary to identify patterns, managing stress, avoiding known dietary triggers, ensuring adequate hydration and sleep, and considering the use of NSAIDs or triptans preemptively during her menstrual cycle as advised by her healthcare provider. Hormonal therapies may also be considered under the care of her healthcare professional.
What are the diagnostic criteria for a migraine without aura?
At least five episodes lasting 4-72 hours each,
with at least two of the following: unilateral location, pulsating quality, moderate to severe pain, and exacerbation with routine activities.
Additionally, at least one of the following symptoms: nausea, vomiting, photophobia, or phonophobia. Cannot be attributed to another disorder.
What are potential triggers for migraines?
Potential triggers include alcohol, stress, menstruation, and certain dietary habits.
What are the conditions or factors that suggest the use of preventive therapy for migraines?
≥2 migraines per month with disability ≥3 days per month, failure or adverse effects from acute treatments, abortive medication use more than twice per week, and uncommon migraine conditions like hemiplegic migraine.
Name first-line therapies for migraine prophylaxis in adults?
Propranolol, metoprolol, timolol, amitriptyline, sodium valproate, and topiramate.
Why might topiramate be preferred for patients with obesity and frequent migraine episodes?
Topiramate can facilitate weight loss, which may be beneficial for patients with obesity.
Why should sodium valproate and topiramate be used with caution in women of reproductive age?
They can have adverse effects on pregnancy, and appropriate contraceptive methods should be considered.
Which symptom complex is referred to as an “aura” in migraine patients?
Sensory phenomena that occur before the headache, such as visual disturbances like flashing lights or zigzag patterns.
What are common symptoms experienced during a migraine?
unilateral throbbing headache, nausea, vomiting, photophobia, and phonophobia.
Which medications should an FNP consider for patients requiring daily preventive migraine treatment?
eta-blockers like propranolol or metoprolol, amitriptyline, sodium valproate, or topiramate.
What characterizes menstrual migraines compared to nonmenstrual migraines?
- A) They are less severe and of shorter duration.
- B) They occur randomly throughout the menstrual cycle.
- C) They are more severe and longer in duration.
- D) They are effectively treated with antihistamines.
Answer:** C) They are more severe and longer in duration.
Rationale: Menstrual migraines are known to be more severe and last longer compared to nonmenstrual migraines. They occur predictably around the menstrual cycle.
Which class of medication is considered first-line abortive therapy for acute menstrual migraines that do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A) Antihistamines
- B) Triptans
- C) Beta-blockers
- D) Calcium channel blockers
Answer:** B) Triptans
Rationale: Triptans are the first-line abortive therapy for acute menstrual migraines that are unresponsive to NSAIDs. They are effective in relieving migraine symptoms quickly.
Why is frovatriptan particularly useful for treating menstrual migraines?
- A) It has been studied the least.
- B) It requires only a single dose.
- C) It has a long half-life.
- D) It is ineffective as an acute therapy.
Answer:** C) It has a long half-life.
Rationale: Frovatriptan is particularly effective for menstrual migraines because its long half-life allows for prolonged relief during the menstrual cycle.
When should frovatriptan be initiated for the treatment of menstrual migraines?
- A) At the onset of migraine symptoms
- B) One week after menses begins
- C) On the first day of menstruation
- D) Two days before the start of menses
Answer:** D) Two days before the start of menses
Rationale: If menses are regular and predictable, frovatriptan should be initiated two days before the start of menses to effectively prevent menstrual migraines. It is usually continued for 5 to 6 days.
What is the role of NSAIDs concerning menstrual migraines before considering triptans?
- A) NSAIDs are ineffective for migraines
- B) NSAIDs are used as a diagnostic tool
- C) They are first tried, and triptans are considered if they fail
- D) They are contraindicated in migraine treatment
*Answer:** C) They are first tried, and triptans are considered if they fail
Rationale: NSAIDs are commonly used as initial therapy for migraines. If NSAIDs do not provide adequate relief, triptans become the next option to consider, especially for menstrual migraines.
What is the most appropriate first-line treatment for a young woman with severe migraine characterized by vomiting at the onset, when simple or combination analgesics are ineffective?
- A) Oral ibuprofen
- B) Oral sumatriptan
- C) Subcutaneous sumatriptan
- D) Propranolol
Answer:** C) Subcutaneous sumatriptan
Rationale: Subcutaneous sumatriptan is recommended for patients with severe migraines accompanied by vomiting, especially when oral administration of medication is not feasible and analgesics have been ineffective. Its rapid onset of action makes it suitable for acute episodes.
What consideration should be made for prescribing triptans to a patient with a family history of coronary artery disease?
- A) Triptans are contraindicated in patients with a family history of coronary artery disease.
- B) There is no need for further consideration; triptans can be prescribed immediately.
- C) Triptans can be prescribed, but the clinician should closely evaluate for possible symptoms of ischemic heart disease.
- D) Triptans should be replaced with glucose tablets in all cases.
Answer: C) Triptans can be prescribed, but the clinician should closely evaluate for possible symptoms of ischemic heart disease.
Rationale: While a family history of coronary artery disease is not a contraindication for triptan use, the clinician should further assess for any signs of ischemic heart disease in the patient before prescribing triptans.
Which of the following conditions is a contraindication to the use of triptans?
- A) Controlled hypertension
- B) Visual migraine aura
- C) Known ischemic heart disease
- D) Family history of migraines
*Answer:** C) Known ischemic heart disease
Rationale: Triptans are contraindicated in patients with known or strongly suspected ischemic heart disease due to the risk of vasoconstriction, which can exacerbate cardiac issues.
Why is subcutaneous sumatriptan preferred over oral triptans in some patients with migraine?
- A) It is less effective for migraine relief.
- B) It has a longer duration of action.
- C) It provides rapid onset of relief, which is beneficial in cases of vomiting.
- D) It has fewer side effects than oral medications.
Answer:** C) It provides rapid onset of relief, which is beneficial in cases of vomiting.
Rationale: In patients who experience vomiting at the onset of a migraine, subcutaneous administration bypasses the gastrointestinal tract, allowing for quicker absorption and providing faster relief. This is particularly beneficial when oral medication cannot be retained.
What non-oral triptan option provides a rapid therapeutic effect and is highly effective in treating acute migraines?
- A) Transdermal zolmitriptan
- B) Intranasal rizatriptan
- C) Subcutaneous sumatriptan
- D) Oral sumatriptan
Answer:** C) Subcutaneous sumatriptan
Rationale: Subcutaneous sumatriptan offers a rapid and effective therapeutic effect ideal for acute management of migraines, especially in patients with severe symptoms or gastrointestinal involvement like vomiting.
Which of the following is NOT a common trigger for migraines?
- A) Alcohol consumption
- B) Stress
- C) Menstruation
- D) Daily exercise
Answer:** D) Daily exercise
Rationale: While migraines can be triggered by various factors, such as alcohol, stress, and hormonal changes associated with menstruation, daily exercise is generally not considered a common trigger. In fact, regular exercise might help in preventing migraines for some individuals. However, excessive or unusually intense exercise can be a rare trigger for some people.
What distinguishes migraine with aura from migraine without aura?
- A) Presence of sensory phenomena, such as visual disturbances, before the headache
- B) More severe headache intensity
- C) Longer duration of headache episodes
- D) Higher frequency of occurrence
Answer:** A) Presence of sensory phenomena, such as visual disturbances, before the headache
Rationale: Migraine with aura is characterized by transient sensory phenomena, such as visual disturbances like flashing lights or zigzag patterns, that occur before the headache phase. These sensory alterations serve as premonitory symptoms indicating the onset of the migraine headache.
Which part of the nervous system is primarily involved in the sensation of pain during a migraine headache?
- A) Autonomic nervous system
- B) Trigeminothalamic circuit
- C) Peripheral nervous system
- D) Vestibular system
Answer:** B) Trigeminothalamic circuit
Rationale: The trigeminothalamic circuit is responsible for the sensation of pain during a migraine. During a migraine attack, this circuit becomes hypersensitized, causing the normal pulsatile blood flow in cerebral vessels to be perceived as throbbing pain.
Which symptom commonly accompanies a migraine, contributing to the patient’s discomfort?
- A) Chills
- B) Edema
- C) Anorexia and nausea
- D) Dysuria
*Answer:** C) Anorexia and nausea
Rationale: In addition to severe headache, migraines are commonly accompanied by gastrointestinal symptoms such as anorexia and nausea. Vomiting may also occur in around one-third of cases, further contributing to the patient’s discomfort.
In migraine management, what does the presence of frequent and severe attacks warrant consideration of?
- A) Exclusive use of over-the-counter remedies
- B) Lifestyle modification only
- C) Prophylactic pharmacotherapy
- D) Surgical intervention
Answer:** C) Prophylactic pharmacotherapy
Rationale: In patients experiencing frequent and severe migraines impacting their quality of life, prophylactic (preventive) pharmacotherapy should be considered to reduce the frequency and severity of attacks. This treatment strategy involves the use of medications taken regularly to prevent migraines before they start rather than treating them acutely when they occur.
What are the red flags of secondary headaches?
Progressive or fundamental change in headache that worsens over time
Patient states, “This is the worst headache of my life!”
New-onset headaches before age 5 or after age 50
Persistent headache precipitated by a Valsalva maneuver, exertion, or sex
Fever, acute glaucoma, hypertension, myalgias, weight loss, or scalp tenderness
Neurological signs and symptoms:
confusion, altered level of consciousness, changes in memory,
papilledema, sensory deficits, reflex asymmetry, or gait disturbances
Headache with syncope or seizures
An older adult patient presents to the clinic with a new-onset headache. What should be the FNP’s initial approach?
- A) Prescribe over-the-counter pain medication
- B) Refer the patient for a neurological examination and imaging
- C) Advise rest and hydration
- D) Recommend lifestyle changes
Answer:** B) Refer the patient for a neurological examination and imaging
Rationale: New-onset headaches in older adults should raise suspicion for underlying serious conditions, such as temporal arteritis or an intracranial lesion. Prompt evaluation, including neuroimaging and, if applicable, further tests for temporal arteritis like erythrocyte sedimentation rate (ESR) and potentially a temporal artery biopsy, is crucial to address any underlying systemic disease.
A 72-year-old patient presents with a sudden, severe headache described as reaching peak intensity within seconds. Which of the following conditions should be immediately ruled out?
- A) Tension-type headache
- B) Migraine
- C) Subarachnoid hemorrhage
- D) Sinus headache
Answer:** C) Subarachnoid hemorrhage
Rationale: A “thunderclap headache” that reaches maximal intensity very quickly is a significant red flag for a subarachnoid hemorrhage, often due to a ruptured intracranial aneurysm. This is a medical emergency and requires immediate evaluation and imaging, typically starting with a CT scan of the head to confirm the diagnosis.
What laboratory test should be ordered if temporal arteritis is suspected in an older adult presenting with a new headache?
- A) Complete Blood Count (CBC)
- B) Erythrocyte Sedimentation Rate (ESR)
- C) Blood glucose level
- D) Lipid panel
Answer:** B) Erythrocyte Sedimentation Rate (ESR)
Rationale: Temporal arteritis, or giant cell arteritis, often presents with elevated ESR, indicating inflammation. High suspicion for temporal arteritis should prompt tests like ESR and possibly C-reactive protein (CRP) levels. A temporal artery biopsy might also be needed for definitive diagnosis.
Which symptom, in addition to a new-onset headache in an older adult, would strongly suggest the need for urgent evaluation for temporal arteritis?
- A) Bilateral squeezing headache
- B) Jaw claudication
- C) Dull, tension-type headache
- D) Occasional nausea
Answer:** B) Jaw claudication
Rationale: Jaw claudication, or pain in the jaw when chewing, is a classic symptom of temporal arteritis. This localized symptom, along with temporal headache, visual disturbances, and scalp tenderness, necessitates immediate evaluation to prevent complications, such as vision loss.
When assessing an older adult with a headache and elevated ESR, what is the primary concern if temporal arteritis is confirmed?
- A) Development of migraine aura
- B) Insomnia
- C) Vision loss due to optic nerve ischemia
- D) Chronic daily headache development
Answer: C) Vision loss due to optic nerve ischemia
Rationale: Temporal arteritis can lead to ischemia of the optic nerve, which can result in sudden vision loss. Prompt diagnosis and treatment with high-dose corticosteroids are necessary to prevent permanent visual impairment. Access to these preventative treatments is vital upon suspicion and confirmation of the condition.
A 55-year-old patient presents with a new-onset headache that progressively worsens over several weeks. What should the FNP prioritize in the evaluation?
- A) Recommend lifestyle modifications
- B) Refer the patient for neuroimaging
- C) Prescribe pain-relief medication and monitor the situation
- D) Record the headache history in detail and encourage hydration
Answer:** B) Refer the patient for neuroimaging
Rationale: A new-onset headache in an individual over 50, particularly one that progressively worsens, raises concern for serious underlying conditions such as an intracranial lesion. Neuroimaging, such as an MRI or CT scan, is crucial to rule out structural causes like tumors or vascular abnormalities.
A patient describes experiencing “the worst headache of their life,” accompanied by syncope. What is the most appropriate immediate action by the FNP?
- A) Arrange for an urgent referral to a neurologist
- B) Prescribe migraine medication
- C) Administer a pain relief injection
- D) Conduct a focused neurological exam and send to the ER
Answer:** D) Conduct a focused neurological exam and send to the ER
Rationale: A “worst headache of life” description paired with syncope suggests a possible subarachnoid hemorrhage or other critical condition. It requires immediate evaluation in an emergency setting to ensure urgent diagnostic imaging and appropriate management.
In a case where a headache is associated with acute visual loss and a fixed, dilated pupil, what should the FNP suspect?
- A) Migraine with aura
- B) Sinus headache
- C) Acute glaucoma
- D) Cluster headache
Answer:** C) Acute glaucoma
Rationale: A headache with acute visual changes and a fixed, dilated pupil raises suspicion for acute angle-closure glaucoma. This requires urgent ophthalmological evaluation to avoid permanent vision loss, emphasizing the need for prompt treatment, such as pressure-lowering medications or surgical intervention.
A 45-year-old patient experiences persistent headaches brought on by exertion. What additional symptom would be most concerning and warrant immediate investigation?
- A) Mild nausea
- B) Fatigue
- C) Gait disturbances
- D) Low-grade fever
Answer:** C) Gait disturbances
Rationale: Persistent headache exacerbated by exertion that is accompanied by neurological signs such as gait disturbances suggests the possibility of increased intracranial pressure or other central nervous system pathology. This finding requires immediate investigation through neurological assessment and imaging to rule out conditions like a brain tumor or vascular disorder.
An older adult presents with headache, fatigue, fever, weight loss, and scalp tenderness. What condition should be highly suspected?
- A) Migraine with aura
- B) Cluster headache
- C) Temporal arteritis (Giant Cell Arteritis)
- D) Tension-type headache
Answer:** C) Temporal arteritis (Giant Cell Arteritis)
Rationale: The combination of systemic symptoms (fatigue, fever, weight loss) along with scalp tenderness are indicative of temporal arteritis. This is especially important due to the risk of vision loss. Immediate testing for inflammatory markers like ESR or CRP and prompt corticosteroid treatment are necessary to prevent complications.
Triptans (serotonin receptor agonists)
Almotriptan (axert)
Eletriptan (relpax)
Frovatriptan (frova)
Naratriptan (amerge)
Rizatriptan (Maxalt)
Sumatriptan (Imitrex, alsuma)
Naratriptan (amerge)
Zolmitriptan (zomig)
A 68-year-old woman reports aching and burning pain on the side of her head, difficulty chewing, and recent visual changes in her right eye. Physical examination reveals tenderness over the temporal artery, and it feels thickened and pulseless.
Question 1: What is the most likely diagnosis for this patient?
- A) Migraine with aura
- B) Cluster headache
- C) Temporal arteritis (Giant Cell Arteritis)
- D) Tension headache
Answer:** C) Temporal arteritis (Giant Cell Arteritis)
Rationale: The patient’s age, symptoms, and physical findings strongly suggest temporal arteritis. Immediate evaluation with ESR or CRP tests and initiation of corticosteroids are critical to prevent vision loss, a common complication of untreated temporal arteritis.
A 42-year-old male presents with persistent headaches that often awaken him at night, accompanied by papilledema upon fundoscopic examination, nausea, projectile vomiting, and recent forgetfulness.
Question 2: What is the primary concern in this presentation?
- A) Severe tension-type headache
- B) Brain tumor
- C) Migraine without aura
- D) Cluster headache
Answer:** B) Brain tumor
Rationale: The presence of papilledema, nocturnal headaches, nausea, vomiting, and neurological changes like altered mental status is highly suggestive of increased intracranial pressure, often caused by a brain tumor. Immediate neuroimaging is warranted to evaluate this possibility.
A 35-year-old woman arrives at the clinic experiencing an abrupt headache she describes as “the worst headache of my life,” with accompanying neck stiffness and altered consciousness.
Question 3: What is the most appropriate immediate action?
- A) Administer migraine treatment
- B) Order a CT scan without contrast
- C) Prescribe muscle relaxants
- D) Refer to an ENT specialist
Answer:** B) Order a CT scan without contrast
Rationale: These symptoms are classic for subarachnoid hemorrhage, especially the sudden and severe onset described as the worst ever, combined with neck stiffness. A CT scan without contrast should be the next step to confirm a bleed, followed by lumbar puncture if CT is negative to rule out small hemorrhages.
A college student presents with severe headache mainly in the neck, high fever, neck stiffness, and positive Brudzinski and Kernig signs.
Question 4: What should the FNP suspect as the most likely diagnosis?
- A) Migraine with aura
- B) Meningitis
- C) Cluster headache
- D) Temporal arteritis
*Answer:** B) Meningitis
Rationale: The combination of neck pain, fever, neck rigidity, and positive Brudzinski and Kernig signs is indicative of meningeal irritation, suggestive of meningitis. This is a medical emergency needing immediate hospital referral for confirmation via lumbar puncture and prompt antibiotic treatment.
A 40-year-old man reports experiencing nightly severe unilateral headaches, associated ipsilateral nasal congestion, and eye tearing. He notes alcohol consumption often triggers these episodes.
Question 5: What is the likely diagnosis for this patient?
- A) Migraine with aura
- B) Cervicogenic headache
- C) Tension headache
- D) Cluster headache
Answer:** D) Cluster headache
Rationale: The characteristics presented — intense unilateral pain, trigeminal autonomic symptoms (lacrimation and nasal congestion), nocturnal pattern, and triggering by alcohol — align with those of cluster headaches. Appropriate management includes acute treatments like triptans and prophylactic strategies.
A 30-year-old woman complains of a bilateral headache that feels like a band around her head. It’s been accompanied by anxiety, insomnia, and overall fatigue.
Question 6:** What type of headache is likely affecting this patient?
- A) Tension headache
- B) Cluster headache
- C) Migraine without aura
- D) Sinus headache
A) Tension headache
Rationale: Tension headaches are characterized by bilateral “band-like” pressure, often related to stress and accompanied by symptoms like anxiety and fatigue. Management often includes lifestyle modification, stress reduction, and over-the-counter pain relief.
A 28-year-old female describes experiencing throbbing headaches, often preceded by visual disturbances like seeing flashing lights, and is sensitive to light and noise. She reports nausea and occasional vomiting.
Question 7: Which condition correlates with her symptoms?
- A) Cluster headache
- B) Temporal arteritis
- C) Migraine with aura
- D) Tension headache
*Answer:** C) Migraine with aura
Rationale: The patient’s symptoms, including throbbing pain, visual aura, photophobia, phonophobia, nausea, and vomiting, are characteristic of migraine with aura. Treatment often involves abortive medications such as triptans and preventive therapies for frequent attacks.
A 45-year-old female with a history of migraine headaches is considering the use of triptans for acute migraine relief. She has a history of frequent tension-type headaches treated with NSAIDs. Which side effect would you advise her to watch for when starting a triptan like sumatriptan (Imitrex)?
A) Double vision
- B) Parasthesia
- C) Hyperactivity
- D) Sinus congestion
Answer:** B) Parasthesia
Rationale: Triptans can cause several side effects, including parasthesia (tingling sensations), which patients should be informed about before starting the medication. It is a common neurological side effect encountered by patients taking these medications.
During a consultation, a patient is noted to experience frequent periorbital migraine attacks. The patient has ischemic heart disease as part of their medical history. What is the most relevant contraindication you should consider when prescribing a triptan?
A) Risk of gastrointestinal upset
- B) Risk of serotonin syndrome
- C) Possibility of rebound headaches
- D) Do not use in ischemic heart disease
Answer:** D) Do not use in ischemic heart disease
Rationale: Triptans are contraindicated in patients with ischemic heart disease due to vasoconstrictive properties, which can exacerbate cardiac conditions by limiting blood flow and potentially triggering ischemic events.
A patient taking triptans complains of new-onset tightness in the chest and neck after taking his medication. Which of the following side effects is the most likely cause?
- A) Cataplexy
- B) Chest and neck tightness
- C) Muscular cramps
- D) Pheromone sensitivity
B) Chest and neck tightness
Rationale: Triptans can cause chest and neck tightness as common side effects due to vasoconstriction. These effects often mimic but differ from cardiac angina and should be assessed carefully to rule out cardiac causes.
Why might a patient with a history of using triptans twice a week regularly experience rebound headaches?
- A) Triptans alter neurotransmitter release
- B) Overuse of triptans leads to rebound headaches
- C) High risk of allergic reactions
- D) Increased airflow obstruction
Answer:** B) Overuse of triptans leads to rebound headaches
Rationale: Frequent use of acute treatments like triptans can lead to medication overuse headaches, characterized by a rebound effect. It is recommended not to use triptans more than twice a week to minimize this risk.
Question 5:** A patient with migraines uses sumatriptan as an injection rather than orally or as a nasal spray. What could be a reason for her choice?
- A) Injection is for migraines with longer duration
- B) Rapid onset of action
- C) Fewer side effects
- D) It’s recommended for migraines caused by food allergies
Answer:** B) Rapid onset of action
Rationale: Sumatriptan injections can be advantageous over oral or nasal preparations due to their rapid onset of action, providing quicker relief of migraine symptoms, which can be crucial during acute and debilitating attacks.
A 52-year-old male with a history of migraines is considering the use of ergotamine combined with caffeine (Cafergot) for migraine attacks. Which condition listed is a contraindication for this medication?
- A) Seasonal allergies
- B) Hepatic disease
- C) Migraine with aura
- D) Mild asthma
Answer:** B) Hepatic disease
Rationale: Ergotamine is contraindicated in patients with hepatic disease because these patients cannot metabolize the drug effectively, increasing the risk of toxicity. It’s important to review a patient’s full medical history to identify any contraindications before prescribing this medication.
*Question 2:** A patient requires treatment for acute migraine attacks and is considering using dihydroergotamine (Migranal) nasal spray. Which of the following conditions would make this treatment inappropriate for the patient?
- A) Frequent sinus infections
- B) History of liver disease
- C) Controlled hyperlipidemia
- D) Hypothyroidism
*Answer:** B) History of liver disease
Rationale: Ergot-based treatments like dihydroergotamine are contraindicated in patients with hepatic conditions. The liver plays a crucial role in drug metabolism, and impaired liver function could lead to increased side effects and toxicity.
- While reviewing a treatment plan for migraine management with ergots, a patient asks why they should avoid use if they have hypertension (HTN). What should your response include?
- A) Ergots alleviate all headache symptoms immediately.
- B) Ergots are vasodilators, increasing blood flow.
- C) Ergots are vasoconstrictors, potentially elevating blood pressure.
- D) Ergots improve coronary circulation.
C) Ergots are vasoconstrictors, potentially elevating blood pressure.
Rationale: Ergots lead to vasoconstriction, which can increase blood pressure. This is problematic for individuals with hypertension (HTN), as it might exacerbate the condition, increasing the risk for cardiovascular events.
A patient with coronary heart disease asks why ergotamine is not an option for them. How should you explain the contraindication?
- A) Ergots increase fluid retention, worsening heart disease.
- B) Ergots slow down the heart rate significantly.
- C) Ergots can cause coronary vasospasm, worsening heart disease.
- D) Ergots primarily affect venous circulation only.
- C) Ergots can cause coronary vasospasm, worsening heart disease.
Rationale: Ergot derivatives can lead to coronary vasospasm, which can significantly worsen conditions like coronary heart disease and increase the risk of angina or myocardial infarction.
A 38-year-old patient inquires about rapid migraine relief options using ergots. Which method provides the quickest onset of action for ergotamine?
- A) Oral administration
- B) Rectal administration
- C) Subcutaneous injection
- D) Intravenous administration
D) Intravenous administration
Rationale: Intravenous administration of medications generally provides the fastest onset of action because the drug directly enters the bloodstream, bypassing absorption delays associated with other routes like oral or rectal. However, this is typically managed in a controlled medical setting.
Class of medications that abort migraines?
triptans (sumatriptan)
Ergot
antiemetics -metoclopromide (end in promide)
nsaids -motrin, aspirin, naproxen sodium
combo oral analgesics -bulabitol-caffeine
opiotes - morphine, oxygen
steroids- medrol dose
What are the classes of medications for prophylactic migraine management?
beta blockers
calcium channel blockers
antidepressants
anticonvulsants
CGRP antagonists (zumab end in)
botox- chronic migraine ingected every 3 months
A 28-year-old female is prescribed metoclopramide (Reglan) for nausea. She reports new onset of unusual muscle movements in her face and stiffness. What adverse effect is likely responsible for her symptoms?
- A) Restlessness
- B) Sedation
- C) Extrapyramidal side effects
- D) Dizziness
C) Extrapyramidal side effects
Rationale: Metoclopramide can cause extrapyramidal side effects, which are drug-induced movement disorders, including facial muscle movements and rigidity. These symptoms can resemble Parkinsonism and are a known adverse effect of this medication.
A patient being treated with prochlorperazine for severe nausea experiences profound fatigue and lack of energy. Which adverse effect of prochlorperazine could explain these symptoms?
- A) Fatigue
- B) Restlessness
- C) Dizziness
- D) Agitation
A) Fatigue
Rationale: Fatigue is a potential adverse effect of prochlorperazine, a first-generation antipsychotic used as an antiemetic. It can cause significant drowsiness and lethargy, impacting a patient’s daily activities.
During a follow-up visit, a patient on metoclopramide reports feeling constant inner restlessness and an urge to move. Which potential adverse effect is this patient experiencing?
- A) Sedation
- B) Fatigue
- C) Akathisia
- D) Dizziness
C) Akathisia
Rationale: Akathisia is a condition defined by a subjective feeling of restlessness and an uncontrollable need to be in motion. It is an extrapyramidal side effect commonly associated with drugs like metoclopramide.
A patient is newly prescribed prochlorperazine for the treatment of migraines associated with nausea. They have been advised about potential adverse effects. Which effect should the patient be specifically cautious about due to its immediate impact on everyday activities?
- A) Extrapyramidal side effects
- B) Sedation
- C) Restlessness
- B) Sedation
Rationale: Sedation is a common side effect associated with prochlorperazine, and it can impact a patient’s ability to perform activities that require alertness, such as driving or operating machinery. Patients should be warned about this so they can take necessary precautions.
A nurse is educating a patient on how to recognize the adverse effects of metoclopramide. Which of the following conditions would most likely require immediate medical attention?
- A) Mild dizziness
- B) Fatigue that improves with rest
- C) Involuntary muscle spasms
- D) Episodic ear ringing
C) Involuntary muscle spasms
Rationale: Involuntary muscle spasms could indicate the onset of extrapyramidal side effects, which are potentially serious and may require immediate medical attention to prevent more severe complications, such as tardive dyskinesia. Early recognition and management can help mitigate these effects.
What drug is ?for both abortive treatment and prophylactic treatment for both abortive treatment and prophylactic treatment?
Rimegepant (Nurtec ODT)
Ubrogepant (Ubrelvy) for abortive treatment
- A 35-year-old woman with a history of migraines is prescribed rimegepant. She asks how this medication is intended to be used. What is the correct explanation regarding rimegepant’s indication?
- A) For treating acute migraines only
- B) For the preventive treatment of chronic migraines only
- C) Both for the acute treatment and preventive treatment of migraines
- D) To alleviate tension-type headaches
C) Both for the acute treatment and preventive treatment of migraines
Rationale: Rimegepant (Nurtec ODT) is unique in that it is approved for both acute treatment of migraines and preventive treatment of episodic migraines. This dual indication provides flexibility for migraine management.
A patient with infrequent migraines is seeking a fast-acting medication for relief of acute migraine attacks. The healthcare provider considers prescribing ubrogepant. Which statement is true regarding the indication of ubrogepant?
- A) Ubrogepant is used only for migraine prophylaxis.
- B) Ubrogepant is used for the acute treatment of migraines.
- C) Ubrogepant is used only for cluster headaches.
- D) Ubrogepant is effective for treating both migraines and tension headaches.
B) Ubrogepant is used for the acute treatment of migraines.
Rationale: Ubrogepant (Ubrelvy) is a calcitonin gene-related peptide (CGRP) receptor antagonist specifically used for the acute treatment of migraine attacks in adults. It provides a targeted approach to relieving migraine symptoms.
When discussing possible side effects of rimegepant with a patient, which of the following should be mentioned as a common side effect that they may experience?
- A) Diarrhea
- B) Sedation
- C) Nausea
- D) Hypertension
Answer: C) Nausea
Rationale: Nausea is one of the more frequently reported side effects associated with rimegepant. Patients should be informed about this potential side effect so they can recognize and manage it appropriately should it occur during treatment.
Question 4:** A patient with a history of severe renal impairment is being considered for migraiment therapy. Which medication would require caution or adjustment due to its metabolism and excretion profile?
- A) Rimegepant
- B) Ubrogepant
- C) Both rimegepant and ubrogepant
- D) Neither medication
Answer:** C) Both rimegepant and ubrogepant
Rationale: Both rimegepant and ubrogepant are metabolized and excreted by the liver and kidneys. Patients with severe renal impairment may require dose adjustments or could be advised to avoid these medications altogether, as impaired renal function can affect drug clearance.
- An FNP is educating a patient about the potential drug interactions of rimegepant. Which type of drug should be used cautiously or avoided due to potential interactions?
- A) Proton pump inhibitors
- B) Strong CYP3A4 inhibitors
- C) Antihypertensives
- D) Antiretroviral agents
Answer:** B) Strong CYP3A4 inhibitors
Rationale: Rimegepant is metabolized by the cytochrome P450 system, particularly CYP3A4. Strong inhibitors of this enzyme can increase rimegepant levels, potentially leading to an increased risk of adverse effects. It’s important for patients to inform their healthcare provider of all medications they are taking to evaluate potential interactions.
What are some complementary treatments for migraines?
- acupuncture, acupresure
- aroma and herbal therapy
- biofeedback
- diet therapy
- exercise
- massage
- capscacin cream
- reflexology
- relaxation therapy
- vitamins
- avoid smoking or second hand smoke
Diet for a migraine?
2 cups strong coffee, celery juice, carrot juice
foods high in magnesium dark leafy greens, seafood, veggies
vitamin c foods- sprouts, cherries, bell peppers, brocoli
What is a tension headache?
Chronic tension-type headaches produce mild to moderate pain that feels like a constant, bilateral head tightness and lasts from a half hour to a week.
These headaches do not pulsate, do not cause nausea, and usually are not made worse by physical activity.
Chronic tension-type headaches occur repeatedly (typically many times a month), have a gradual onset during the day, and are more common in people with depression.
The basic cause of the hypersensitization is not known, although it is thought that chronic tension-type headaches result from abnormalities in the serotonin, norepinephrine, or dopamine pathways that originate in the brainstem and that modulate the trigeminothalamic or cervicothalamic pain circuits.
is the most common type of headache, with an estimated 80% to 90% of the population experiencing tension headaches at some period in their lives?
Tension
It occurs more often in women (86%) than in men (65%).
Its prevalence peaks at about age 30 to 38.
Tension headache occurs more frequently in whites (40%), especially with increasing educational levels (48%).
More than 40% of people affected reported decreased effectiveness at work, home, or school because of this type of headache.
These muscle contraction headaches may either be primary (without underlying pathology) or secondary (the result of pathology such as trauma, infection, arthritis, or tumor).
Tension headaches
What is the treatment for a tension headache?
NSAIDs, acetaminophen, cool compresses, and stress-reduction techniques. Drug therapy for acute headache should generally not exceed more than 3 days per week on a regular basis. More frequent treatment may result in medication-overuse chronic daily headaches
What is the treatment for a cluster headache?
Triptans (sumatriptan or zolmitriptan), Oxygen inhalation is highly effective for cluster headaches when administered at the beginning of an attack with a nonrebreathing facial mask at 7 to 15 L/min. Most patients will obtain relief within 15 minutes.
What is the treatment for a migraine?
: It is appropriate for the clinician to take a trial-and-error approach to identify medications most successful in the relief of headaches and associated symptoms with the fewest adverse effects, minimal costs, and a return to normal functioning for each patient. Some patients may require a combination of medications. See the next 3 slides for more details.
When should you see a neurologist if you have headaches?
considered for any patient with episodes of transient neurological deficits;
increasing frequency and severity of unilateral headaches;
atypical auras;
changes in personality;
excessive sleepiness; and new onset of progressive deficits suggesting a mass lesion
, hemorrhage, or
structural disorder.
What is a combination analgesics for abortion of migraines?
Butalbitol 50 mg/acetaminophen 325 mg/caffiene 40 mg (Fioricet)
Butalbital 50 mg/ASA 325 mg mg/caffeine 40 mg (Fiorinal)
Adverse side effects:
-increases alcohol affects
Adverse effects:
-drowsiness, dizziness, GI disturbances
True or false use of bulalbital- containing medications is not recommended as first-line treatment for migraine headaches avoid if possible (abortive)
True
Opiates (morphine, oxycodone) adverse effects: (abortive)
sedation, resp failure, constipation, addiction
**use of oppiates is not recommended as first-line treatment for migraine headaches; avoid if possible.
Steroids medrol dose pack (methylprednisolone) dexamethasone intramuscular IM/IV
can use as adjunct therapy to refractory migraine headaches
What prophylactic medication are preferred for a patient who is hypertensive and or has angina?
beta blockers
-propranolol (inderal)
-timolol (blocadren)
-metoprolol (lopressor, toprol)
-atenolol (tenormin)
-nadolol (corgard)
**Do not in asthma, sinus bradycardia, second or third atrioventricular block
Antidepressants (prophylactic) for migraines?
venlafaxine (effexor XR)
nortriptyline
amitriptyline
**may cause sedation amitriptyline recommend nighttime dosing
Calcium channel blockers Verapamil (Calan) (prophylactic)
may take several months t be effective
DO NOT GIVE IN PREGNANCY
What are the adverse side effects of verapamil (calan) ca+ channel blocker prophylactic for treatment of migraine headache?
bradycardia
fatigue
weight gain
constipation
nausea
edema
muscle pain
anticonvulsant agents (prophylactic for migraines)
topiramate (topamax)
Gabapentin (Neurontin)
valproic acid (Depakote)
what are some adverse effects?
dizziness
somnolence
tremor
weight gain
teratogenic effects
paresthesia
kidney stones
What is the preferred prophylactic migraine treatment for patients who have seizure disorder or peripheral neuropathy?
anticonvulsant agents (prophylactic for migraines)
topiramate (topamax)
Gabapentin (Neurontin)
valproic acid (Depakote)
What are the adverse effects of anticonvulsant agents (prophylactic for migraines)
topiramate (topamax)
Gabapentin (Neurontin)
valproic acid (Depakote) ?
somnolence
dizziness
asthenia
CGRP antagonists prophylactic medications?
Erenumab (aimovig)
Fremanezumab (ajovy)
Galcanezumab
eptinezumab (vyepti)
Zumab
What are the CGRP antagonists prophylactic of migraines?
newer meds approved for migraine prevention
Monoclonal antibodies that block calcitonin gene related peptide (CGRP) activity
Injectable meds given 1-3. months
What med classes are used for prophylactic of migraines?
Beta blockers- lol
antidepressants - ptyalin
calcium channel blockers -pamil
anticonvulsants-
CGRP- Zum-ab
Botox
What are foods that cause headaches?
condiments, nitrates, aged smoked meats, chocolate, yogurt, red meats, dairy products, soft drinks, alcohol, salty, sugary and wheat based foods
What are some vitamins that help with headaches?
magnesium citrate- 800 mg daily
niacin- 100-500 mg daily
ginko biloba- 120-240 mg BID
valerian root- 2-3 grams TID
Parenteral antidopaminergics (i.e., IV metoclopramide or IV prochlorperazine) are effective first-line agents for migraine regardless of GI symptoms or ability to tolerate oral medication.
first line mild to moderate headache?
consists of NSAIDs, acetaminophen, acetylsalicylic acid, or combinations including caffeine.
moderate to severe headache treat with
Migraine-specific agents: triptans (e.g., sumatriptan) OR ergotamine; do not combine these agents!
If nausea/vomiting are present or there is a higher analgesic requirement, consider one of the following for moderate to severe headaches?
Sumatriptan
Zolmitripta
Remember to check for drug interactions (e.g., with SSRIs or macrolides) before starting triptans or ergotamines to avoid adverse events. Coronary spasm and/or serotonin syndrome can occur if triptans and ergotamines are combined.
Ergotamines are contraindicated in pregnancy. [
A SUMo wrestler TRIPs ANd falls on his head: SUMaTRIPtANs are used for headaches (cluster and migraine).
Sumatriptan?
serotonin 5-HT 1B/1D Receptor Agonist
Treats acute migraine
Treats cluster headache
Do not take with an MAO inhibitor
Causes- vasoconstriction
side effects:
- paresthesia- pins and needles
-dizziness, malaise
- frequent intake of medications can cause headaches
Who should you not give sumatriptan to?
-CAD
-PAD
-Vasospastic angina
-HTN
Who should you not give Ergotamine to?
-pregnancy
-PVD
-CAD
-HTN
Do not give ergotamine with?
macrolides
azole antifungals
protease inhibitors
1st line prophylaxis of migraine?
anticonvulsants, beta blockers
2nd line prophylaxis of migraine?
TCA’s -amitryphytiline
NSAIDs
OR calcium channel blockers
What is the first line treatment for a menstrual related migraine?
Frovatriptan
Frova= ova :) Got it!!
No black box warning
Do not give uncontrolled HTN
Ischemic heart disease
CVD
PVD
zolmatriptan treats?
acute migraines
jaw tightness
warm, hot cold sensation
heaviness sensation
Treatment for chronic migraine?
Botox
Or
Monoclonal antibodies “zumabs”
Management of migraine
CT/MRI for Red flags of headaches
decrease light/noise
fluid hydration
nsaids
treat n/v if present
What are the red flags of a migraine?
- use of anticoagulation (brain bleed)
-thunderclap headache worst headache of my life
-change in mental status
Mild to moderate migraine start
nsaids
moderate to severe start?
triptans
ergotamines
Escalating therapy for treatment of migraine?
NSAID, ergotamine, dexamethasone, valproic acid
inpatient treatment
neuro consult
alternative diagnoses?
