Therapeutics - Migrain Part 2 Flashcards
which 2 beta blockers are actually indicated for migraine prophylaxis
propranolol
timolol
(others are used off label)
true or false
the dose of b blockers is the same for HTN as it is for migraine prophylaxis
FALSE - different
beta blockers mask ______
hypoglycemia
use with caution in diabetics
name 3 potential antiepileptics for migraine prophyalxis
valproate
divalproex
topiramate
true or false
all 3 FDA indicated antiepileptics for migraine prophyalxis are teratogenic
TRUE
if the patient is pregnant, USE BETA BLOCKERS INSTEAD
side effects of valproic acid/divalproex
nausea and vomiting
weight gain, alopecia, weight gain, somnolence
which formulation of divalproex sodium is best to use and why
ER divalproex sodium – QD and is better tolerated than the enteric coating
valproate’s most serious side effect
hepatotoxicity - monitor LFT!
true or false
valproate is CI in pregnancy
true
valproate is contraindicated in pregnancy
what are some of its other contraindications?
history of pancreatitis or chronic liver disease
true or false
valproic acid and divalproex sodium are interchangeable
FALSE - not. there’s a conversion process
most extensively studied med for migraine prophylaxis
topiramate
**patient is a candidate for migraine prophylaxis and epileptics would be best to use
which particular med?
topiramate!!!! better than valproic acid in this case. AE of topiramate is weight loss (desirable)
which particular antidepressants are used in migraine prophylaxis
TCA (tricyclics) and SNRI (venlafaxine)
not SSRI!
true or false
the beneficial effects of antidepressants in migraine are INDEPENDENT of their antidepressant activity
TRUE
TCA common side effects
thus patients with what 2 disease states shouldnt really get it?
anticholinergic side effects
BPH and glaucoma
true or false
the doses used for depression are the same doses used for migraine prophylaxis
false - for migraine prophylaxis they’re used at lower doses
triptans are useful for prevention?
YES - menstrual migraine specifically
which specific triptans are effective as migraine prophyalxis
frovatriptan is the only one indicated, but naratriptan and zolmitriptan are effective too
patient is taking frovatriptan for menstrual migraine prevention
explain to them when they should take it
1-2 days before period, and then throughout the duration of the period. up to 5 days!
patient is taking NSAID for migraine prophyalxis
explain to them when they should take it
1 WEEK before the expected onset, and continue no more than 10 days!
5 miscellaneous migraine agents
magnesium
riboflavin
petasites
boutlinum toxin (not effective)
coq10
magnesium is a potential agent for migraine. it is probably most helpful in which type?
with aura
menstrual migraine
true or false
migraines in pregnant women, though uncomfortable, are not a clinical concern
FALSE - they are. increased risk of preeclampsia
3 migraine options in pregnancy
acetaminophen
ibuprofen (avoid in 3rd trimester!)
triptans (sumatriptan preferred)
true or false
ibuprofen can be used for migraine throughout the entire pregnancy
false - only can be used in 1st and 2nd trimesters.
avoid in 3rd
name 2 pain meds that should be avoided in pregnant patients who have migraine
aspirin or opiates
which antiemetic should always be avoided in pregnancy
metoclopramide
2 antiemetics that CAN be used in pregnancy
ondansetron and prochlorperazine
if a pregnant patient needs migraine prophylaxis, what should you use
beta blockers
medication overuse headaches can be caused by:
taking simple analgesics for how long?
migraine-specific, opioid, or combo meds for how long?
simple analgesics - for 15 days/month for 3 or more months
migraine-specific, opioids, or combo meds - 10 days/month for 3 or more months
true or false
it is possible that medication overuse can reduce the efficacy of acute and prophylactic migraine treatment
true
consideration when fixing a patient’s medication overuse headache
include some counseling points
GRADUALLY taper them off the med either inpatient or outpatient depending on the severity
tell pt the headaches may worsen at first, but will gradually improve
most common type of primary headache
tension headache
when is a tension headache considered chronic
if had for over 15 days/month
do patients get aura from a tension headache
no
________ are the mainstay of acute therapy for tension headache
simple analgesics
nonpharm tension headache treatment
massage, hot baths, relaxation
physical therapy, accupuncture
as mentioned, simple analgesics are the main treatment for tension headache
explain how long they can be used
if combo analgesic - no more than 9 days
if using an NSAID - no more than 15 days ( dont want med overuse headache!)
patient has chronic tension headache (over 15 days/months).
what can be given
amitryptiline QD
limited studies on other stuff
what is the most SEVERE of the primary headaches
cluster headache
is aura present in cluster headaches?
no
abortive therapy treatment regimen for cluster headache
1 treatment is oxygen - have to go somewhere for it. at least 12-15L/min. effects start 10-20 mins after treatment
if O2 isn’t available, triptans are next step
than ergots
triptans are the second choice for cluster headache
explain the specifics of this
subq and intranasal triptans only’
oral triptans have limited use in cluster
explain the role of ergotamines as abortive treatment for cluster headaches
sublingual provides relief
IV may be given as bolus and then repeated administration over several days to break the cycle of attacks
preferred first line prophylaxis for cluster
when do benefits appear?
verapamil
benefits appear within 2-3 week of therapy
what is the more 2nf like prophylactic option for cluster headache
lithium
when using lithium for cluster prophylaxis, what should the lithium levels be
between 0.4-1.2 meq/L
lithium side effects
tremor
thyroid and renal dysfunction
name 2 transitional prophyalctic agents for cluster headaches
corticosteroids
occipital nerve blocks
ie - buy time before the verapamil starts to work
