Therapeutics - Migraine Flashcards
one of the most important nonpharm counseling points for a migraine patient
keep a food diary!!!!!!! can help to prevent
patient presents with a migraine
they have HBP, or have recently had a stroke.
is it acceptable to just give advil
NO
need to refer to dr
may be due to underlying cause
migraines are becoming increasingly more prevalent in what age range
children and adolescents
differentiate between primary and secondary headache in terms of any structural or metabolic abnormalities
primary - no structural or metabolic abnormalities
secondary - there IS structural or metabolic abnormalities
which type of headache is due to a medical condition
secondary
name the 3 types of primary headache
migraine
tension
cluster
what’s the only type of primary headache that is bilateral
tension
does the patient tend to remain active if they have a primary headache?
depends
yes for cluster and tension
no for migraine
which type of primary headache is more common in males and smokers
cluster
true or false
migraines are commonly misdiagnosed
true
commonly they are mistakenly diagnosed as sinus headaches or tension headaches
true or false
migraines do not cause a huge economic burden
FALSE - they do
for treatment (direct) and indirect by missing work days
name 3 GENERAL triggers of migraine
food
environmental
behavioral
name some foods that can trigger migraine
caffeine
alcohol
aspartame
tyramine-containing foods
nitrate-containing (processed meat)
monosodium glutamate (chinese food)
chocolate
when women have menstruation-related migraines, when do they typically start
around 2 days prior to menstruation (and lasts throughout)
true or false
migraine with aura is more common than migraine without aura
FALSE - migraine without aura is more common
which tends to be more DISABLING – migraine with aura or without aura
without aura
when counseling a patient when to take their abortive/acute migraine therapy, what should you say
if they get migraines with aura – TAKE RIGHT WHEN THE AURA STARTS!!!!!!! med takes time to work
name 3 types of aura
visual
sensory (unilateral numbness in arms or face)
speech disturbance
what are the 3 phases of migraine attacks and how long do they last
prodrome
headache
postdrome
prodrome is hours-days BEFORE the actual headache
headache -lasts up to 72 hours
postdrome - lasts up to 48 hours
what may a patient experience in the prodrome phase of migraine
nonpainful symptoms like fatigue, mood changes, food cravings, difficulty concentration, etc
2 types of pharmacologic treatment for migraine
abortive/acute
preventative
*true or false
as long as a patient gets migraines, they are a candidate for prophylaxis
FALSE - there are specific criteria
name some nonpharm therapies for migraine
ice packs to head (to vasoconstrict)
rest
avoid triggers!
keep a headache diary of the frequency, severity, and duration
relaxation therapy
true or false
a good counseling point for a migraine patient is to exercise to help with the pain – like go to the gym
FALSE - something like yoga - not the gym
patient has migraines that are associated with severe nausea and vomiting
what pharm treatment is good
pretreat with an antiemetic
may not be able to use oral therapies - consider sppository/parenteral/intranasal
patient has a migraine with MILD-MODERATE symptoms
explain the treatment regimen
- start with a simple analgesic like NSAIDS, tylenol
- if insufficient response, do a combo analgesic like tylenol/aspirin/caffeine
- if still insufficient response, can do triptans or the ergots. however, we typically start with triptans bc less side effects
- if STILL inadequate response, combo, rescue therapy (potentially add ergotamine to a triptan)
patient has migraines with SEVERE symptoms
explain the treatment regimen
immediately start with either triptan or ergot (typically triptan)
if insufficient response on one, combo therapy/rescue therapy
abortive drug therapies for migraine are most effective when given when?
within the 1st hour of onset of the migraine
shortens the duration and severity of the migraine
differentiate between when non-specific agents are used vs migraine-specific agents
nonspecific - used for mild-moderate
migraine-specific - used for moderate-severe
can ODT be used if the patient is nauseas
YES
in what medical condition should the oral route not be used for migraine treatment and why
gastroparesis (delayed gastric emptying)
will reduce absorption of the drug and patient won’t get relief - use other route
1st line nonspecific treatment for mild-moderate migraine pain
nonspecific abortive therapies
analgesics, NSAIDS
onset dose of tylenol for migraine
1000mg (2 xs tabs)
which nonspecific agent for migraines has little evidence as being effective as monotherapy, and therefore, it’s often not used alone for migraine
acetaminophen
a patient asks if there is a specific NSAID she should get for migraine
what do you say
really no difference – all equally effective
2 systems that NSAIDS negatively affect and thus the duration of use for them is limited
GI
CNS (somnolence, dizziness)
true or false
if a patient doesn’t respond to 1 triptan, it is pointless to try a different one
FALSE
can try a different one - varying responses
imitrex
sumatriptan
zomig
zolmitriptan
maxalt
rizatriptan
axert
almotriptan
relpax
eletriptan
naramig
naratriptan
frova
frovatriptan
what 2 dosage forms does zolmitriptan come in
oral tabs
nasal spray
what dosage forms does sumatriptan come in
a lot
injection
tabs
nasal spray/powder
what dosage forms does rizatriptan come in
regular oral tabs and ODT
2 classes of drugs that are a DDI concern with triptans, and explain the interactions
SSRIs/SNRIs – serotonin syndrome with triptans
ergots - prolonged vasospastic reaction. avoid within 24 hours of each other!!!
triptans contraindication
in uncontrolled BP or CAD!!
serious CV events and death due to vasospasm (rare)
pretty common SE of triptans and is this a concern
chest pain or pressure
usually not serious and not due to ischemia
true or false
ergot alkaloids are nonselective 5HTa1 agonists
TRUE
so they basically vasoconstrict everywhere
ergot alkaloid contraindications
LOT OF THEM
CAD
within 2 weeks of MAO inhibitors
pregnancy/nursing
renal or hepatic failure
uncontrolled HTN
with CYP3A4 inhibitors
ergot alkaloids are considered 2nd line agents
name 3 scenarios their use is appropriate
-when triptans are ineffective or intolerable
-when there is a high risk of recurrence
-migraines that last over 48 hours
which ergot alkaloid is more nauseating than the other
ergotamine (with or without caffeine) is more nauseating than dihydroergotamine
why is it important to follow the dose limits for ergot alkaloids
medication overuse headache
which is a more potent vasoconstricor - ergotamine or dihydroergotamine
ergotamine is a more potent vasoconstrictor
how does lasmiditan work
selective 5HT1F serotonin receptor agonist
decreases stimulation of the trigemino vascular system
TRUE OR FALSE
unlike triptans, lasmiditan does NOT cause undesirable vasoconstriction
true
due to selectivity for the 5HT1F serotonin receptor
is lasmiditan a controlled substance
yes - schedule 5
lasmiditan is generally reserved for which patients
who have failed/cannot use NSAIDS or triptans
with triptans, the patient can repeat the dose in 2 hours if their symptoms still persist
is this the case for the ditans? (lasmiditan)
NO
NO MORE THAN 1 DOSE IN 24 HOURS
brand name lasmiditan
reyvow
AE of lasmiditan
driving impairment
CNS depression - dizziness and sedation
CGRP agonists or antagonists are used for migraine
antagonists
CGRP is high in migraines, contributing to pain
why are cgrp antagonists not really used, being that they’re effective
access and cost
how to recognize the CGRP antagonists that aren’t mabs
“pant”
**which cgrp antagonists are indicated for acute treatment?
ONLY rimegepant and ubrogepant
(nurtec and ubrelvy)
the mabs + qulipta (atogepant) are for prevention!!!!!
5 antiemetics that can be used for migraine patients
promethazine
prochlorperazine
metoclopramide
trimethobenzamide
ondansetron
which antiemetic is commonly used as pretreatment before IV dihydroergotamine
reglan (metoclopramide)
explain the method to know if a patient needs a change in their abortive migraine treatment
if they answer “no” to 1 or more of these questions:
does your med work for most attacks?
does the headache dissapear within 2 hours?
are you able to function normally within 2 hours?
are you comfortable enough with your med to be able to plan your daily activities?
HOWEVER, before changing, we HAVE TO ASSESS THEIR ADHERENCE AND DOSE!!!!!
***Explain when a patient would be a candidate for migraine prophylaxis
-4 or more attacks/month or 8 or more headache days/month
-failure/CI/SE of abortive meds
-pt preference
-impacts pt’s daily life despite proper lifestyle management and acute treatment
-menstrual migraine
*true or false
a woman who gets menstrual migraines is a candidate for prophylaxis
true
when giving prophylaxis for migraines, it’s important to give the patient realistic expectations
what does this mean
THIS IS NOT A CURE
just meant to decrease the frequency and intensity
you still most likely will get them
when counseling a pt getting migraine prophylaxis for the 1st time, how long to tell them for it to work?
up to a month and a half to start working
when giving migraine prophylaxis, the treatment should be maintained for t least how long? when can we try to withdraw the drug?
maintain for at least 3 months
after 6-12 months, try to withdraw the drug SLOWLY
what dose should migraine prophylaxis be started on
LOW DOSE and increase slowly until therapeutic effects develop, max dose is reached, or AE becomes intolerable
**patient’s headaches recur in a predictable pattern - like menstrual migraine.
what prophylactic agent should be tried 1st? what if this is ineffective
NSAID OR TRIPTAN
then try B blocker (or verapamil if CI or ineffective)
then tricyclic antidepressant
then anticonvulsant
then combo therapy and consult specialist
**patient meets the criteria for migraine prophylaxis.
they are healthy OR have comorbid angina
what agent should be tried first? explain algorithm
1st - beta blocker or verapamil if b blocker is CI or ineffective
-then TCA
-then anticonvulsant
-then consider combo therapy and see specialist
**pt is a candidate for migrain prophylaxis and has comorbid depression or insomnia
what agent should be tried first?
explain the algortihm
tricyclic antidepressant first
then anticonvulsant
then consider combo therapy
*pt is a candidate for migraine prophylaxis and has comorbid seizure or bipolar disorder
what agent should be tried first?
explain algorithm
anticonvulsant
if ineffective, try b blocker/verapamil
then consider combo therapy
