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Ph Neuro Migraine
Pharma Neuro
| Question | Answer |
|---|---|
| TTH: 2 types | Episodic (attacks occur 3 days/month); Chronic (15 or more attacks/month; in <5% of population) |
| TTH: Cause: | initially, myofascial head pain with altered central processing |
| TTH prevalence | 1-year prevalence 30-90%, highest in adult F |
| TTH dx | ≥2 of (Bilateral head pain; Non-pulsating pain; Pain intensity mild-mod) AND both of: No N/V; and EITHER photophobia or phonophobia; Also, poss palpable head mx tender points |
| TTH: Episodic or Acute: Tx | OTC analgesics; nonresponders: prescription analgesics; Rarely, require butalbital combo, Midrin, or APAP + opioid; consider prophylaxis if need >2 day/wk |
| TTH: prophylactic tx | TCA (amitriptyline); skel mx relaxants (Zanaflex may promote weaning from other analgesics); Botox (to cranial mx) |
| TTH: antidepressants | TCA (amitriptyline, nortriptyline; CI in severe heart dz); Duloxetine (8 wks) |
| TTH: Mx relaxants: Caution | Sedating (don’t drive); dizziness; liver tox; may take 2-4times/day |
| Cluster HA: Abortive Tx | O2 100% at 6-8 L/min x 15 min; DHE-45 IV; Sumatriptan or Zomig; Intranasal lidocaine; Poss Lupron IM |
| Cluster HA: Prophylactic Tx: | Verapamil; Lithium; ergotamine (poss w/Li tx); corticosteroids (Prednisone taper; relief in 1-2 days; Poss HA recurrence if d/c tx) |
| Lithium: caution | Renal dz, diuretic use, CV disease, PG, DI; life-threatening AE’s w/ lithium intoxication |
| Triptans: MOA: | constrict intracranial blood vessels, inhibit vasoactive neuropeptide release, & interrupt pain signal transmission centrally |
| Triptans: AE: | paresthesias, fatigue, dizziness, flushing, warm sensations, somnolence, chest tightness (up to 15%), possible rebound HA |
| Triptans: CI: | ischemic heart dz, uncontrolled HTN & cerebrovascular dz, basilar or hemiplegic migraines |
| Triptans: DI: | MAOIs, ergot, caution w/SSRIs (serotonin syndrome), some 3A4 interactions |
| Sumatriptan | Fast onset, short duration; repeat dose in 1 hr if nec; oral CI in elderly (HTN risk); SQ, oral, nasal; Never give IV or IM |
| Sumatriptan: indications | migraine (abortive tx); acute tx cluster HA |
| Naratriptan | Slow onset, long duration; may repeat once after 4 hrs; |
| Naratriptan: dosing caution: | CI if CrCl <15; avoid in endstage liver dz; lowest dose in hep impaired; fx < sumatriptan at 2 hrs but >sumatriptan at 24 hrs |
| Rizatriptan | Fast onset, short duration; may repeat q2hr (3 in 24 hr); fx/AE better at 2 hr than Suma |
| Rizatriptan dosing | Use lowest dose if pt on propranolol |
| Zomig | Oral, nasal (poorly tolerated: taste problem); Fast onset, short duration; may repeat in 2 hr (usu give once) |
| Zomig: dosing | Use lowest dose if pt has liver dz |
| Frovatriptan | Oral; Slow onset, longest duration; may repeat in 2 hrs (to 3/day); HA recur < Suma |
| Frovatriptan: indications | slow onset HA, predictable migraine pattern (e.g., menstrual migraine) |
| Eletriptan | Fast onset, short-moderate duration; may redose in 2 hrs; 2-hr HA relief > Suma & Nara |
| Treximet (Suma/Naproxen combo) | Suma peak 1 hr; Naproxen peak 5 hr; less need for rescue med |
| Ergotamine MOA | PO, PR, SL, injection; direct sm mx vasoconstrictor |
| Ergotamine: AE: | vasoconstriction, HTN, peripheral ischemia, N/V/D, pruritus, vertigo, cramps, paresthesias, cold skin, dec pulses in extremities; rebound HA, pulmo fibrosis (LT use) |
| Ergotamine: CI: | CAD, PVD, HTN, liver/kidney dz, protease inhib, PG (category X) |
| Ergotamine: DI: | triptans, methysergide, CYP 3A4 inhibitors |
| Other abortive tx: | Combo w/ sympathomimetics; opioids; combo w/ barbiturates; anti-emetics; intranasal lidocaine |
| Beta blockers | migraine prophylaxis; 50-60% efficacy |
| Beta blockers: MOA: | central/serotonergic, beta-1 mediated |
| Beta blockers AE: | sedation, fatigue, dizziness, depression, orthostatic hypoTN, impotence |
| Beta blockers: CI/cautions: | Asthma, decompensated HF (?), PVD (non-selective agents), IDDM (may mask signs of hypoglycemia) |
| TCA: indication | migraine prophylaxis |
| Migraine: prophylaxis options | Beta; TCA; SSRIs; atypical antidepressants (bupropion); Nardil; anticonvulsants (Valpro FDA approved); CCB (verapamil); NSAIDs (ST for predictable) |
| Prophylactic Tx: Pt selection | ≥2 attacks/mo -> disability ≥3 days/mo; HA refractory to abortive tx; using abortive tx ≥2 days/wk; uncommon & serious HA types; individualize tx based on pt & consider concomitant dz states |
| Prophylactic tx: adequate trial of tx: | 6-8 weeks |
| Menstrual migraine: Tx | NSAIDs: begin 2-7 days prior to menses, continue through last day of flow; Hormonal therapy (OCP) |
| TCA MOA | antagonism of vascular or brainstem 5-HT2 |
| TCA AE | anticholinergic, sedation, postural hypoTN, arrhythmias, tremor, wt gain |
| TCA CI | MAOIs, acute recovery MI |
Created by:
Abarnard
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