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Benitez CNS 1A
Therapeutics of Headache disorders Acute Tx
| Question | Answer |
|---|---|
| According to the international Classification of HA disorders (ICHD-3)—> primary headache is caused by? | independent pathomethansims (not by other disorders) |
| According to the international Classification of HA disorders (ICHD-3)—> secondary headache? | develops as secondary symptom due to another disorder |
| Examples by ICHD-3 primary headaches are? | 1. Migraines 2. Tension-type HA (TTH) 3. trigeminal autonomic cephalalgias (TACs), includes cluster HA 4. Other primary HA disorders |
| Examples by ICHD-3 secondary headaches are? | headaches attributed to—> trauma/injury; cranial or cervial vascular disorder; non-vascular intracranial disorder; *substance or it’s withdrawal***; infection; disorder of homeostasis; headache or facial pain attributed to disorder or facial or crevices structure; psychiatric disorder |
| ***Headaches attributed to substances: exposure to a substance such as: | -Nitric oxide donor (isosorbide, mono, or denigrate, Na+ nitroprisside)**** -***Phosphodiesterase inhibitor (slide foil, vardenafil, tadalafil) Carbon monoxide; Alcohol; cocaine; Histamine; Calcitonin gene-related peptide CGRP); Vasopressors |
| Headaches attributed to substances: Medication-overuse via—> | Ergotamine use >/=10 days/month Triptan use >/=10 days/month NSAIDS >/= 15 days/month APAP use >/= 15 days/month Opioids use >/= 10 days/month Use >/= 10 days/month of multiple drug classes w/o overuse of any single drug |
| Headaches attributed to substances: Substance Withdrawal: | Caffeine (initial consumption > 200 mg/day for at least 2 weeks) Opioid (intake daily for > 3 weeks) Estrogen (daily intake for >/= 3 weeks) |
| Epidemiology and global burden of headache disorders: | 1. headache disorders affect approx. 50% of the adult pop. 2. 50-75% of adults experienced a HA in the last year (30% of which were migraine headaches 3. HA disorders are the 3rd leading cause of years lost due to disability, miraine HA are the 6th leading cause, and medication overuse HA are the 20th cause. |
| Epidemiology of Migraines: | Estimated to affect 10-15% of the pop.; More prevalent in women (**3x more likely to occur in women) (18% of women; 6% of men); Younger age of onset, majority will have first attack before age 40; Migraine w/o aura most common (25-30% experience aura) 6th leading cause of disability |
| ICHD-3 classifications for migraines: Migraine w/o aura is _______ _______ | common migraine (Episodic migraines) |
| ICHD-3 classifications for migraines: Migraine w/ aura is _____ _______ | classic migraine (Episodic migraines) |
| ICHD-3 classifications for migraines: Chronic migraine can have w/ or w/o ______ | aura; **Numerical cut off is 15 headaches per month/ anything less thatn 15 is episodic |
| What is an aura? | Sensory disturbance that immediately precedes migraine attack, cuase by cortical spreading disease |
| Most common disturbance in aura is _______. % of pts that experience an aura is _______ | ***Visual; 25-30% |
| Acronym for Migraine Characteristic Summary: | P: Pulsating pain (throbbing) O: one-day duration (4-72h) U: Unilaterial (one-sided) N Nausea and vomiting D: Disabling intensity |
| migraine characteristics may come w/ or w/o Reversible aura symptoms which are? | visual; motor; sensory; speech/language; motor; brainstem; retinal--> Chronic if >/= 15 days/month for > 3 months |
| **Memorize the 15--> If a pt experiences at least 15 headache days per month that is our numerical cut off for? | chronic as opposed to episodic |
| Chronic migraine is primary headache with at least 15 headache days per month (migraine or tension-type) with: | or at least 8 days meeting migraine classification for > 3 months |
| Medication-overuse headache--> is considered ________ headache. | secondary. HA >/= 15 days/month due to regular ANALGESIC use (ergotamine, triptan, non-opioid, opioid, or combo) on >/= 10-15 days/month for > 3 months |
| Benitez: Not easy to determine if your treating chronic migraine or medication overuse HA, yet the most common cuase of symptoms suggestive of chronic migraines is in fact _______-______ | medication-overuse |
| Benitez: if we get them to cut back on analgesic use of their acute meds, they (50%) will revert back to ______ and have fewer migraines per month. Many pts overusing medication do not improve after drug withdrawal. | Episodic |
| Migraine treatment should be _____-______. Differ b/w pts and even b/w attacks in the same pt. Variances such as frequency/duration/severity/ disability/auras/N/V/ sensitivity to light and sound as well as variance in: | pt specific; RESPONSIVENESS AND TOLERANCE TO MEDICATIONS |
| Two major migraine treatments are? | All pts: Acute tx (stop pain of headache as they occur dosed as PRN) +/- Adjunct tx (something to help with nausea, vomiting, etc) Some pts: Pharmacologic preventative Tx (prophylactic, do nothging for the pain, take on a regular basis? meant to decrease FREQUENCY) |
| Goals of therapy for Acute Tx are: | treat attacks rapidly and consistently w/o recurrence; restore ability to function; minimize the use of back-up and rescue meds; cost-effective for overall management; minimal or no adverse events; **Guard against medication-overuse HA (limit use of abortive tx to <10 days/month or </= 2 days/wk) *since they can cuase secondary HA |
| Acute Pharm Therapy based on severity: Mild to moderate--> | 1st line: non-opiiod analgesic: NSAID or NSAID combo product or APAP (*APAP monotherpay not receommended, 2015 guidelines state that it can be considred for non-incapacitating migrains *if pt responds poorly--> Triptan +/- Antimimetics (Meto, prochlor, chlorpromazine for IV mono; PO antimimetics are optional adjunctive therapy for N/V |
| Acute Pharm Therapy based on severity: Moderate to Severe--> | 1st line: Triptan (if no CI); All triptans GRADE A; if N/V--> use non-oral ROA; 2nd line: Based on pt specific factors: Consider NSAID + Triptan combo; Dihydroergotamine (if no CI); Never classes: "gepants and lasmiditan; Last line option--> Opioid analgesics & barbituate combo +/- Antimimetics (Meto, prochlor, chlorpromazine for IV mono; PO antimimetics are optional adjunctive therapy for N/V |
| Acetaminophen: know dosing--> | 1000 mg PO at onset of HA (only the 1000 mg dose has been shown to be effective); IV APAP not been shown to significnaly reduce migraine HA; Notes: only level A for evidence for Non-incapacitating attacks |
| Acetaminophen, aspirin, and caffeine brand name? Combo shown in randomized trials to relieve migraine pain signifcantly better than--> Ibuprofen, caffeine mono, APAP mono, ASA mono, ASA + APAP combo. | Excedrin Extra strength or Excedrin Migraine; |
| General guidance with caffeine and HA is for pts who are suffering from HA disordes, we recommend: | being cautious with caffeine intake, avoiding excessive intake and fluctuations intake. |
| Determining if Medication trial was appropriate: What is 1st to consider? | 1. Assess if dose was appropriate (higher dose have much better repsonses; Oral BA may be rediced during migraine attack due to changes in GI track reduced motility or stasis; Link b/w migrains and GI changes but is not fully understood. *Applies to all acute medications options |
| Determining if Medication trial was appropriate: What is the 2nd thing to consider? | 2. Assess if timing of the dose was appropriate (evidinece that acute therapies work best taken immediately after onset of migraine pain); Survey study found that nearly 50% of pts admitted to avoiding or delaying therapy when they started to experience a migraine attack. |
| Benitez question: if a pt tried Ibuprofen 200 mg, then solution could be? | a dosage increase to see if they have a better response |
| Treatment approach: Mild-moderate Migraines: Initial therapy will either be? | acetaminophen (non-incapacitating attacks only), NSAID monotherapy, or NSAID combination is appropriate |
| Treatment approach: Mild-moderate Migraines: If initial therapy "fails?" | assess whether use was appropriate (eg. what dose was taken, when was the dose taken in relation to headache onset) |
| Treatment approach: Mild-moderate Migraines: If failure confirmed--> | reasonable to try a different medication, a higher dose, or a combination product before initiating a triptan |
| Treatment approach: Mild-moderate Migraines: Before trying a triptan it is reasonable to try the: | combination of aspirin, acetaminophen, and caffeine as this has been shown in trials to be more effective than individual components or combination without caffeine |
| example question: Treatment failure if pt tried APAP 500mg q8h? | No, because they did not try the highest dose |
| Studies looking at 25 mg of Sumatriptan in clinical tries found that its: | no better than placebo. so a higher dose can have better responses |
| Sumatriptan brand name is? | Imitrex |
| Zolmitriptan brand name is? | Zomig |
| Naratriptan brand name is? | Amerge |
| Rizatriptan brand name is? | Maxalt |
| Almotriptan brand name is? | Axert |
| Eletriptan brand name is? | Relpax |
| Frovatriptan brand name is? | Frova |
| Adverse rxns of Triptans include? | CNS: dizziness, paresthesia, sensation of pressure or tightness, alterations in temperature sensation, "feeling strange"; CARDIO: chest discomfort or pain, jaw or thrat discomfort, chest pressure GI: nausea MSK: neck pain or stiffness, weakness, myalgias Injection: injection site rxn, warm sensation at injection site NASAL: unpleasant taste, nasal discomfrot |
| Contraindications with Triptans include? | Ischemic Heart Disease, history of cerebrovascular diseases (CVA or TIA); Peripheral vascular disease (including ischemic bowel disease; uncontrolled hypertension; drug interactions: use w/in 24h of ergotamine derivative or another triptan for all triptans concurrent admin or w/in 2 wks of d/c an MAOI for some triptans |
| Triptan associated CV and Cerebrovascular risk: | Activation of Trigeminovascular pathway releases neuropeptides and NT (CGRP); CGRP has potent Vasodilatory effects, exacerbates neurogenic inflamamtion, and nociceptor pain signaling. |
| Triptans are Agonists at 5-HT1D and 5-HT1B receptors, what are their effects on these receptors? | 1D: decrease release of CGRP 1B: vasoconstriction of blood vessles and CV warnings *The problem is that 1B receptor that leads to Vasoconstriction, which ultimately leads to a lot of those CV and cerebrovascular warnings. |
| CV risk with Triptans and Ergots: Patients with migraines have a higher risk of CV Disease--> | MOA unclear, higher risk with aura; MI, CVA, PVD, & CV mortality |
| CV risk with Triptans and Ergots: Limitations of Use--> | 3 million Americans with episodic migraines are CI Majority of patients with migraines (61%) have at least one CV risk factor |
| CV risk with Triptans and Ergots: Real-World Prescribing--> | Pts with CV risk factors and disease are still prescribed triptan and ergots though less frequently |
| CV risk with Triptans and Ergots: Serious and fatal ischemic events have occurred--> | Rates of < 1 per 4 million uses (since triptan may cause fatal ischemic event) Greater risk w/excessive doses (ergots) |
| Counseling points for pts on Triptans and Ergots--> | Per the Package Insert (PI) recommend a CV evaluation and/or administering 1st dose in supervised; Overall CV event risk is low but should still be monitored Remind patients that “triptan sensation” can occur as well and usually dissipates after administration |
| When to consider avoiding triptans/ergots: | Patients with contraindications to triptans (esp. if reason for CI was recent) as opposed to patients with CV risk factors or not-contraindicated CV disease; If patient has had a previous CV event on a triptan or ergot derivative |
| Safety considerations: DI: Any drug that increases serotonin or is a serotonin modulators--> | Nature of Interaction: Risk of serotonin syndrome (Includes majority of antidepressants: SSRIs, SNRIs, MAOIs, TCAs, mirtazapine, buspirone, trazodone; Also includes: ergot derivatives, tramadol, linezolid, St. Johns wort, methadone, dextromethorphan, fentanyl, lithium, and others) |
| Safety considerations: DI: 5HT1 Agonists | Nature of Interaction: Triptans and ergot derivatives should NOT be used together and this may enhance vasoconstrictive effects. Multiple triptans or multiple ergot derivatives should also NOT be used together |
| Safety considerations: DI: MAOIs | Increased concentrations of any triptan that is metabolized by MAO with exception to (frovatriptan, eletriptan, and naratriptan are safe in combination with MAOIs) |
| Other considerations: N/V--> | Recommended to use non-oral route of administration if patient is experiencing nausea and vomiting ODT may be an option for some patients Sumatriptan (IN, SQ); Zolmitriptan (IN); Rizatriptan (ODT) |
| Triptan Efficacy: ALL TRIPTANS are given a class A recommendation and can be used as 1st line. Selection is based on? | Pt specific factors |
| Pts who do not respond to 1 triptan may respond to? | another triptan |
| Before confirming a triptan “failure” assess if: | the dose was sufficient and if the administration time was sufficient |
| 1/2 life is longer in which 2 triptans? | Naratriptan (5-6h) and Frovatriptan (25h) |
| Frovatriptan has been shown to have significantly | lower 24 hour & 48 hour recurrence rates compared to other triptans, while Naratriptan has less evidence of improved recurrence rates |
| Short-term efficacy of frovatriptan and naratriptan is comparable to other triptans and onset of action is: | slower. Onset of Naratriptan (1-3h); Frovatriptin (2-4h); all other oral triptans (30 min-1h) |
| When selecting a triptan consider starting with: | 1. any triptan (taking patient-specific factors into account) Sumatriptan tablets are generally the most affordable 2. If initial triptan does not work and it was an adequate trial (adequate dose taken at the appropriate time), try a different triptan or different formulation 3. If patient experiences significant recurrence of symptoms within 24-48 hours, they may have improved efficacy with frovatriptan Remember frovatriptan has a slower onset of action and is more expensive than other agents |
| Triptan Non-responders: About 60-70% of patients respond to triptan therapy (commonly measured reduction in pain by 2 hours post-triptan administration), approx. 1/3 of patients will be pain-free, however that means about: | 30-40% of patients that do not respond to one triptan may respond to another triptan; Not all patients achieve full headache relief by 2 hours, some may experience recurrence of headache within 24 hours |
| What are our 2 Ergotamine Derivatives? Which has a "A" level of evidence? | Ergotamine(Ergamor) and Dihydroergotamine (Migranal (IN) or D.H.E. 45 injection); Dihydroergotamine |
| Ergots come from? | Fungus that can infect grains, particularly rye Consumption can cause direct damage to humans Contains numerous chemicals, including a precursor to LSD Historically linked to thousand of deaths |
| Historical significance: St. Anthony's Fire or Ergotism--> Clinical toxicity varied based on specific toxins: | N/V; Gangrene, *Severe vasoconstriction (loss of limbs)); Convulsions, *violent muscle spasms, muscle pain, intense burning or tingling of skin; *hallucinations (LSD precursor), mania, psychosis; Miscarriages, infertility, inhibit lactation |
| Safety considerations with Ergots: ADRs--> ** | Ergotamine: vertigo, paresthesia (numbness/tingling sensation), cold extremities, changes in heart rate, edema, hypertension, vasospasm, nausea/vomiting, myalgia, weakness Dihydroergotamine (nasal): dizziness, *nausea/vomiting, *taste disturbance, *rhinitis |
| Safety considerations with Ergots: Warnings--> ** | Cardiovascular: intense vasoconstriction/vasospasm, may cause direct myocardial toxicity. Valvular fibrosis (valve thickening) Pleural/retroperitoneal fibrosis Periphery: “Ergotism”, intense vasoconstriction resulting in possible gangrene. Greatest risk if combined with CYP3A4 inhibitor or if recommended dose is exceeded. |
| Safety considerations with Ergots: Contraindications-->** | Ischemic heart disease, peripheral artery disease, uncontrolled hypertension; Pregnancy category X (triptans mostly C) Drug interactions: Strong CYP3A4 inhibitors (boxed warning) Use within 24 hours of another ergotamine derivative or triptan Avoid pressors/vasoconstrictive drugs Serotonin syndrome risk |
| Ergot use in Practice--> Comparable efficacy to triptans at equivalent doses but more: | adverse effects/warnings; Ergots have slower dissociation from target receptors (longer duration compared to triptans), some evidence for lower recurrence rates |
| Ergots are not first line but should be considered before opioids, these are: | migraine-specific agents and lack risk of abuse associated with opioids Consider trial if patient has failed multiple triptans |
| DHE nasal spray has the highest level of evidence however it: | Ranges from $1500 to $2300 for 8 vials |
| Sumatriptan/Naproxen Sodium brand name is? Dose? Notes on Combo? | Treximet PO: 85 mg/ 500 mg tablet, take one tablet, can repeat if needed after 2 hours. Max of 170 mg/1,000 mg/day Safety considerations for NSAIDs and triptans CI in severe renal or hepatic impairment |
| Efficacy of Triptan/NSAID combo--> 2 randomized double blind placebo controlled studies: Brandes et al found: | 2,956 pts w/ and w/o aura who experience 2-6 mod-severe migraines/month--> **Sumatriptan + naproxen had significantly higher rates of 2-hour and 24-hour pain-free response compared to either agent alone |
| Efficacy of Triptan/NSAID combo--> 2 randomized double blind placebo controlled studies: Ninan et al found: | 283 pts w/without aira who experience 1-8 migraines/month (excluded if ≥15 days per month) who d/c treatment with a short-acting triptan due to poor response or intolerance (average of 3.3 triptans before study entry) Compared sumatriptan + naproxen to placebo **Sumatriptan + naproxen had significantly higher rates of 2- through 24-hour sustained pain-free response |
| Using the Triptan/NSAID combo in practice has been shown to have: | improved efficacy over NSAID or triptan monotherapy, with 2 hour and 24 hour improved response. significant improvements compared to placebo for patients that have failed triptan monotherapy **Combination option for patients with poor response to triptans |
| Cost of Combination Sumatriptan/NSAID combo Treximet: | Cost of combination therapy (via GoodRx) Naproxen 500 = approx. $10 for 60 tablets = 17 cents/dose Sumatriptan 100 mg = $20 for 9 tablets = $2.22/dose Treximet 85 mg/500 mg = $300 for 9 tablets = $33.33/dose |
| Opioid/Barbiturate combo product: Acetaminophen Butalbital, and caffeine brand name? Level of evidence? Notes? | Floricet C Risk of abuse: not a control medication |
| Opioid/Barbiturate combo product: Aspirin, butalbital, and caffeine brand name? Level of Evidence? Notes? | Florinal C Bleeding risk, NSAID associated risks; Risks of abuse: C-III |
| Opioid/Barbiturate combo product: Acetaminopen and codeine brand name? Level of evidence? Notes? | Tylenol #3 B Risk of abuse: C:III |
| Opioid/Barbiturate combo product: Tramadol and Acetaminophen brand name? Level of evidence? Notes? | Ultracet B Risk of abuse: C-IV |
| Opioid monotherapy: Butorphanol NASAL SPRAY brand name? Level of evidence? Notes? | Stadol A Risk of abuse: C-IV |
| Opioids and combination use in practice: Per 2015 guidelines “although opioids, such as butorphanol are probably effective, they are not **** | *****recommended for regular use; generally considred as *last line, or as *rescue therapy **** |
| Opioids and combination use in practice: Rescue therapies are intended for use when abortive treatment fails or if you’ve | reached the max dose on abortive therapy without relief; Abortive agent (eg. triptan) should be taken correctly and prior to opioid |
| Opioids and combination use in practice: Butorphanol has the highest level of evidence, but: | but that does not mean it is recommended for use. Should still be avoided due to abuse risk |
| Based on the 2021 American HA society update--> Opioids and other controlled substances *not included in recommendations for: | acute tx options; Rescue options for self-administration: SC sumatriptan, dihydroergotamine IM or nasal spray, IM ketorolac, or corticosteroids Prescribing rates of opioids for migraines in practice: 30-50% |
| Ditan class--> 5-HT1F receptor agonist--> Lasmiditan brand name? Notes? | Reyvow *C-V – associated with drowsiness, dizziness, and decreased alertness – do not drive within 8 hours of taking dose *Still concerned with medication overuse headaches and serotonin syndrome |
| Gepant class--> CGRP Antagonists approved for ACUTE MIGRAINE TX: Ubregepant brand name? Notes? | Ubrelvy *Few notable adverse effects, no risk of serotonin syndrome |
| Gepant class--> CGRP Antagonists approved for ACUTE MIGRAINE TX: Rimegepant brand name? Dose? FDA approval? Notes? | Nurtec Dosing: Treatment--> 75 mg by mouth as needed (max 75 mg/24 hours)* Prevention--> 75 mg by mouth every other day (ODT formulation) FDA approved for Treatment Feb 2020; May 2021 Prevention Notes: *Repeated exposure not associated with medication overuse headaches (dual role in prevention and treatment, though dual use in the same patient has not been evaluated) |
| Gepant class--> CGRP Antagonists approved for ACUTE MIGRAINE TX: Zavegepant brand name? | Zavzpret |
| Unique MOA: Triptans are agonists at 5-HT1D and 5-HT1B receptors: 1D/1B receptors effect? | 1D receptors – decrease release of CGRP 1B receptors – vasoconstriction of blood vessels and cardiovascular warnings |
| Lasmiditan is a selective agonist of 5-HT1F receptor that decreases release of? Gepants antagonize the _______ receptor | CGRP |
| Ditans and Gepants have no Cardiovascular or cerebrovascular related contraindications because? | no action at the 5HT-1B receptor |
| In patients with migraine (with aura, without aura, or chronic migraine), use of a “ditan” or “gepant” class is appropriate when: | Contraindication to or inability to tolerate triptans OR Inadequate response to two or more triptans |
| Acute Tx: N/V affect at least ________. Possibly linked to gastric stasis & delayed emptying during migraine. May interfere with drug absorption of acute/abortive medications; can last as long as the migraine does and is highly debilitating | 60% of pts, more common in females |
| Tx of N/V: Acute/abortive therapies ______ should relieve sx of nausea & vomiting. If significant nausea/vomiting, best to use: (2) Take acute/abortive therapy at (3) (proven to work better when taken early than delayed | 1. (eg. triptans) 2. non-oral routes of administration 3. onset of headache pain |
| Acute Tx: N/V: Antiemetic agents: ______ _______ can be recommended in acute attack as *adjunctive therapy to treat N/V. *should not be considered as monotherapy | Oral antiemetics -can be considered adjunctively, those demonstrating IV efficacy are often considered |
| ***Acute Tx: N/V: IV metoclopramide, chlorpromazine, and prochlorperazine are options for: | *monotherapy of acute migraines (level B) |
| Summary of Acute Tx: In mild to moderate start with? | with NSAIDS (or high dose acetaminophen for some patients), combination therapy may be more effective if no response to monotherapy, triptans if NSAIDS/combos fail |
| Summary of Acute Tx: In moderate to severe start with? | triptan, if triptan fails consider other triptan trial, if multiple fail, move to second line options |
| Summary of Acute Tx: **Ensure that the dose and timing of administration was appropriate and know that opioids are ALWAYS: | LAST-LINE (safety and efficacy) |
| oral Antiemetics are ______; IV can be used as monotherpay in hospital setting | adjunctive |
| ***Medication overuse of all acute pharamcologic options can cause HA (ideal use is: | <10 days/month or <2x/wk (only exception being the CGRP antagonist |
| Exceeding PM contains what ingredients? | acetaminophen, ASA, and diphenhydramine but no caffeine |
| Excedrin Tension HA contains what? | has acetaminophen and caffeine |
| Sumatriptan (Imitrex) Dose—> | PO:25mg, **50mg**, 100 mg at onset; may repeat in 2h (max of 200mg/day IN—> 1 spray (5mg, 10mg, 20mg) in nostril; may repeat in 2h (max of 40mg/day SQ—> 6mg; may retreat in 1h (max of 2 injections/day) |
| Zolmitriptan (Zomig, -ZMT) Dose—> | PO: 2.5 mg at onset; May repeat in 2 hr (max of 10 mg/day) Intranasal: 1 spray (2.5 mg, 5 mg) in nostril; May repeat in 2 hr (max of 10mg/day) |
| Rizatriptan (Maxalt, -XLT) Dose—> | 5 mg -10 mg at onset; May repeat in 2 hr (max of 30mg/day) |
| Sumatriptan comes in what type of formulations? | IN (powder or solution; SQ |
| Zolmitriptan comes in what type of formulation? | IN; ODT |
| Rizatriptan comes in what other form than PO? | ODT |
| Dihydroergotamine brand names? | Migranal (nasal spray) (Level of Evidence A)** D.H.E. 45 (injection |
| Consider using the Triptan/NSAID combo during? | Combination option for patients with poor response to triptans; significant imporovements compared to placebo for pts that have failed triptan monotherapy; has been shown to have improved efficacy over NSAID or triptan monotherapy with 2h and 24h improved response |
| Treximet dosing is? | PO: 85 mg/ 500 mg tablet, take one tablet, can repeat if needed after 2 hours. Max of 170 mg/1,000 mg/day |
| Generic and Brand name of Triptan/NSAID combo? | Sumatriptan/ naproxen sodium; Treximet |
| In pts with migraine (with aura, without aura, or chronic migraine), use of a distance or Gepant class is appropriate when? | CI or or inability to tolerate Triptans; Inadequate response to 2 or more Triptans; Safety, Triptans (1st line); Efficacy |
| CGRP antagonists safety considerations: AE? | Well tolerated in trials with low incidence rates of adverse effects • Injectable: injection site reactions, nausea, constipation, hypersensitivity reactions • Oral: gastrointestinal (abdominal pain, dyspepsia, nausea, constipation, decreased appetite), weight loss with atogepant, drowsiness, hypersensitivity reactions |
| Botox safety considerations: AE? | injection site reaction, headache, neck or back pain, muscle weakness, eyelid drooping |
| CGRP-targeting therapies were considered for patients who had an inadequate response to an 8-week trial of at least 2 non-specific medications: • Ex. Topiramate, divalproex sodium, metoprolol, amitriptyline, etc.—-> CGRP-targeting therapies were second-line based on the available evidence and clinical experience at the time—> NOW—> | increased efficacy, tolerability, safety; studies found fewer SE and better adherence compared to other options. *CGRP targeting therapies are now first-line options for migraine prevention |
| AHS 2024 recommendation—> Episodic migraines (15 days per month) Tx to consider—> Non-specific oral medications with highest evidence (ex. topiramate, divalproex sodium, metoprolol, candesartan, amitriptyline, venlafaxine, etc) & other Level A or B treatments according to AAN. 2? 3? | 2. Monoclonal antibodies targeting CGRP or its receptor 3. Gepants, including atogepant and rimegepant |
| AHS 2024 recommendation—> Chronic migraines >/= 15 days per month. Tx to consider—> 1. Non-specific oral medications with highest evidence (ex. topiramate, divalproex sodium, metoprolol, candesartan, amitriptyline, venlafaxine, etc) & other Level A or B treatments according to AAN—> 2? 3? 4? | 2. OnabotulinumtoxinA (Botox) 3. Monoclonal antibodies targeting CGRP or its receptor 4. Gepants, including atogepant (*remember that Rimegepant is not for chronic) |
| Considerations for Drug selection include: | Assess safety; Take coexisting conditions into account; Assess efficacy; Classification of migraines; Cost |
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Xander635
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