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Benitez CNS 1B
Therapeutics of Headache disorders Preventative Tx
| Question | Answer |
|---|---|
| Considerations for when to use preventative therapy when: | Attacks significantly interfere with daily routine despite acute treatment; Frequent attacks (≥ 4 migraine headaches per month); CI to, failure of, or overuse of acute therapies *(remember that overuse defined as >/= 10 days/month; AE with acute tx; Pt preference |
| Considerations for when to use preventative therapy when in presence of uncommon migraine conditions such as: | hemiplegic migraine, migraine with prologned aura |
| Goals of Therapy with Preventative Treatment inlcude: | -Identify and prevent migraine triggers -Reduce the number of migraine attacks per month -Prevent medication overuse headaches -Improve quality of life -Use preventative medications that are well tolerated and efficacious |
| Non-pharm treatment options to prevent migraine triggers--> | Intense light/sound Caffeine, alcohol, tobacco Stress (mental or physical) Menstrual cycle/hormonal changes Hunger or hypoglycemia Sleep changes Weather changes **Recommend migraine diary to identify triggers; preventing triggers can be done by ALL PTS |
| Considerations for pharmacologic options in preventative therapy: recommendations can differ based on ____ __ ______ | **frequency of migraines |
| A migraine occurring < 15 days/month is? | Episodic |
| A migraine occurring >/= 15 days/month is? | Chronic -Only represent 7.7% of total migraine population Longer duration of attacks (treated and untreated) and higher intensity of pain |
| Some preventative medications are ______-______ and others are not | migraine-specific |
| List medications that are not specific to migraines: | Antiepileptic medications: *topiramate and *divalproex sodium Beta blockers: *metoprolol, *propranolol, *timolol, atenolol, nadolol Antidepressants: *amitriptyline, nortriptyline, *venlafaxine, duloxetine Antihypertensives: *candesartan *Onabotulinumtoxin A (Botox) |
| Dosing considerations for Medications not specific to migraines: -doses for migraine prevention are often (1) -unlike acute tx, preventative medications are ___(2)___ and must be used regularly to be most effective; Oral medications taken daily; Botox administered every (3) | 1. lower than for other indications 2. scheduled 3. 12 weeks |
| Medications specific to migraines: Monoclonal antibodies targeting CGRP or its receptor: Erenumab brand name? Admin/dosing? | Almovig; Monthly SQ |
| Monoclonal antibodies targeting CGRP or its receptor: Fremanezumab Brand name? Admin/Dosing? | Ajoby; Quarterly or monthly SQ |
| Monoclonal antibodies targeting CGRP or its receptor: Galcanezumab Brand name? Admin/Dosing? | Emgality; monthly injections SQ |
| Monoclonal antibodies targeting CGRP or its receptor: Eptinezumab Brand name? Admin/Dosing? | Vyeptil; quarterly injections IV |
| Small-molecules targeting the CGRP receptor (gepants): Atogepant Brand name? Admin/Dosing? | Qulipta; once daily oral dosing |
| Small-molecules targeting the CGRP receptor (gepants): Rimegepant Brand name? Admin/Dosing? | Nurtec; 75 mg PO every other day |
| CGRP-targeting therapies were considered for patients who had an inadequate response to an 8-week trial of at least 2 non-specific medications such as: | Topiramate, divalproex sodium, metoprolol, amitriptyline, etc. |
| CGRP-targeting therapies were second-line based on: | the available evidence and clinical experience at the time |
| Updated recommendations (2024) regarding used of CGRP-targeting therapies in migraine prevention by the: | American Headache Society (AHS) |
| The rationale for chages in the 2024 updated AHS recommendation is due to: | -Substantial new evidence supporting their efficacy, safety, and tolerability -Extensive real-world experience and publications supporting use -Studies showing fewer side effects and better adherence compared to other options -Some superiority evidence – head to heal trial comparing erenumab to topiramate, also evidence supporting efficacy in those who have failed other established treatments |
| Based on the updated recommendation from the 2024 AHS for migraine prevention: CGRP-targeting therapies are now? | First-line options for migraine prevention!! |
| In the case of Episodic migraines lasting <15 days/month--> Treatments to consider should be: | 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. **Monoclonal antibodies targeting CGRP or its receptor 3. Gepants, including atogepant and **rimegepant |
| In the case of Chronic migraines >/= 15 days/month--> Treatments to consider should be: | 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. **OnabotulinumtoxinA (Botox) 3. Monoclonal antibodies targeting CGRP or its receptor 4. Gepants, including **atogepant |
| Considerations for Drug Selection for migraine prevention--> | 1. Assess Safety (AE and CI associated w/ each medication 2. Take Coexisting conditions into account (risk vs benefit) 3. Assess efficacy (highest level of efficacy first) 4. Classification of migraines (Chronic vs Episodic) 5. Cost (CGRP-targeting therapies and botox tx are more expensive |
| Considerations Chronic vs Episodic for migraine prevention--> | 1. **Botox is only effective and recommended for CHRONIC MIGRAINES 2. Nearly all CGRP-targeting therapies used for migraine prevention can be used for either episodic or chronic migraines (exception is rimegepant is FDA approved for episodic only) 3. Non-specific oral medications can be used for chronic and episodic migraines but are most studied in episodic migraines (studies generally excluded patients with chronic migraines) |
| Considerations for Adequate Trial for migraine prevention--> | 1. **It may take 2-3 months to achieve full clinical benefit: advise patient to keep migraine diary to track episodes per month to assess progress At least 8 weeks generally recommended for adequate trial at target or usual effective dose Use lowest effective dose, start low and titrate 2. **Avoid interfering medications (medication overuse of acute tx) |
| Efficacy of Non-migraine specific medications for prevention: On average patients in studies experienced 6 headaches per month and saw a reduction of | 1-2 headaches per month (16-33% reduction); 20-40% of patients achieve > 50% reductions in headaches* -Botox--> not effective for episodic; average reductions of 2 headaches per month for chronic with 40-50% achieving 50% reduction*; Reduction can improve up to 24 wks (recommend 2 tx to evalualte efficacy |
| Efficacy of CGRP antagonists for prevention: Similar reductions of 1-2 HA per month for _____; reductions of 2-3 headaches per month for ______ | episodic; chronic* -40-50% achieved 50% reduction (long-term data showing 76% with 50% reduction; 56% with 75% reduction) Response may continue increasing beyond 2-3 months, some evidence of late-responders (around 6 months) **Main takeaway--> help to reduce migraine frequency but will not eliminate migraines |
| Counseling migraine prevention therapy: **Medications must be taken _______ to work. | REGULARLY; Poor overall adherence rates to preventative medications (about 20% at 12 months) |
| Counseling migraine prevention therapy: **Pt should NOT expect ________ ________ of attacks. | complete cessation -Many experience a 30-50% reduction (varies across patients) |
| Counseling migraine prevention therapy: **Medications often take time to reach ______ ______ | Full effect;(at least 8 weeks, but improvement up to about 6 months can be seen) |
| Counseling migraine prevention therapy: These medications can help **reduce attack _______, attack ______, or attack ________ | frequency, duration, severity; *Encourage patients to give it time to work and track their progress |
| Safety: Prevention therapy: CGRP antagonists: well tolerated in trials with low incidence rates of AE such as: | Injectable: injection site reactions, nausea, constipation, hypersensitivity reactions Oral: gastrointestinal (abdominal pain, dyspepsia, nausea, constipation, decreased appetite), weight loss with atogepant, drowsiness, hypersensitivity reactions -Long-term data up to 4.5 years shows <5% of patients discontinue therapy due to adverse effects |
| Safety: Prevention therapy: Botox adverse effects such as? | Common: injection site reaction, headache, neck or back pain, muscle weakness, eyelid drooping Long-term data (study followed 716 patients over 2 years) showed 18% experienced ≥1 adverse effect (neck pain); only 1 serious adverse effect reported (rash) |
| Tension Type HA Epidemiology--> | Very common, lifetime prevalence of 30% to 78% in general population (chronic, ≥ 15 days/month occurring in 2-3% of population) Slightly more common in women (female to male ratio of 5:4) |
| TTH Characteristics: Acronym--> | P: Physical activity does not aggravate symptoms I: Intensity is mild to moderate V: Variable duration (30 min - 7 days) O: Occipitofrontal and bilateral T: Tightening or pressing pain (not pulsatile) **+ NOT accompanied by nausea or vomiting **+ No more than one of photophobia or phonophobia |
| TTH can either be _______ or ________ | Episodic; Chronic |
| Episodic TTH (tension-type HA) can have ________ or _______ | Infrequent (<1 day/month, < 12 days/yr) OR Frequent (1-14 days/month, > 12 days/yr) *in order to qualify as episodic must have ≥10 episodes have occurred *+ For frequent/chronic: > 3 months |
| Chronic TTH (tension-type HA) can have ________ | chronic (≥ 15 days/month, ≥ 180 days/yr) |
| TX: 1st line for TTH consists of --> NSAIDS or APAP. Dose of Acetaminophen? | Stronger evidence for 1,000 mg dose (500 mg found to be comparable to placebo in 3 studies) *Some studies indicate NSAIDS may be more effective than acetaminophen (even at 1,000 mg) |
| TX: 1st line for TTH consists of --> NSAIDS or APAP. Dose of NSAID? | Aspirin: effective in doses from 250 mg – 1,000 mg Ibuprofen: effective in doses from 200 mg – 800 mg (most evidence for 400 mg) Naproxen: effective in doses of 375 mg and 550 mg |
| Dosing evidence of 1st line TTH meds show doses are more _____, however pt should take _______ dose that effectively relieves HA | effective; lowest |
| Tx: 2nd line for TTH: The combination with Caffeine has evidence of | improved efficacy in combinations of simple analgesics with caffeine; 2nd line as monotherapy is generally effective and some addverse effect concerns are associated with caffeine |
| Medications not recommended for TTH are Migraine-specific meds such as: | 1. Triptans, ergot derivatives, lasmiditan, gepants; Patients with migraine and TTH will benefit from these medications for migraine headaches but not for TTH (important to counsel on) 2. Muscle Relaxants 3. Opioids |
| Treatment for Chronic TTH. What therapies are effective? how could TTH get exacerbated? | Prophylactic terapy has been found to be effective; can be exacerbated by medication-overdose; |
| First line Tx for chronic TTH? 2nd line? Use of Botox for TTH? | Amitriptyline mirtazipine or venlafaxine Has been studied in chronic TTH and was found to be ineffective and is NOT RECOMMENDED |
| Non-Pharamcological Prevention strategies for TTH includes? | For all patients, triggers should be identified and avoided Most common: stress, irregular meals, high intake or withdrawal of caffeine, dehydration, sleep disturbance, reduced or inadequate physical exercise, hormone changes (menstrual cycle) |
| Epidemiology of Cluster HA is rare and _____ _______ primary HA disorder. Prevalance is < 0.1%. | highly debilitating |
| Cluster HA occur more in men than women. What is the ratio? | 3-4:1 |
| Cluster HA's occur in a series for weeks/months ("cluster periods"), 10-15% of pts have chronic HA w/o _______ | remission |
| 4 types of primary HA's are: | 1. migraine 2. TTH 3. Trigeminal autonomic cephalgias (TACs), including cluster HA 4. Other primary headaches |
| Cluster HA Acronym is: | R. Restlessness or agitation O. Orbital or supraorbital location U. Unilateral and very severe pain N. Nasal or ocular symptoms (rhinorrhea, lacrimation, swelling) D: Duration shorter (15-180 min untreated); more frequent (every other day to 8 times/day |
| Cluster HA can either be ________ or ________ | Episodic; Chronic |
| Episodic Cluster HA is: | ≥ 2 cluster periods lasting 7 days – 1 year; separated by pain-free remission ≥ 3 months |
| Chronic Cluster HA is: | Occurring without remission, or with remissions lasting < 3 months |
| What are the pharmacologic options for Cluster HA? | Acute/Abortive--> (Sumatriptan, zolmitriptan, or high flow oxygen (6-12 L/min) Less evidence: octreotide, ergotamine) Preventative/Prophylactic--> Suboccipital steroid injections, oral corticosteroids, galcanezumab, or verapamil Less evidence: lithium, topiramate, frovatriptan, valproic acid, melatonin |
| What are the non-pharamcologic options for Cluster HA? | Not as highly associated with environmental triggers like migraines or TTH For some patients avoiding nicotine or alcohol may be beneficial |
| Testing efficacy (migraine prevention)—> Set realistic expections when counseling!. —> | • Must be taken regularly to work • Poor overall adherence rates to preventative medications • Patient should NOT expect complete cessation of attacks • Many experience a 30-50% reduction (varies across patients) • Medications often take time to reach full effect (at least 8 weeks, but improvement up to about 6 months can be seen) • These medications can help reduce attack frequency, attack duration, or attack severity • Encourage patients to give it time to work and track their progress |
| Epidemiology of TTH is? | • Very common, lifetime prevalence of 30% to 78% in general population (chronic, ≥ 15 days/month occurring in 2-3% of population) • Slightly more common in women (female to male ratio of 5:4) |
| Epidemiology of Cluster HA is? | • Rare and highly debilitating primary headache disorder • Prevalence < 0.1% • More common in men (3-4:1) • Most attacks occur in a series for weeks/months (“cluster periods”), 10-15% of patients have chronic headaches without remission |
| Know that Cluster HA are VERY RARE and more common in MEN. Know that these HA types are highly debilitating and cannot be treated with _______ medications | OTC |
Created by:
Xander635
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