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JGR-headache
| Question | Answer |
|---|---|
| What are the analgesics used for treatment of migraines? | Acetaminophen (Tylenol®) Acetaminophen + aspirin + caffeine (Excedrin Migraine®) Acetaminophen + butalbital + caffeine (Fioricet®) Aspirin + butalbital + caffeine +(Fiorinal®) (C-III) Acetaminophen + isometheptene + dichloralphenazone (Midrin®) (C-IV) |
| Which analgesic has a greater efficacy for migraines? | (Excedrin Migraine®)-reasonable first line choice |
| What are the butalbital containing analgesics best for? | Tenstion type headaches |
| What is butalbital? | Sedative/hypnotic |
| What does adding caffeine to a drug do? | Causes vasoconstriction |
| What is the Isometheptene component of Midrin®? | sympathomimetic amine that produces vasoconstriction of arteries and veins |
| What is Dichloralphenazone? | phenazone:chloral hydrate mixture Phenazone – analgesic Chloral hydrate – sedative/hypnotic |
| What are the contraindications for Midrin®? | Contraindicated in glaucoma, and/or severe renal or hepatic disease, hypertension, and those taking monoamine oxidase inhibitors (MAOI) |
| What is the MOA of NSAIDs in migraine therapy? | Prevents neurogenically mediated inflammation in the trigeminovascular system through the inhibition of prostaglandin synthesis |
| What is the dosing for Ibuprofen (Motrin®) ? | 200-800mg every 6 hours (not more than 2.4 g/day) |
| Who should not take NSAIDs for migraines? | Avoid in patients with active gastritis, peptic ulcer disease, renal insufficiency, and bleeding disorders |
| What are the drugs of choice for mild to moderate migraines? | NSAIDs (limit to < 15 days per month to avoid overuse “rebound” headaches) |
| How do you treat “rebound” headaches? | Take patient off offending agent (usually analgesics, opiates, ergotamines and triptans) Consider TCA Amitriptyline (Elavil®) during withdrawal |
| How are rebound headaches prevented? | Limiting acute migraine therapies to 2 days per week |
| What is the MOA of ergotamines? | partial agonist activity at 5-HT1A, 1B, 1D, 1F, 2A, 2C, 3, 4, D2 receptors in the chemoreceptor trigger zone (CTZ), and alpha-adrenergic receptors resulting in peripheral and cranial vasoconstriction and depression of the central vasomotor centers |
| What are the results of activation of each receptor? | 5-HT1B,1D – migraine relief 5-HT1A - nausea and dysphoria 5-HT2A – peripheral vasoconstriction D2 agonist – nausea and vomiting α1-adrenergic – severe vasoconstriction |
| When are ergotamines most effective? | When administered early on |
| List the ergotamines | Ergotamine (Ergomar®) sublingual Ergotamine + caffeine (Cafergot®) oral tablets Ergotamine +caffeine (Cafergot®) suppository |
| What are the contraindications for ergotamines? | Contraindicated in peripheral vascular disease, coronary artery disease, liver or kidney disease, hypertension, with potent CYP3A4 inhibitors (e.g., azole antifungals, macrolide antibiotics, etc.), and pregnancy (stimulates uterus |
| What are the adverse reactions to ergotamines? | Ergotism – intense vasoconstriction resulting in peripheral vascular ischemia and possible gangrene, as well as possibly tonic-clonic convulsions accompanied by mania and hallucinations Overuse headache |
| What are the drug to drug interactions of ergotamines? | Do not use within 24 hours of a triptan and with potent CYP3A4 inhibitors |
| Which is more effective ergotamines or triptans? | Triptans |
| Which is better tolerated, oral or suppository form of Cafergot®? | Suppository |
| What is the advantage of ergotamines? | Lower rate of recurrence |
| What should be considered when administering ergotamines? | Consider using an anti-emetic |
| What is the advantage of dihydroergotamine? | Less potent α1-adrenergic vasoconstriction, and nausea & vomiting |
| List the dihydroergotamines | Migranal® 1 spray DHE 45® (IV, IM/SubQ) |
| What are the drug to drug interactions of dihydroergotamines? | Do not use within 24 hours of a triptan and with potent CYP3A4 inhibitors |
| What are the indications for dihydroergotamines? | DHE IV plus antiemetics IV is an appropriate treatment for patients with severe migraine |
| How effective are dihydroergotamines? | No placebo-controlled trials in migraine patients have demonstrated efficacy and safety of DHE subQ/IM/IV as monotherapy but it is a reasonable choice when the headache is moderate-to-severe and NSAIDs have failed |
| What are the adverse reactions to dihydroergotamines? | Similar to ergotamine with less vasoconstriction, and nausea & vomiting Taste disturbances and rhinitis with the nasal spray |
| Which is a better choice for migraine therapy, ergotamines or dihydroergotamines? | Dihydroergotamines |
| What is the MOA of triptans? | 5-HT1B/1D receptor agonists with additional activity at 5HT1F receptors |
| What occurs when each of the receptors are activated by triptans? | 5-HT1B Cranial vasoconstriction 5-HT1D Peripheral neuronal inhibition (e.g., CGRP, substance P, etc.) 5-HT1B/1D/1F? Inhibition of the trigeminocervical complex (i.e., decreased excitability) |
| What is a special consideration when monitoring triptan therapy? | Consider administering the 1st triptan dose in the clinic with vitals ± ECG in patients with a likelihood of unrecognized coronary disease such as patients with significant HTN, hypercholesterolemia, obese patients, diabetics, smokers, etc |
| List the triptans | Almotriptan (Axert®) Eletriptan (Relpax®) Frovatriptan (Frova®) Naratriptan (Amerge®) Rizatriptan (Maxalt®) Sumatriptan (Imitrex®) Zolmitriptan (Zomig®) Sumatriptan + naproxen (Treximet®) |
| Which triptan has the longest half-life? | Frovatriptan (Frova®) Tmax is long (2-4 hours) |
| Which triptan has shortest Tmax? | Sumatriptan (Imitrex®) subQ = 12 min Sumatriptan (Imitrex®) intranasal = 30 min |
| Which triptan comes in an ODT form? | Zolmitriptan (Zomig®) |
| Which triptan contains a sulfa group? | Almotriptan (Axert®) |
| Which triptans are not metabolized by MAO and should not be used within 72 hrs of potent CYP3A4 inhibitors (e.g., azole antifungals, clarithromycin, etc.)? | Eletriptan (Relpax®) Frovatriptan (Frova®) Naratriptan (Amerge®) |
| Which triptan requires a reduced dose in patients taking propranolol? | Rizatriptan (Maxalt®) |
| Who should not take triptans? | Contraindicated in patients with a history of ischemic heart disease (e.g., angina, previous MI, etc.), uncontrolled hypertension, and cerebrovascular disease (e.g., stroke) |
| What are the drug to drug interactions of triptans? | Contraindicated within 2 weeks of MAOI Do not use within 24 hrs of ergotamines Caution with other serotonin active medications (serotonin syndrome) |
| What is serotonin syndrome? | Potentially life threatening drug reaction resulting in excess serotonin. Symptoms include: – Cognitive effects – Neuromuscular dysfunction – Autonomic dysfunction |
| Which triptan has the greatest efficacy for quick relief? | Rizatriptan (Maxalt®) |
| Which drug has greatest efficacy for sustained relief? | Frovatriptan (Frova®) |
| What is the advantage of triptans over ergotamines? | Less nausea/vomiting due to D2 receptor not being stimulated |
| What is the drawback of triptans? | Higher incidence of chest pains |
| What is the MOA of Butorphanol nasal spray (C-IV)? | mixed agonist-antagonist with low intrinsic activity at receptors of the µ-opioid type (morphine-like) and with agonist activity at κ-opioid receptors resulting in analgesia |
| what is the drawback of butorphanol (Stadol®)? | drug dependence and CNS depression |
| List the antiemetics for migraines | Metoclopramide (Reglan®) chlorpromazine (Thorazine®) prochlorperazine (Compazine®) |
| What is the DOC for anti-emetics in migraines? | Metoclopramide (Reglan®) |
| What is the overall superior treatment for migraines? | Triptans |
| What is the criteria for requiring migraine prophylaxis? | Historically > 2 migraines per month Presently : > 2 times per week, interferes with daily life, non-responsive to symptomatic therapies, uncommon variants (prolonged aura) and patient preference |
| How long is an adequate trial for migraine prophylaxis? | 2-3 months |
| How long should treatment last? | 3-6 months after frequency decreases Then taper off for 2-4 weeks then discontiunue |
| What is the prophylaxis given for patients with predictable patterns of migraine recurrence? | NSAIDs |
| What prophylaxis is given when NSAIDs do not work for predictable recurring migraines? | Beta-blockers |
| What prophylaxis is administered for predictable recurring migraine when NSAIDs are ineffective there is a contraindication for Beta-blockers? | Verapamil (Calan®) |
| What is first line migraine prophylaxis for patients with comorbid HTN, angina or anxiety? | Beta-blocker |
| What is first line migraine prophylaxis for patients with comorbid depresson or insomnia? | TCAs |
| What is first line migraine prophylaxis for patients with comorbid seizure disorder or manic-depressive disorder? | Anti-convulsant B-blocker if anti-convulsant is ineffective Methysergide (Sansert®) if both are ineffective |
| What is Methysergide (Sansert®)? | Serotonin antagonist (5-HT2 receptor) What are the adverse reactions of Methysergide (Sansert®)? |
| List the anti-convulsants given as migraine prophylaxis | Divalproex Na (Depakote®) Valproic Na (Depakene®) Topiramate (Topamax®) |
| What is the TCA given for migraine prophylaxis? | Amitriptyline (Elavil®) |
| List the beta-blockers given as migraine prophylaxis | Propranolol (Inderal®) Timolol |
| What Beta blockers are ineffective for migraine prophylaxis? | Those with ISA: Acebutolol Pinolol |
| What are the contraindications for use of beta-blockers in migraine prophylaxis? | should not be used in patients with asthma, Raynaud’s |
| What treatment is best for children and adolescents with migraines? | For children (age > 6 years) Ibuprofen (effective) 7.5 – 10 mg/kg/dose Acetaminophen (probably effective) 15 mg/kg/dose For adolescents (age > 12 years) Sumatriptan nasal spray (effective) 5 – 20 mg |
| What drugs are contraindicated in the third trimester of pregnancy? | NSAIDS |
| What drugs are contraindicated for pregnancy throughout gestation and lactation? | Ergotamines |
| What treatment for migraines do you give a pregnant or lactating woman? | Acetaminophen (Tylenol®) |
| AB is a 37-year-old female with left-sided severe headaches and severe nausea and vomiting. Which of the following triptans is best to treat AB migraine headaches? | Rizatriptan (Maxalt®) |
| What distinguishes an episodic tension-type headache from a chronic tension-type headache? | >15 days per month = chronic Mild Nausea/vomiting = chronic |
| What distinguishes a tension-type headache from a migraine? | Bilateral location Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by routine physical activity such as walking or climbing stairs No more than one of photophobia or phonophobia No mod-severe nausea/vomiting |
| What is the most common type of primary headache? | Tension-type headache |
| What are the treatments for acute tension-type headaches? | Acetaminophen NSAIDs |
| What is the prophylaxis of choice for tension-type headaches? | TCA-Amitriptyline (Elavil®) |
| What distinguishes a cluster headache from migraines or tension-type headaches? | > 5 attacks of severe intensity At least one of the following: Ipsilateral lacrimation, nasal congestion and/or rhinorrhea, eyelid edema,sweating, miosis and/or ptosis A sense of restlessness or agitation |
| What is the most severe form of primary headaches? | Cluster headaches |
| When do cluster headaches tend to occur? | At night |
| Do male or females tend to get more cluster headaches? | Males |
| What distinguishes episodic from chronic cluster headaches? | Chronic attacks occur for more than a year without remission or with remissions lasting less than one month |
| What behavior is different in patients with cluster headaches than migraines or tension-type headaches? | They do not retreat to quiet dark place, they sit and rock back and forth or pace |
| What are the treatments for acute cluster headaches? | Oxygen Sumatriptan (Imitrex®) Zolmitriptan (Zomig®) |
| What are the prophylactic treatments for cluster headaches? | Verapamil (Calan®) Prednisone (Deltasone®) Lithium (Eskalith®) |
| What prophylactic is considered the drug of choice for cluster headaches? | Verapamil (Calan®) |
| Which cluster headache prophylaxis requires monitoring of trough levels? | Lithium (Eskalith®) |
Created by:
joannasan
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