Pharmacology > HEADACHE > Flashcards

HEADACHE Flashcards

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1
Q

What is the cause of rebound headaches?

A

simple and combination analgesics

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2
Q

How many days should you limit medication use for migraines?

A

<10 days/month

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3
Q

POUND mnemonic

A

pulsating headache with duration of 4-72 hrs, unilateral, nausea, and vomiting and disabling

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4
Q

What are non pharmacological treatments?

A

sleep
dark room
cold compress

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5
Q

What are the 4 stages of a migraine?

A
  1. premonitory symptoms-24 hours prior to onset of migraine attack, vague and vegetative symptoms
  2. Aura-focal neurological deficits
  3. Headache-unilateral, throbbing, photophobia and phonophobia
  4. Post drome: malaise, fatigue,
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6
Q

What is cortical spreading?sensitization?

A
  • causes aura
  • prolonged activation of trigeminal nerve
  • hyper excitable trigeminal nerve release sub P and CGRP leading to vasodilation and neurogenic inflammation
  • sensitization: neuron response to nociceptive and non nocipective receptors
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7
Q

T/F Blood brain barrier is altered by metalloproteinase activation and upregulation

A

TRUE

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8
Q

What is the prototype of triptans?routes?

A

Sumatriptan

given as oral, injection, and nasal

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9
Q

What is MOA of triptans?

A
  1. Bind 5-HT1B and 5-HT1D receptors
    - enhanced vasoconstriction
    - inhibition of pain transmission
    - inhibition of vasoactive release of peptides from trigeminal neurons
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10
Q

When do you use triptans?

A

first line therapy for moderate to severe migraines

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11
Q

What is clinical use sumatriptan?

A

Migraines

Cluster headaches

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12
Q

What are ADE of triptans?

A

coronary spasm, chest pain, parasthesias, dizziness

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13
Q

What pt should avoid triptans?

A

uncontrolled HTN, PAD, brainstem or hemiplegic migraine

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14
Q

what is “triptan sensation”?

A
  • chest pain
  • chest tightness
  • chest heaviness
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15
Q

What are drug interactions with triptans?

A

MAO-I and ergotamines

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16
Q

Which triptans are used for patients that have long duration migraines?

A

Fovatriptan

Naratriptan

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17
Q

Which triptan needs to be given at 5mg if taking propanolol?

A

Rizatriptan

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18
Q

Which drugs can cause seratonin syndrome? 7

A
  • SSRI
  • fentanyl
  • meperidine
  • sumatriptan
  • St. Johns Wart
  • tramadol
  • linezolid
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19
Q

What are the symptoms of seratonin syndrome?

A
  • hyperthermia
  • clonus
  • agitation
  • tachycardia
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20
Q

What is tx for seratonin syndrome?

A
  1. benzos, intubation, ventilation

2. 5-HT2 blockers chlorpromazine or cyproheptadine

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21
Q

Which drugs cause neuroleptic malignant syndrome

A

D2 blocking anti psychotics

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22
Q

What is CP of neuroleptic malignant syndrome?

A
  • reduced bowels
  • parkinsonism
  • hyperthermia
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23
Q

what is tx for neuroleptic malignant syndrome?

A

diphenhydramine parenteral

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24
Q

What is the drug that causes malignant hyperthermia?

A
  • volatile anesthetics

- succinylcholine

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25
What is tx for malignant hyperthermia?
Dantrolene | cooling
26
What is MOA Lasmitditan?
binds 5-HTF1 receptor that reduces stimulation of the trigeminal nerve but DOES NOT vasoconstrict
27
What are ADE of Lasmiditan?
palpitations, chest discomfort,
28
What is MOA of CGRP antagonists?
- block CGRP receptors - blocks neurogenic inflammation - decreases artery vasodilation - blocks transmission of pain from trigeminal nerve to trigeminal nucleus accumbens
29
Name two CGRP antagonists?
Rimegapant | Ubrogepant
30
What are ADE of ubrogepant?
CNS drowsiness
31
When should you avoid use of CGRP antagonists?
- hepatic impairment | - drugs that are CYP3A4-Inhibitors (increase drug concentration)
32
what is ADE of both ubrogepant and rimepagant?
xerostomia , GI nausea
33
What is clinical use of CGRP antagonists?
acute migraine
34
Name three CGRP monoclonal antibodies?
- erenumab - Fremanezumab - Glacanezumab
35
What is MOA of CGRP monoclonal antibodies?
Ab block the CGRP ligand and blocks its binding to the receptor
36
what are benefits of using CGRP antibodies?
- long half lives with once monthly administration | - they act at the periphery and thus avoid CNS side effects
37
what are the ADE of CGRP antibodies?
- flu like symptoms - development of neutralizing antibodies - constipation - muscle cramps
38
what is the clinical use of CGRP antibodies?
prevention of migraines
39
What is the MOA of ergotamines?
- nonselective 5-HT1 receptor agonists - vasconstricts intracranial blood vessels - central inhibition of the trigeminalvascular system
40
what is clinical use of ergotamines?
-rescue drug
41
Name two ergotamines?
Ergotamine tartrate | Dihydroergotamine
42
What is route of Ergotamine tartrate?which are treated with an anti emetic?
- rectal - sublingual - oral PO * rectal and oral routes are treated with anti emetics
43
What is route of delivery for Dihydroergotamine?
Injection | Nasal spray: prime spray 4 times in nose, dont tilt head back, discard open ampule after 8 hrs
44
who should avoid ergotamines?
PAD, HTN, people on triptans, coronary artery disease
45
Who gets preventive therapy for migraines?
- recurring migraines >2x/week | - symptomatic therapies that produce serious side effects
46
Name 4 preventive drugs?
- propanolol - timolol - topiramate - divalproex sodium
47
T/F therapeutic drugs for prevention need a 2-3 month trial to determine reduced frequency of migraine
TRUE
48
How long does it take for preventative therapy to reduce severity of migraines
6-12 months
49
How long is tx continued after HA severity and frequency is reduced?
6-12 months
50
Which drug is used for menstrual migraine prevention?
Ibuprofen given 2-3 days before cycle
51
Which triptan can be used to prevent menstrual migraines?
Fovatriptan taken 1-2 days before and continued during period of vulnerability
52
Which supplement may help with menstrual migraine or migraines with aura?
Mg
53
Which drug acts as a prokinetic and can be given in cancer patients to propel the medication into the intestine and speed up the effect of sumatriptan?
Metoclopramide
54
Which triptans have a longer duration of action and slower onset?
Naratriptan | Frovatriptan
55
T/F PK of Lasmiditan requires no renal adjustment
True
56
What is prophylactic tx for migraines that recur in a predictable pattern?
NSAID or triptan at time of vulnerability
57
What is prophylactic tx if migraine with co morbid HTN or angina?
beta adrenergic antagonist | or verapamil if b-adrenergic contraindicated
58
What is prophylactic tx if migraine with co morbid insomnia or depression?
TCA
59
What is prophylactic tx if migraine with co morbid seizure or bipolar illness?
- anti-convulsants | - use beta adrenergic antagonist or verapamil if beta adrenergic contraindicated
60
What is the most common primary headache type?
Tension type headache-like band squeezing the head
61
What is the presentation of a cluster headache?
- pain is in and around one eye - unilateral, excruciating pain peaks within minutes and last about 3 hrs - lacrimation, miosis, ptosis, rhinorrhea on ipsilateral side - HA lasts weeks to months followed by periods of remission
62
What is 1st line tx for TTHA?
simple analgesics:Acetaminophen +/- caffeine
63
What is 2nd line tx for TTHA?
Aspirin, NSAIDS
64
Acute TTHA tx?
codeine or butalbital
65
What are the limits (# days) you can use butalbital,combination analgesics, or NSAIDS
butalbital < 3 days/month analgesics <9 days/month NSAIDS <15 days /month
66
T/F There is no evidence to support the use of muscle relaxants in the management of TTHA?
TRUE
67
Which drugs are not recommended for TTHA?
- SSRI's | - botulinum
68
Which drug might work in TTHA?
SNRI: Mirtazapine TCA Topiramate or gabapentin
69
T/F Hypothalamus might be a modulator in cluster HA
TRUE
70
What is the hallmark sign of cluster headaches?
circadian rhythm of painful attacks
71
T/F People with migraine headaches sit quietly while people with cluster headaches pace the room
TRUE
72
What is the tx for acute cluster HA aka abortive therapy?
- 100% oxygen non rebreather mask at 12L/min for 15-30 min | - serotonin agonist or ergotamines
73
Which Triptans are highly effective for cluster HA?
injection or nasal Triptan | exception: oral zolmitriptan 10 mg
74
Which ergotamines are helpful in the tx of cluster HA?
IV dihydroergotamine | ergotamine tartrate
75
What is prophylactic tx for cluster HA?
1st: Verapamil 2nd: lithium, monitor thyroid and renal function, ADE: lethargy, nausea, diarrhea 3rd: corticosteroids (prednisone X 5 days and then tapered) 4th: Galcanezumab, binds to CGRP ligand
76
What are miscellaneous agents in tx of cluster HA?
intranasal lidocaine hyperbaric oxygen subQ octreotide
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