Headaches

Question 1

Supply criteria sumatriptan

Answer 1

1. Migraine must be diagnosed by Dr/pharmacist
2. Established pattern of migraine (a history of 5 or more migraine attacks over at least 1 year)
3. Simple analgesics tried and ineffective.

Question 2

Precautions for sumatriptan use

Answer 2

Concomitant use: SSRI/SNRI
St John’s wort
COC
Heart disease risk factors (CI who have three or more risk factors i.e. DB, high cholesterol, smoking/use of NRT).

Question 3

sumatriptan counselling
- P medicine
Supply criteria:
1. Migraine must be diagnosed by a doctor or pharmacist
2, Established pattern of migraine (a history of five or more migraine attacks occuring over a period of at least one year)
3, Simple analgesics tried and ineffective.

Answer 3

• Dose = one 50mg tablet taken ASAP after the migraine has started
• Swallow whole with water
• A single dose should relieve symptoms after 30 min : if symptoms do not improve in this time no further doses should be taken for the same migraine attack
• If there is a 2nd migraine attack within 24 hours a 2nd dose may be taken
• Drowsiness may affect performance of skilled tasks (e.g. driving)
• A migraine diary may help identify personal trigger factors.

Question 4

Types of episodic headaches

Answer 4

tension headache
migraine
cluster headache

Question 5

Ages that sumatriptan is contraindicated in

Answer 5

<18 and >65

Question 6

Can sumatriptan be given in the following scenarios Y/N
1. headache lasting >24 hours
2. prevention of migraine
3. migraine with photophobia
4.

Answer 6

1. Refer
2. No - only for start of migraine
3. Yes

Question 7

Migraine characteristics

Answer 7

• pounding, mod - severe headache
• each episode lasts 4-72 hours and <15 attacks per month
• unilateral location
• accompanied by n+v, photophobia, phonophobia

Question 8

tension headache

Answer 8

• generalised bilateral; tight or band-like across head
• mild - moderate lasting min-days
• less common than migraines; not disabling
• mildly nauseated but no vomiting
• mild disturbance of sensorium but not confluence of them (more migraine)

Question 9

cluster headache

Answer 9

• severe headache occurring in episodes and intervals of weeks to years
• agitation and distress; pacing, moaning, repetitive type behaviours
• episodic form, rarely chronic
• 1-7 times a day attacks lasting 90-180 mins and come on abruptly at predictable time of day. plot on calendar.
• quick trigger alcohol even smell
• usually focused on one side during a period of cluster headaches with peri-orbtal or fronto-temporal focus
• associated with autonomic changes around face; swelling/tearing of eye, redness, stuffiness, runny nose, sweating

Question 10

Migraine acute treatment

Answer 10

• Analgesia NSAID eg ibuprofen 400-600mg or Naproxen 250-500mg
• Anti-emetic metoclopramide 10mg or domperidone 10-20mg
• Sumatriptan 50mg – 100mg
• Propranolol 20-320mg od may also be used for prevention (metoprolol/topiramate/amitriptyline)

Question 11

Sumatriptan counselling

Answer 11

• 1 dose = 50mg taken asap after start of migraine swallow with water
• Onset 30min if symptoms do not improve in this time do not take further doses for same attack
• Second attack in 24 hours, second dose can be taken
• Drowsiness may affect performance of skilled tasks like driving
• Migraine diary useful for personal trigger factors

Question 12

They are contraindicated in patients with ischaemic heart disease, previous myocardial infarction, coronary vasospasm or uncontrolled or severe hypertension
A. 5HT1 agonists
B. NSAIDs
C. Prokinetic anti-emetics
D. Aspirin

Answer 12

A

Question 13

migraine associated gastric stasis

Answer 13

common symptom; gastric motion is inhibited, causing n+v and reducing the absorption of medication from the gastrointestinal tract. Patients should be advised to take medication as soon as an attack starts, as this is when absorption is least inhibited by gastric stasis.

Question 14

Preferred anti-emetics in migraine treatment?

Answer 14

prochlorperazine 3mg buccal tablets or metoclopramide 10mg tablets are the anti-emetics of choice for nausea and vomiting in migraine. Domperidone can also be used, although the UK MHRA advised that care must be taken because of the cardiac risks associated with its use

Question 15

\_\_\_\_\_\_\_\_\_must not be used for treatment of migraine as they can delay recovery and can cause medicines overuse headaches.
A. Tricyclic Antidepressants
B. Domperidone
C. Opioids
D. NSAIDs

Answer 15

Opioids must not be used for treatment of migraine as they can delay recovery and can cause medicines overuse headaches.

Question 16

1st line beta blocker for prevention of migraine:
A. Sotalol
B. Propranolol
C. Metoprolol
D. Atenolol

Answer 16

B propranolol 40 - 240mg divided doses

BB are competitive antagonists of the effects of catecholamines at beta-adrenergic rec sites, however in relation to migraines, MOA not fully understood. BB are contraindicated in pts with asthma, heart failure, peripheral vascular disease, depression, diabetes and low blood pressure

Question 17

Menstrual migraines

Answer 17

Menstrual migraines are associated with fluctuations of oestrogen during the menstrual cycle and are usually migraines without aura. Management should follow the same acute migraine treatments. In addition to 1st line options, mefenamic acid 500mg qds for simple analgesia can be used. For prophylaxis of menstrual migraines, frovatriptan 2.5mg od or naratriptan 1mg bd taken two days before day one of the menstrual cycle and for a further four to five days thereafter is recommended.

Question 18

Women suffering from migraines, particularly with aura, and using the combined oral contraceptive pill are at an increased risk of 
A. heart failure
B. toxic shock syndrome
C. bleeding
D. mood swings
E. ischaemic stroke

Answer 18

E. ischaemic stroke

decision regarding use of CHC is based on expert opinion and the risks should be discussed with the patient, before initiation of treatment. However, there is no increased risk of thrombotic events with POC and this may be the contraceptive of choice

Question 19

[Migraine] In pregnancy, paracetamol is the first-line analgesic of choice. Aspirin, naproxen and ibuprofen can be used in combination with paracetamol in the
A. 1st and 2nd trimester
B. 2nd and 3rd trimester
C. 3rd trimester only
D. 1st trimester only

Answer 19

A

Question 20

Can the following be used in pregnancy?
A. Propranolol
B. Sumatriptan
C. Amitriptyline
D. Anti-epileptics

Answer 20

Sumatriptan has been associated with safe use throughout pregnancy, although limited data is available. For prophylaxis, propranolol has the best evidence for safety in pregnancy. Amitriptyline at its lowest effective dose may also be used. Anti-epileptics should not be used during pregnancy

Question 21

Migraine references

Answer 21

https: //www.rpharms.com/resources/quick-reference-guides/sumatriptan
https: //pharmaceutical-journal.com/article/ld/migraine-management
http: //www.londonscn.nhs.uk/wp-content/uploads/2015/03/neuro-adult-with-headache-edu-videos-032016.pdf
https: //www.independentpharmacist.co.uk/cpd-module-headache-and-migraine

Question 22

Headaches that require urgent referral include those where there is

Answer 22

· possible injury to the head, eg a fall
· severe/intense pain not experienced before
· a sudden change in speech, memory, or vision
· drowsiness or confusion
· high fever, stiff neck or rash
· redness in an eye

Question 23

Treatment options for people under 18 yrs with migraine

Answer 23

in people under 18 years: nasal sumatriptan or an NSAID may be suitable, but note that oral triptans are not licensed for use in people under 18 years. Metoclopramide may be used as an anti-emetic in people aged 12 and over, while prochlorperazine can be used by children under that age. Suppositories may be a better dosing option than oral routes.