Term
| Name the 3 types of primary headaches: |
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Definition
| Cluster, Migraine, Tension |
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Term
| What pro-inflammatory neuropeptides are released during cortical spreading depression? |
|
Definition
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|
Term
| What nerve is activated in migraines, and where does it come from? |
|
Definition
| Trigeminal Afferent from dural vasculature |
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Term
| What neurotransmitter do most antimigraine drugs act on (in both an agonist and antagonist capacity)? |
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Definition
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Term
| Migraine attack risk increases during therapy with what drugs? |
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Definition
| Reserpine and fenfluramine |
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Term
| As migraine approaches, in the aura phase, what characterizes the possible visual field deficits? |
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Definition
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Term
| What chemical, released from vascular endothelium, causes sensitization of sensory nerves leading to discharge and neuropeptide (CGRP and Substance P) release? |
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Definition
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Term
| Under what circumstances are Triptans prescribed? |
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Definition
| These are ABORTIVE migraine medications for INFREQUENT, non-complicated attacks |
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Term
| Name the 7 triptan drugs and what they have in common: |
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Definition
Sumatriptan, rizatriptan, naratriptan, almotriptan, frovatriptan, electriptan, zolmitriptan
THEY ALL HAVE TRIPTAN IN THE NAME |
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Term
| What is the effect of triptans on cerebral vasculature? |
|
Definition
| They constrict the carotid arteriovenous anastomoses and reverse cerebral ischemia and hypoxia |
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|
Term
|
Definition
| The release of pro-inflammatory neurotransmitters (CGRP, Substance P) in the perivascular space in the area of the trigeminal nerve |
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Term
| Why do we not give triptans for prophylaxis (on a daily basis) against migraines, and instead when do we give them? |
|
Definition
Triptans cause many side effects
They are preferred for ACUTE attacks |
|
|
Term
| In what patients are triptans contraindicated? |
|
Definition
Coronary artery disease- can be dangerous
(coronary spasm- theoretical risk)
Ischemic diseases |
|
|
Term
| Describe the onset of triptans: |
|
Definition
| Very rapid, especially if given as a nasal spray |
|
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Term
| Describe the gross anatomical mechanism of migraines: |
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Definition
| The blood vessels outside the cranial circulation become disproportionally dilated which shunts blood to the outside leaving the brain in a hypoxic state |
|
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Term
| Concurrent use of triptans and what other class of medication is contraindicated? |
|
Definition
Do not use triptans with ergot alkaloids
(Within 24 hours) |
|
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Term
| What three triptans are contraindicated in patients taking MAO A inhibitors? |
|
Definition
Sumatriptan
Rizatriptan
Zolmitriptan |
|
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Term
| What are the potential side effects of oral doses of triptans? |
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Definition
| Paresthesia, asthenia(weakness), fatigue, pain in the neck, chest, or jaw |
|
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Term
| What is the prototype triptan, and how are the second generation triptans different? |
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Definition
Sumatriptan is prototype
Second generation: natratriptan, zolmitriptan, electriptan, almotriptan, rizatriptan, frovatriptan- similar mechanism with lower adverse effect profile and faster onset of actions |
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Term
| What drug, effective against migraines sometimes, is useful when aspirin is contraindicated? |
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Definition
| Acetaminophen (NSAID-like but no antiinflammatory activity) |
|
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Term
| What drugs are combined with acetaminophen for moderate headaches? |
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Definition
| Acetaminophen with isometheptene mucate, dicholorphenazone |
|
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Term
| What is the mechanism of action of acetaminophen? |
|
Definition
| Selective against COX2- no prostaglandins |
|
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Term
| What do we combine with acetaminophen for infrequent headaches of moderate to severe intensity? |
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Definition
|
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Term
| What drug combination is the ONLY viable option for headaches during pregnancy? |
|
Definition
| Acetaminophen and opioids (CODEINE) |
|
|
Term
| How is acetaminophen overdose treated? |
|
Definition
|
|
Term
|
Definition
| Acetaminophen combined with barbiturates- reinforces GABA transmission, inhibits CNS |
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Term
| Name 3 NSAIDS, what they do, and what type of migraine they are indicated for: |
|
Definition
Aspirin, Ibuprofen, Indomethacin
Analgesic- inhibit prostaglandins
ABORTIVE MIGRAINE MEDICATIONS |
|
|
Term
|
Definition
Agonizes opiod receptors
Partial agonist at Mu receptors
Full agonist at K receptors
ABORTIVE MIGRAINE MEDICATION |
|
|
Term
| Why is butorphanol very addictive? |
|
Definition
| Because it is a partial agonist on Mu receptors |
|
|
Term
| How is butorphanol given? |
|
Definition
Intranasal spray for migraines
ABORTIVE MIGRAINE MEDICATION |
|
|
Term
| What are the adverse effects of butorphanol? |
|
Definition
Sedation, confusion, dizziness
And remember, because it is a partial Mu agonist it is very addictive |
|
|
Term
|
Definition
An abortive migraine medication, given IV
Usually used in the ER for SEVERE migraine pain
-it is like morphine or phentanyl |
|
|
Term
| Regarding migraines, what is important about Oxycodone and Hydrocodone? |
|
Definition
Effective pain killers but huge addiction liability
Antitussive
CAUSE CONSTIPATION |
|
|
Term
|
Definition
An antiemetic abortive migraine medication
Used alone or in combination with aspirin for migraines |
|
|
Term
| What is the mechanism of action of metoclopramide? |
|
Definition
Agonist at 5HT4; ANTAGONIST at D2 and 5HT3 receptors
ANTIEMETIC FOR MIGRAINES |
|
|
Term
| Where is 90% of serotonin found? |
|
Definition
|
|
Term
| What are some non-migraine clinical uses of metoclopramide? |
|
Definition
Gastric stasis after diabetic gastroparesis
GI Radiology to increase transit in barium studies
Stimulate lactation |
|
|
Term
| What are the adverse effects of metoclopramide? |
|
Definition
| Galactorrhea, extrapyramidal effects, tardive dyskinesia |
|
|
Term
| When is the use of metoclopramide contraindicated? |
|
Definition
| Pheochromocytoma, Parkinson's Disease |
|
|
Term
| What do antiemetic drugs act on? |
|
Definition
| Block 5HT3 and D2 receptors in the area postrema |
|
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Term
| What are the effects of chlorpromazine and prochlorperazine? |
|
Definition
These are anti-psychotics
Anticholinergic, antidopaminergic, weakly antiadrenergic and antihistaminergic |
|
|
Term
| What are the clinical uses of chlorpromazine and prochlorperazine? |
|
Definition
| ANTIEMETIC FOR MIGRAINES, schizophrenia, tourettes, huntington's chorea, and dementia |
|
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Term
| What are the adverse effects of chlorpromazine and prochlorperazine? |
|
Definition
Poikilothermia, blurred vision, constipation, agranulocytosis (serious), phototoxicity (CHLORPROMAZINE
Significant emesis in some patients |
|
|
Term
| What antiemetic abortive migraine medication causes a painful light reaction/phototoxicity? |
|
Definition
|
|
Term
| What are the extrapyramidal adverse effects of chlorpromazine and prochlorperazine? |
|
Definition
| Neuroleptic Malignant Syndrome, TARDIVE DYSKINESIA, amenorrhea, galactorrhea, false positive pregnancy in women, gynecomastia and decreased libido in men |
|
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Term
| What antiemetic abortive migraine medication is CONTRAINDICATED in patients with prolonged QT interval, and why? |
|
Definition
prochlorperazine
It amplifies quinidine-mediated cardio toxicity
Can be dangerous in patients with prolonged QT |
|
|
Term
|
Definition
A combo of acetaminophen, dichloraphenazone, and isometheptene
given for ABORTIVE MIGRAINE TREATMENT |
|
|
Term
| What is dichloralphenazone? |
|
Definition
Analgesic and antipyretic
SEDATIVE used for insomnia
Given in combo with acetaminophen and isometheptene as Amidrine- for ABORTIVE MIGRAINE TREATMENT |
|
|
Term
|
Definition
| A vasoconstrictor- given in combination with acetaminophen and dichloralphenazone as Amidrine- for ABORTIVE MIGRAINE TREATMENT |
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|
Term
| When is propranolol (and timolol) given for migraines and why? |
|
Definition
PROPHYLAXIS- beta blockers- highly lipophilic
Mechanism in migraines is unknown |
|
|
Term
| What are the effects of Propranolol (beta blockers)? |
|
Definition
| Hypertension, tachyarrhythmias, angina, MIGRAINE PROPHYLAXIS |
|
|
Term
| What are the adverse effects of Beta Blockers? |
|
Definition
| Bronchospasm, atrioventricular block, postural symptoms, sedation, decreased libido, fatigue |
|
|
Term
| When are beta blockers (propranolol) contraindicated? |
|
Definition
DO NOT GIVE TO ASTHMA PATIENTS
or to Olympic Athletes |
|
|
Term
| What is pizotifen used for, and what is its mechanism of action? |
|
Definition
MIGRAINE PROPHYLAXIS-
antagonsit of 5HT1, 5HT2A, and 5HT2C
Moderately antihistamine and
mildly anticholinergic |
|
|
Term
| When is pizotifen especially useful? |
|
Definition
| MIGRAINE PROPHYLAXIS in patients where beta blockers are contraindicated |
|
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Term
| A 24 year old patient presents to you with severe headaches 6 days per week that last the whole day. They only improve in the dark. The patient has asthma. What do you prescribe? |
|
Definition
You prescribe Pizotifen for migraine prophylaxis
Because the patient has asthma, beta blockers are contraindicated |
|
|
Term
| What are the side effects of pizotifen? |
|
Definition
| Weight gain, antimuscarinic effects, potentiates drowsiness from sedatives and tranquilizers and antidepressants |
|
|
Term
| When is pizotifen contraindicated? |
|
Definition
| When the patient is on MAO inhibitors |
|
|
Term
| What drugs for migraine prophylaxis cause significant weight gain? |
|
Definition
| Pizotifen, Amitryptiline, Valproic Acid |
|
|
Term
| What tricyclic antidepressants are prescribed for migraine prophylaxis, and what is their mechanism of action? |
|
Definition
Amitriptyline, dothiepin, nortriptyline
5HT and NE reuptake inhibitors
Block Na+ channels, antimuscarinic, antihistamine, antiadrenergic, antidopamine |
|
|
Term
| What class of drugs would you prescribe to a patient with daily migraines, pain syndrome, and chronic fatigue? |
|
Definition
| Tricyclic antidepressants (amitriptyline, dothiepin, nortriptyline) |
|
|
Term
| What are the adverse effects of tricyclic antidepressants? |
|
Definition
| First primary AV bundle branch block, anorexia, blurred vision, dry mouth, confusion, constipation, tachycardia, urinary retention, sedation, weight gain, hypotension, reflex tachycardai, dizziness |
|
|
Term
| What class of drugs may precipitate mania in bipolar affective patients? |
|
Definition
| Tricyclic antidepressants (Amitriptyline, dothiepin, nortriptyline) |
|
|
Term
| What is topiramate used for and what is its mechanism of action? |
|
Definition
GIVEN FOR MIGRAINE PROPHYLAXIS
Blocks voltage-gated Na+ channels, enhances GABA transmission, inhibits AMPA/Kainate receptors and high voltage Ca2+ channels |
|
|
Term
| What are the adverse effects of topiramate? |
|
Definition
P450 inducer
Increased intraocular pressure, poor concentration and memory, ataxia, somnolence, weight loss |
|
|
Term
| What is valproic acid used for, and what is its mechanism of action? |
|
Definition
MIGRAINE PROPHYLAXIS, seizures
Stabilizes Na+ channels in the inactive state- inhibits low threshold T-type Ca2+ channels, increases GABA transmitter |
|
|
Term
| What are the adverse effects of valproic acid? |
|
Definition
| Drowsiness, weight gain, tremor, hair loss, fetal abnormality, liver abnormality, bone marrow depression |
|
|
Term
| What is gabapentin used for, and what is its mechanism of action? |
|
Definition
MIGRAINE PROPHYLAXIS, seizures, neuroleptic pain
Structural analog of GABA, inhibits high voltage-activated Ca2+ channels (HVA) |
|
|
Term
| What are the adverse effects of gabapentin? |
|
Definition
| Dizziness, sedation, peripheral edema (at high doses), may be associated with withdrawl |
|
|
Term
| What is Methysergide used for, and what is its mechanism of action? |
|
Definition
Highly Effective for MIGRAINE PROPHYLAXIS, severe refractory migraines, cluster headaches
5HT2 and 5HT1A Antagonist |
|
|
Term
| Why is methysergide rarely used? |
|
Definition
| SIDE EFFECTS: Retroperitoneal fibrosis, fibrosis of heart valves and pleura |
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