Term
| what characterizes the migraine attack? |
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Definition
| prodromal phase (cerebral vasoconstriction) and headache phase (abnormal dilatation of cranial arterioles) |
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Term
| what is a classic vs common migraine? |
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Definition
| classic: w/aura, common: no aura |
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Term
| when do 90% of migraine cases begin? |
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Definition
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Term
| what is effective nonpharmacologic migraine tx? |
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Definition
| avoid triggering phenomenon (vasodilating substances such as alcohol/tyramine), regulation of lifestyle (proper diet/exercise/adequate sleep), psychotherapy, biofeedback, physical therapy, and OMT |
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Term
| what characterizes use of acute/abortive migraine agents? |
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Definition
| therapy: 2-3 days/wk max (more frequent use can cause a *constant rebound h/a). recurrent h/a (that which reappears after the pt has obtained significant relief from an abortive agent w/in the time frame of the attack). n/v ADRs may cause more incapaciation than the pain itself. decreased GI motility ADRs may hinder absorption. rectal/nasal/IM/SC modes of administration may be employed for quicker onset. |
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Term
| what are the acute/abortive migraine meds? |
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Definition
| metoclopramide, acetaminophen, ASA, naproxen, butorphanol, ergotamine tartrate, dihydroergotamine, naratriptan, rizatriptan, almotriptan, eletriptan, frovatriptan, and zolmitriptan. |
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Term
| what characterizes metoclopramide as an acute/abortive migraine med? |
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Definition
| this is a DA-blocking agent (anti-emetic) which increases GI motility (increased PO efficacy). |
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Term
| what characterizes acetaminophen as an acute/abortive migraine med? |
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Definition
| if this will work, it is the DOC. max daily dose: 4 g. |
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Term
| what characterizes the NSAIDs as acute/abortive migraine meds? |
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Definition
| this will help if there is an inflammatory process involved. ASA can be used alone or with caffeine/butabital - but does inactivate platelets. naproxen has been demonstrated to be as efficacious as ergotamine tartrate (quicker recovery of platelets). ibuprofen, ketoprofen, and piroprofen may also be used. |
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Term
| what characterizes butorphanol as an acute/abortive migraine med? |
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Definition
| this opioid will allow rapid onset of analgesia - used in the ER. |
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Term
| what are the serotonin agonist acute/abortive migraine meds? |
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Definition
| the ergot derivatives and triptans |
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Term
| what characterizes the ergot derivative acute/abortive migraine agents? |
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Definition
| these are agonists at all 5-HT1 and 5HT-2 receptors. they can induce *vasospasm (myocardial or peripheral ischemia) or *fibrotic complications (scar tissue in heart, lungs, or GI tract - esp w/methysergide). contraindications: severe coronary heart disease and peripheral vascular disease (raynaud's or uncontrolled HTN) |
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Term
| what characterizes ergotamine tartrate as an ergot derivative acute/abortive migraine agent? |
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Definition
| this is widely used after no response to analgesics - it is not an analgesic. it is most effective if taken early during attack but may be effective if taken soon after. ergotamine tartrate is ineffective for tension h/a. due to ADRs: poor benefit/risk ratio. |
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Term
| what ADRs are associated w/ergotamine tartrate? |
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Definition
| n/v (preventable w/antiemetic), drowsiness (limits use at work), vascular occlusion/gangrene (rare - but occurs w/OD or beta-ABAs/erythromycin/troleandomycin). w/overuse there is risk of rebound h/a or ergotamine h/a. |
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Term
| what characterizes dihydroergotamine as an ergot derivative acute/abortive migraine agent? |
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Definition
| this derivative of ergotamine is available parenterally or as a nasal spray and is *less vasoconstrictive than ergotamine (less hypertensive), causes less n/v, and has little/no risk of rebound h/a. ADRs: diarrhea/muscle cramps. |
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Term
| what are the serotonin agonist acute/abortive migraine agents? |
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Definition
| frovatriptan, sumatriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and zolmitriptan |
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Term
| what characterizes the serotonin agonist acute/abortive migraine agents? what are the triptan sensations? biotransformation? |
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Definition
| these have the largest amount of clinical data showing benefit in migraine relief. all have a similar efficacy: ~ 60% of pts go from moderate-severe intensity -> mild. the triptan sensations are sensations of hot/cold/pressure, heaviness/tightness in chest/throat, tingling/numbness, and anxiety (not thought to be cardiac-related). most of these agents have a lot of biotransformation. |
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Term
| what are contraindications for the serotonin agonist acute/abortive migraine agents? |
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Definition
| uncontrolled HTN, CAD, peripheral vascular disease, and use of other 5-HT1 agonists/ergotamine or derivatives w/in the past 24 hrs. also - do not administer in pts in whom unrecognized CAD is likely until evaluation is performed for underlying CV disease. such pts include postmenopausal women, males > 40 y/o, and pts with risk factors for CAD such as hypertension, hypercholesterolemia, obesity, diabetes, smokers, strong family hx. |
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Term
| what characterizes sumatriptan as a serotonin agonist acute/abortive migraine agent? |
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Definition
| sumatriptan is available parenterally, as tablets, and as a nasal spray. it is proven to be effective, but has the lowest bioavailability of the tripans = 14%. 50% ADR rate (but 33% on placebo reported ADRs). |
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Term
| what characterizes naratriptan as a serotonin agonist acute/abortive migraine agent? |
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Definition
| naratriptan has a lower rate of h/a recurrence than other triptans (25%), fastest onset is SC = parenteral is the most effective route. |
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Term
| what characterizes rizatriptan as a serotonin agonist acute/abortive migraine agent? |
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Definition
| rizatriptan comes in orally disintegrating tablets (preferred by pts). 74% of pts get relief in 2 hrs. |
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Term
| what characterizes the preventative/prophylactic migraine agents? |
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Definition
| daily therapy w/these drugs (even absence of attacks) reduces frequency, severity, and duration of migraines. realistic migraine attack reduction goal: 50%. satisfactory response in about 60% of pts. randomized placebo-controlled clinical trials do not show significant differences among meds used for prevention. therefore, condition of pt and ADRs of planned med choice should be the most important determining factors. whenever possible, use one med; there are no studies which support combined pharmacotherapy. |
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Term
| what are the ergot derivative preventative/prophylactic migraine agents? |
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Definition
| methysergide, ergonovine maleate, and methylergonovine - do not need to know for exam. |
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Term
| what are the beta blockers used as preventative/prophylactic migraine agents? what characterizes their use? |
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Definition
| propanolol, metoprolol, and timolol. these are the DOC for migraine prevention: will reduce frequency but will not reduce auras. ADRs: fatigue, depression, and orthostatic hypotension. contraindicated in asthma and CHF pts. will mask symptoms of hypoglycemia in DM pts. |
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Term
| what are the TCA preventative/prophylactic migraine agents? |
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Definition
| amitriptyline has been show to give 80% improvement in 60% of pts. nortriptyline has less ADRs. |
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Term
| what are the SSRI preventative/prophylactic migraine agents? |
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Definition
| fluoxetine, paroxetine, and venlafaxine - which have not proven to be effective. also severe interactions w/MAOI. |
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Term
| what are the Ca++ channel blocker preventative/prophylactic migraine agents? |
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Definition
| verapamil (moderately effective), diltiazem, and nifedipine (mixed results) |
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Term
| should opioids be used as preventative/prophylactic migraine agents? |
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Definition
| there is no clinical evidence which supports reduction in migraines, so probably not |
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Term
| what are the anticonvulsant preventative/prophylactic migraine agents? |
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Definition
| gabapentin, divalproex, and topiramate. these suppress electrical activity to take care of the neuronal hyper-excitability component. ADRs: tingling in extremities. |
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Term
| what is the NSAID preventative/prophylactic migraine agent? |
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Definition
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Term
| what is the alpha-2 adrenergic agonist preventative/prophylactic migraine agents? |
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Definition
| clonidine. there are some issues w/this. |
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