thera II test I migraines

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thera II test I migraines
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2013-02-22 11:52:32
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thera II test I migraines
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  1. 7 goals of long-term migraine Tx
    • 1. reduce frequency, severity and disability
    • 2. reduce reliance on poor pharmacotherapies
    • 3. improve quality of life
    • 4. prevent HA
    • 5. avoid escalation and HA med use
    • 6. educate patients to manage the disease
    • 7. reduce HA related distress and psychological symptoms
  2. 6 goals for acute migraine Tx
    • 1. treat rapidly and consistently w/o reoccurence
    • 2. restore ability to function
    • 3. minimize backup & rescue medications
    • 4. optimize self-care for overall management
    • 5. be cost effective in overall management
    • 6. cause minimal or no AE
  3. butterbur for migraine prevention
    • 1. petadolex brand
    • 2. 75 mg BID
    • 3. anti-spasmotic on smooth muscle/vascular walls, anti-inflammatory 
  4. NSAIDS for migraine prevention
    Do not use
  5. Magnesium for migraine prevention
    watch for AE of diarrhea
  6. Feverfew (MIG-99)
    • 1. more effective in pts with more frequent/severe migraines
    • 2. not for pts with allergies to ragweed, chrysanthemums, marigolds, daisies, etc
  7. riboflavin for migraine prevention
    • 1.400mg qd - 200am & 200pm
    • 2.local pharmacies carry 25mg so be aware
    • 3. AE - florescent yellow urine
  8. Combo: riboflavin, magnesium & feverfew for migraine prevention
    Not going to hurt anything to try
  9. Coenzyme Q10 for migraine prevention
    • 1. 100mg TID
    •        - minimizes SE by limiting 100mg/dose
  10. Cyproheptadine for migraine prevention
    • 1. equal to propranolol
    •      - use along with
    • 2. SE - drowsiness
    • 3. 2mg BID
  11. Anti-hypertensives for migraine prevention
    • 1. metoprolol (lopressor) - XR 20-200mg/day
    • 2. propranolol (inderal) - 40mg BID
    • 3. verapamil (calan) - 80mg TID
  12. CI for anti-hypertensives for migraine prevention
    • 1. decreased HR
    • 2. decreased respiratory rate
  13. anti-depressants for migraine prevention
    • 1. amitriptyline
    •        -10mg, increasing to 20-50mg qhs
    •        -good for sedation
    • 2. venlafaxine (effexor)
    •        - XR 150mg QD
    •        - good for pain
    •        - AE hard to come off of
    • 3. fluoxetine (prozac)
    •        - 20mg QD
    •        - good for sleeping
  14. CI for anti-depressants for migraine prevention
    • 1. elderly
    • 2. people taking SSRI's
    • 3. any psychosis or mental health
  15. menstrual migraine hormonal therapy
    • 1. estrogen (premarin)
    •       - on days 22-28
    •       - give at hs
    • 2. extended cycle contraceptives
    •       - lybrel
    •       - seasonale
    •       - seasonique
  16. anti-epileptic for prevention of migraine
    • 1. topomax (topiramate)
    •       - 25mg QHS 1wk, then 25mg BID 1wk   with a max of 200mg/day
    •       - SE dopomax - memory difficulty
    •                           - parasthesia 50% pts
    •                           - weight loss
    •                           - preg category D
    • 2. gabapentin (neurontin)
    •       - titrated to 2,400 mg/day 
    •       - SE fatigue
    • 3. depakote (divalproex)
    •       - leave to neurologists
    •       - SE weight gane
  17. nonspecific preventative Tx for menstrual migraine
    • 1. naproxen (aleve)
    •       - 550mg BID x 7d before menses continue for 13 days
    • 2. frovatriptan/zolmitriptan
    •       - 2.5mg once or twice daily x 2d before menses, continue for 6 days
  18. abortive nonspecific Tx of menstrual migraine
    1. NSAIDS, triptans
  19. mild-moderate migraine TX
    • 1. APAP - 1000mg
    • 2. ASA - 1000mg
    • 3. Ibuprofen 400mg and noproxen 500mg
    •       - diclofenac 50mg
    • 4. Excedrin (APAP/ASA/caffeine)
  20. triptan dosing
    • 1. 1 tab at first sign of HA, ok to repeat in 2hrs
    •       -Amerge wait 4 hrs
    •       - sumavel (dosepro) ok to repeat in 1hr
    • rule of thumb
    •       - max-dose in 24hrs is 2 tablets of max-dose strength
    •      
  21. max dose of imitrex
    100mg
  22. max dose of maxalt
    10mg
  23. max dose of maxalt when combined with propranolol
    5mg/dose
  24. 6 CI to triptans
    • 1. HTN (170/90)
    • 2. CV disease
    • 3. PAD
    • 4. basilar type migraines
    • 5. migraine with prolonged aura
  25. AE of triptans
    • 1. paresthesias
    • 2. fatigue
    • 3. dizziness
    • 4. flushing
    • 5. warm sensations
    • 6. somnolence
    • 7. 15% report chest tightness, not usually cardiac
  26. ergot alkaloids for migraine Tx
    don't use - CI in coronary disease and cerebral PAD
  27. dosing of triptans together
    don't use within 24 hours of one another
  28. 4 take home points for preventive therapy
    • 1. consider adding this as soon as migraines become a significant problem
    • 2. must give adequate trial of 2+ months
    • 3. don't forget non-prescription options
    • 4. choose prescription agents based on comorbidities
  29. 5 take home for abortive therapy
    • 1. try 2-3 headaches before giving up on an acute Tx
    • 2. be aggressive with NSAIDA/ASA dosing
    • 3. max Maxalt 5mg when combined with propranolol
    • 4. balance slightly greater AE with slightly greater efficacy at higher doses of triptans
    • 5. for menstrual migraine, don't be afraid of hormones.
    •       Or consider abortive therapies given 2-7 days prior to menses and continued for 6-13 days
  30. level A migraine prevention therapies
    • metoprolol
    • propranolol

    • topiramax
    • depakote - divalproex
  31. Level B migraine preventive therapies
    • amitriptyline
    • venlafaxine
  32. level U (4) migraine preventive therapies
    • verapamil
    • gabapentin
    • fluoxetine

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