Triptans - Zomig, Imitrex , Relpax, Maxalt - Spendy ($20/pill – Imitrex cheap now) - 80% effective - Increase risk of CV event - Don’t use in people uncontrolled HTN, h/o CV disease - SE – dizzy, flushing, “feel strange”

19 - Headaches Flashcards by Andrea Okas

What are the types of primary headaches?

Migraine
Tension-type headache
Trigeminal autonomic cephalalgias
Other primary headache disorders

Likely heightened response to pain or part of the brain that suppresses pain in head not working

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What are some other primary types of headaches?

Probable primary cough headache
Primary exercise headache
Probable primary exercise headache
Primary headache associated with sexual activity
Probable primary headache associated with sexual activity
Primary thunderclap headache
Cold-stimulus headache
Headache attributed to external application of a cold stimulus
Headache attributed to ingestion or inhalation of a cold stimulus
Probable cold-stimulus headache
Headache probably attributed to external application of a cold stimulus
Headache probably attributed to ingestion or inhalation of a cold stimulus
External-pressure headache
External-compression headache
External-traction headache
Probable external-pressure headache
Probable external-compression headache
Probable external-traction headache
Primary stabbing headache
Probable primary stabbing headache
Nummular headache
Probable nummular headache
Hypnic headache
Probable hypnic headache
New daily persistent headache (NDPH)
Probable new daily persistent headache

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What are the types of secondary headaches?

Headache attributed to trauma or injury to the head and/or neck
Headache attributed to cranial or cervical vascular disorder
Headache attributed to non-vascular intracranial disorder
Headache attributed to a substance or its withdrawal
Headache attributed to infection
Headache attributed to disorder of homoeostasis
Headache or facial pain attributed to disorder of the cranium, neck,
eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure
Headache attributed to psychiatric disorder
Painful cranial neuropathies, other facial pains and other headaches
Painful cranial neuropathies and other facial pains
Other headache disorders

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What are the three types of primary headaches?

Tension
Migraine
Cluster

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What are they types of secondary headaches?

Secondary (sinus, hypertension, etc…)

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How common are head aches?

Almost everyone in America has them at some time

The concerning aspect is when they are different ***

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When are head aches concerning?

The concerning aspect is when they are different ***

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Describe age extremes in head aches

We always worry when elderly or kids have HA
20% of elderly c/o frequent HA
75% of kids have HA by time 15; 28% of those migraine.

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Describe a tesnion headache

Aka “stress”
90% in US; more common in women (in kids equal boys/girls)
Usually has a trigger
Usually constant, bilateral, not associated with nausea or photophobia

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When do tension headaches occur?

Change in sleep
Stress
Skipped meal
Hormone fluctuation
Certain foods (MSG)

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What’s at the bottom of tension headaches?

No more muscle tension
Chemical changes (likely serotonin)

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How do you treat a tension headache?

Avoiding triggers
Ibuprofen (any OTC NSAIDS)
Tylenol
Caffeine as adjunct
Biofeedback/relaxing

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Describe migranes

12% population
Female more than male
Can “outgrow” them
Kids can get too

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Describe the pathology of migraine

Theory on pathology of migraine not clearly figured out. Believe it is vasodilatation of temporal artery, leads to inflammation, more dilation. This process also stimulates sympathetic nervous system (dilated pupils, nausea)
Newer belief that neurotransmission leading to vascular changes

Some theories on DA being involved, but again likely serotonin is issue

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What are patterns of migraines

Usually start in young adulthood

Genetic component

Most “outgrow”

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What are the signs and symptoms of migraine

Throbbing
Movement makes worse
Moderate to severe
Photophobia
Sound sensitive
Fatigue
Nausea/vomiting
Visual issues
Unilateral (2/3) and often switches side
Triggers (hormone is biggie)

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Describe some patterns we see in a migraine

20% have an aura…visual changes prior to the HA; can also have paresthesias

Visual migraines have the changes and often no HA

Can also have short term paralysis

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How do you treat a migraine?

Rest/light avoidance

NSAIDS/caffeine – NSAIDs can be as effective as triptans – especially when anti-nausea meds and/or caffeine added. (Many are FDA approved)

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Describe triptans

Triptans

Zomig, Imitrex , Relpax, Maxalt
Spendy ($20/pill – Imitrex cheap now)
80% effective
Increase risk of CV event
Don’t use in people uncontrolled HTN, h/o CV disease
SE – dizzy, flushing, “feel strange”

How do triptans work?

Serotonin receptor agonist
Possibly leads to vasoconstriction
80% migraine sufferers could get benefit but only 18%.
Why? CV risk (1/ 1/mil compared to 1/200 NSAIDs), cost, pt doesn’t tell doctor about HA
New combos of NSAID + triptan more effective than either alone
Triptans are FDA approved

Describe treatment of migraines with intranasal lidocaine

Effective in about 50% of migraines (and clusters) within 5 minutes

What does she use to treat migraines in the ER?

IVF
Toradol/Vistaril
10 mg Compazine IV
25 mg – 50 mg Benadryl IV
Droperidol/Benadryl
Imitrex (SQ)

Can treat about 100% HA without narcotics

What are treatments that are “out of style” and NOT FDA approved?

Ergots (can still get – nasal, oral, IM IV)

Narcotics (do NOT do this***)

Vicodin #1 med in US
Doesn’t address problem
Rebound
Addiction

Barbiturates (Fioricet)

What does compazine do? She uses it for nausea

What does Compazine do? DA inhibition…treats nausea???

Makes them sleepy, can easily prescribe in PO, okay in pregnancy

Benadryl – prevents tardive dyskinesias; helps with nausea

What is compazine highly effective in?

Peds migraines (Ann Emerg Med Feb 2004) - Compazine 85% effective - Toradol 55% effective She sees a much higher "bang for her buck" with toradol, especially when given IV

Describe migraine treament based on pain

Pain scale (1 – 10) after Compazine or Toradol in adults (Acad Emerg Med June 98) - 0.5 Compazine - 3.9 Toradol

Describe the use of droperiod and benadryl

Other combo is droperidol/Benadryl…an old anti nausea medicine. Has bad wrap for QT prolongation. In 30 years of use, 9 cases of torsades de points Droperidol also Dopamine (DA) blocker, with alpha adrenergic blockage as well My observation is about 95% after 1.25 mg twice Neurology Jan 2003 found 82% compared to 57% placebo

Describe prophylaxis against migraines ******

``` meds to prevent – consider when HA interfere with life, > 2/wk, > 2/month that don’t respond, or cant take rescue meds Beta blockers BCP Antidepressants Antiseizure (Neurontin) ```

Describe botox

31 injections in 7 spots about q 12 weeks 8 to 9 fewer HA/mo. vs 6 to 7 fewer with placebo Doesn’t work on tension HA Unsure MOA Only for those >15 migraines/mo.

Describe prophylaxis

Prophylaxis considered successful if decrease number by 50% (and that happens about 50% of the time)

Describe cluster head ache *******

Clusters (weeks or months) of HA that can last from 3 min to hours. Pain so intense person can consider suicide. Much more common in males Eye/nose on one side often affected (red/runny eye, runny nose) Believe cause trigeminal nerve issue 0.4% population

How do you treat a cluster head ache? *****

02 Triptans Narcotics (this is the one she will give it for) Occipital nerve stimulation

What are the secondary causes of secondary head ache?

- Bleed - HTN - Metabolic issues (thyroid, DM) - Caffeine or med withdrawal - Tumor - Brain Infection - Stroke - Vision - Illness/fever - Acute sinusitis - Sleep apnea

Describe encephalitis

- HA - Fever - +/- rash (scary rash - look at slide 38) - Very stiff neck (touch chin, bounce on toes)

Describe the use of caffeine

Withdrawal of even 100 mg/day symptoms of HA, irritability, difficult concentrate Starts 12- 24 hours after stopping, peaks 2-3 days

Describe sleep apnea

Only about 1/3 of those with HA and sleep apnea improved c CPAP

When should you worry about secondary causes that could be life threatening

- Age extremes..over 50 without clear history or cause - Neuro changes - Different HA - Worst of life - Trauma - Seizures (new) - Neck/fever/exposure - PMH of cancer or HIV

Describe what you get in the ER if you come in with a head ache

- CT (with or without contrast) - LP - Can’t get MRI in ER usually

Describe the use of CT in headaches

Studies found that 95% SAH are found on noncontrast CT; therefore many believe that one needs to get LP if CT is negative to see if blood in the CSF

Describe hypertension and head ache

Some people never have s/s of HTN, others very sensitive

Describe a sinus head ache

90% of “self diagnosed” sinus HA actually migraines…61% given ABX by physician (Allergy Asthma Proc Mar 2004)

Describe sinusitis

- Almost no sinusitis is bacterial (.5-5%) - 70% of healthcare visits get ABX for chronic, 83% for acute - What works instead– nasal saline, nasal steroids, decongestants, prednisone, antihistamines If no better 10 days, fever (not “felt warm”), ill then consider ABX - Fall allergies will get better after the first hard freeze

Why do antibiotics make people with headaches feel better?

Due to the anti-inflammatory properties Can use: - Quinolones - Bactrim - Clarithromycin - Cephalexin

What is chiari?

Chronic headaches that occur by narrowing of the skull (squeezing the brain) Need brain surgery

What is temporal arteritis? ***

- Inflammation of temporal artery - > 50 yrs. old - Women > men - 15-30/100,000

How do you diagnose temporal arteritis? ***

- > 50 y/o - New onset - ESR > 50 (high sed rate) - Pain at site or decreased pulse - Bx of temporal artery (biopsy?) TX Prednisone prior to BX (to prevent permanent visual loss)

What are some newer treatment options for headaches?

Antipsychotics (U of I uses Haldol/Benadryl in ER)