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Pharmacy > 301 Headache & Migraine > Flashcards

301 Headache & Migraine Flashcards

1
Q

What are the types of headache?
Non-migraine
Migraine

A
  1. Acute muscle contraction (tension), ‘ice-cream/ice-pick’, chronic daily, cluster, sinister
  2. Classical (with aura), common (without), children, associated with childhood travel sickness
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2
Q

What classes of drugs are common causes of headaches?

A
  1. Hormone meds (birth control, HRT)
  2. Erectile meds
  3. Caffeine (because of caffeine withdrawal)
  4. Heart & BP meds.
  5. Vitamins
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3
Q

What is a tension headache?

A

Most common cause of headache
Due to muscle spasm in neck/scalp
Caused by emotional stress (tension, anxiety, fatigue)
Pain is mild/moderate, non-throbbing, vice-like, tightness/squeezing/weight pressing on head
Usually both sides of head
Worsen through day, worse by stress

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4
Q

How does a migraine differ from a tension headache?

A

M: moderate/severe pain, unilateral, pulsating, aggravated by normal activity that patient has to stop
T: mild/moderate, bilateral, non-pulsating, not aggravated by normal activity

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5
Q

Management of a tension headache:
Pharmacological
Non-pharmacological

A
  1. OTC analgesic
  2. Relaxation, massage, hot bath
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6
Q

What headaches to we need to refer?

A
  1. “Ice cream”
  2. Chronic daily
  3. Cluster
  4. Sinister
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7
Q

“Ice cream” headache:
Pain
Duration
Trigger

A
  1. Severe, short & piercing, like “flash of lightening”, centred in one eye
  2. Seconds to minutes
  3. Eating cold food/drinks
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8
Q

Chronic daily headache:
Pain
Duration
Trigger

A
  1. Neck stiffness, migraine-type symptoms, vary by patient
  2. 4+ hours or >15 days a month
  3. Analgesic dependence
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9
Q

Cluster headache:
Pain
Duration

A
  1. Rare but 6-9x more common in men, unilateral excruciating pain, red eye, lacrimation, nasal congestion, rhinorrhoea, face swelling, miosis, droopy eye lid and oedema (mistaken for eye injury)
  2. Sudden - wake patient from sleep, intermittent - 8x a day, typically occurs same time daily, last 10 mins to 3 hrs
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10
Q

Cluster headache:
Management

A
  • Rarely responds to analgesics
  • Requires prophylactic treatment if attacks frequent or >3 weeks
  • 100% O2 at 7-12L/min rate may abort attack
  • Sumatriptan S/C
  • High dose verapamil
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11
Q

What can sinister headaches indicate?

A

Meningitis, subarachnoid haemorrhage, temporal arteritis, trigeminal neuralgia, depression, glaucoma, raised intracranial pressure

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12
Q

Trigger points for referral in headaches

A
  • Unresponsive to analgesics
  • Children U12, with stiff neck or skin rash
  • Occurs after recent (1-3 month) trauma or injury
  • Lasted >2 weeks
  • Accompanied by N + V but no other classical migraine symptoms
  • Accompanied by neurological symptoms such as consciousness change
  • New/severe in patient 50+
  • Worsening symptoms
  • Cluster symptoms
  • Sudden/severe onset
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13
Q

Rash with headache

A

Tiny, red spots, do not go white when pressed
Urgent medical attention required
Death can occur within 2 hours of symptom onset

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14
Q

Warning symptoms of headaches:
Onset/severity
Frequency & duration
Accompanying symptoms
Pattern
Pain location

A
  1. Sudden, disabling, appears ill, meningococcal meningitis - child complain of cold hands, severe leg pain & pale skin
  2. Unremitting, worsening
  3. Loss of consciousness, rash, neck stiffness, altered vision
  4. Worsens on awakening
  5. Temporal location, above or lateral to eye
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15
Q

What is a migraine? And what are the symptoms?

A
  1. Episodic, patient well between attacks
  2. Prodrome, aura, headache & postdrome, headache, lateralised & pulsating, associated with N + V, phono/photophobia, trigger factors
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16
Q

Pathogenesis of migraine: prodromal phase

A

Activation of intracranial centre (hypothalamus, thalamus)
Explains irritability, food craving, mood swings, fatigue, stiff neck & phonophobia symptoms

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17
Q

Pathogenesis of migraine: aura phase

A

Cortical spreading depression

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18
Q

Pathogenesis of migraine: headache phase

A

Activation of trigemini-vascular system
Release of inflammatory markers: CGRP, substance P, VIP etc.

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19
Q

Pathogenesis of migraine: postdrome phase

A

Least studied phase could be result of continuation of brainstem activation

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20
Q

Associated genes with migraines:
Familial hemiplegic migraine
Migraine aura
Migraine chronification
Medication overuse headache

A
  1. CACNA1A, ATP1A2, SCN1A & PRRT2
  2. TRESK
  3. CALCA, RAMP1, NPTX2 & SH2D5
  4. COMT, GIT2, ZNF234 & SOCS1
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21
Q

Risk factors of migraines

A
  • Trigger factors (keep diary)
  • Foods (alcohol, caffeine, chocolate, diary products)
  • Hormonal changes
  • HRT, contraceptive pill, pregnancy
  • Environmental
  • Emotion, weather
  • After stressful period
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22
Q

Migraine triggers: physiological & biochemical factors

A
  1. Deviated enzyme level
  2. Conc. of heavy metal level nitric oxide
  3. Mitochondrial enzyme dysfunction
  4. Disrupted neural networks in head
  5. Changes in ovarian hormone secretion
  6. Increased oxidative stress
  7. Metabolic derangements
  8. Monosodium glutamate
  9. Free iron deposition
  10. High insulin level
  11. Oestrogen level
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23
Q

Migraine triggers: genetics

A
  1. Polyglutamine repeats
  2. Frameshift variation
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24
Q

Migraine triggers:
Daily life patterns

A
  1. Weather changes
  2. Fasting and exhaustion
  3. Changes in sleep pattern
  4. Emotional stress
25
Q

Migraine triggers:
food

A
  1. Chocolate
  2. Citrus fruits
  3. Fatty and fried food
  4. Sucralose, gluten
  5. Food colourings
  6. Tea, coffee
  7. Beverages containing caffeine
  8. Alcohol
  9. Diary products
26
Q

Phases of migraines: prodrome (premonitory)

A

Heighten sensations, foreboding

27
Q

Phases of migraines: aura

A

Fortification spectra, flashing lights, scotoma or paraesthesiae
Less common: speech difficulties

28
Q

Phases of migraines: headache

A

Unilateral pulsatile, photophobia & phonophobia, N + V

29
Q

Phases of migraines: postdrome

A

Headache - resolution, washed out

30
Q

Symptoms of migraine: AUSTIN

A

Aggravated by activity
Unilateral location
Sensitivity to light & sound
Throbbing in nature
Intensity, moderate/severe
N + V present

31
Q

Diagnosis of migraines (International Headache Society - IHS)

A

Repeated attacks of headaches lasting 4-72 hrs which have
2 of: unilateral pain, throbbing pain, aggravated by movement, moderate/severe intensity
1 of: N + V, phono/photophobia

32
Q

Migraines differential diagnosis:
When to refer to GP
Central cause
Children
ADRs

A
  1. Headache 24+ hrs, eases as day progresses
  2. Effortless vomiting in morning, unsteadiness/clumsiness
  3. Children U12
  4. Suspected ADRs
33
Q

Migraine management

A

Concordance paramount
Eliminate triggers
Acute intervention
Break-through attacks
Prophylaxis (high frequency >4 attacks/month)

34
Q

How to manage migraine trigger factors:
Anxiety/emotion
Change of habits
Specific foods
Bright lights & noise
Strenuous exercise

A
  1. Relaxation/coping, yoga/meditation
  2. Revert to usual habits (is change true trigger?)
  3. Exclude for weeks trial (consult dietician)
  4. Avoid
  5. Avoid (physical exercise of benefit)
35
Q

Current medicines for migraine treatment

A
  1. Meds to control pain
  2. Meds to abort/treat acute attack
  3. Products reducing N + V
  4. Meds reduce frequency of attacks
36
Q

NICE guidance on:
Preventing migraines

A
  1. Galcanezumab (Inj)
  2. Fremanezumab (Inj)
  3. Erenumab (Inj)
  4. Rimegepant (Oral)
37
Q

Migraine treatment: acute 1st line

A
  1. Offer simple analgesics
  2. Offer oral sumatriptan alone/with NSAID or paracetamol (if V restricts oral, consider zolmitriptan nasal spray or SC sumatriptan)
  3. Ibuprofen suitable NSAID, tolfenamic acid, naproxen & diclofenac
  4. If V restricts, consider non-oral NSAID, diclofenac suppositories (off-label)
38
Q

Migraine treatment: acute monotherapy

A

If monotherapy preferred, offer oral triptan or NSAID, or aspirin (900mg every 4-6 hrs when necessary up to max. of 4g daily), or paracetamol

39
Q

Migraine treatment: acute anti-emetic

A
  • Consider anti-emetic (metoclopramide, domperidone or prochlorperazine) even in N + V absence
  • Metoclopramide: not recommended >5 days
  • Domperidone: not recommended >7 days (max. 10mg TDS) or <35kg weight
40
Q

Migraine treatment: acute - triptans (POM) & P
C/I
Side effects

A
  1. 5HT1 agonists (specifically 1B & 1D)
    Constrict blood vessels back to normal
  2. IHD, uncontrolled high BP + 65+
  3. Tiredness & dizziness (common), heaviness on chest + throat
41
Q

Examples of triptans

A
  1. Sumatriptan
  2. Almotriptan
  3. Eletriptan
  4. Frovatriptan
  5. Naratriptan
  6. Rizatriptan
  7. Zolmitriptan
42
Q

OTC sumatriptan 50mg tablets

A
  • Indicated 18-65 year olds
  • Established pattern of migraine
  • New migraines since 50 yrs: refer
  • Wait 2 hours before 2nd dose
43
Q

Migraines: acute - ergotamine

A

DO NOT USE
- 5HT1 partial agonist
- a-adrenoceptor, vasoconstrictor, trigeminal nerve
- Superseded by triptans
- Acute SEs: N + V, abdominal pains, leg cramps
- Overuse: ergotism
- Form of chronic daily headache
- Gangrene?

44
Q

Medication overuse in headaches

A
  • Taking meds too often for tension-type headaches/migraines
  • 1 in 50 affected
  • Pain oppressive, worse in morning
  • Treat: stop current therapy, pain gets worse before better
  • Patients at risk: using analgesics/triptans >15 days/month, refer requests for N4 Imigran/month
45
Q

Preventing medication overuse headaches

A

Painkillers
- <15 days/month
- 3-4 doses over 1-2 days is OK
- Do not take consecutively for >2 days
- Avoid codeine containing products
Already used meds quota
- Cold turkey
- Speak to GP

46
Q

Guide to migraine prophylaxis: 2 or 3 triptans tried unsuccessfully

A
  1. Start lowest dose
  2. Titrate up slowly
    - Risk v benefit
  3. Give adequate trial
  4. Stable
    - Avoid interfering meds
  5. Period of stability
    - Taper or discontinue therapy
47
Q

Migraine prophylaxis treatment options:
1st line

A

Topiramate
- Risk of foetal malformations & impair effectiveness of hormonal contraceptives
Propranolol
- Suitable for coexisting hypertension or anxiety, not suitable in asthma, COPD, peripheral vascular disease or uncontrolled HF

48
Q

Migraine treatment: other prophylactic agents
Antidepressants
Anticonvulsants
OTC
Acupuncture

A
  • Most discovered by chance
    1. TCA (amitriptyline)
    2. Valproate - prolonged/atypical migraine aura (no headache), not good for young women
    3. Feverfew
49
Q

Botox (Botulinum Toxin Type A)

A
  • Non systemic meds is appealing
  • Mechanism unknown
  • Relaxes muscles - blocks pain feedback
  • Repeated injections to head & neck
50
Q

Migraines: monoclonal antibodies (Inj)
Galcanezumab, fremanezumab, erenumab

A
  • All recommended as option for preventing migraine in adults only if:
    They have 4+ migraine days/month
    At least 3 preventative drug treatments have failed and company provides according to commercial arrangement
51
Q

OTC sumatriptan:
supply criteria

A
  • Migraine must be diagnosed by doctor/pharmacist
  • Establish pattern of migraine (5+ migraine attacks over a year)
  • Simple analgesics tried & ineffective
52
Q

OTC sumatriptan: precautions for use

A
  • Concomitant use
  • SSRI/SNRI
  • St. John’s Wort
  • CoC
  • Heart disease risk factors (C/I in patients with 3+ risk factors (diabetes, high cholesterol levels, smoking/NRT use))
53
Q

OTC sumatriptan: counselling points

A
  • Dose: 1 50mg tab taken ASAP after migraine started
  • Swallow whole with water
  • Single dose should relieve symptoms after 30 mins if symptoms not improved, no further doses taken for same migraine attack
  • If 2nd migraine within 24 hrs, second dose may be taken
  • Drowsiness may affect performance of skilled tasks (driving)
  • Migraine diary may identify personal triggers
54
Q

Sumatriptan: not to be used for

A
  • Prevention of migraine
  • Hemiplegic migraine
  • Basilar migraine
  • Ophthalmoplegic migraine
55
Q

Sumatriptan C/I: hypersensitivity to

A
  • Sulfonamides
  • Sumatriptan
  • Any excipients in preparation
56
Q

Sumatriptan C/I: history of

A
  • Seizures
  • MI
  • CVA/stroke
  • Transient ischaemic attack (TIA/mini-stroke)
  • CoC (if migraine recently started/symptoms got worse)
  • Concomitant St. John’s Wort use
57
Q

Sumatriptan C/I: other contraindications

A
  • Hepatic/renal impairment
  • Prophylactic use of sumatriptan
  • Ischaemic heart disease
  • Coronary vasospasm
  • Cardiac arrythmia
  • Peripheral vascular disease
  • Hypertension
58
Q

Sumatriptan C/I: interactions

A
  • Ergotamine (& derivatives e.g. ethysergide)
  • MAOIs
  • 5HT1 receptor agonists (triptans)
  • TCAs
  • SSRIs/SNRIs
59
Q

Sumatriptan C/I: patient characteristics

A
  • Risk of heart disease.3+ CV risk factors
  • U18s or 65+
  • Pregnancy/breastfeeding

Pharmacy (23 decks)

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