4 - Headache Flashcards
Which type of headaches are described as “pulsating,” and aggravated by physical activity?
MIgraine
Which type of headache presents bilaterally, described as “pressure” or “tightening”, and no nausea?
Tension
Which headache is predominantly found in males, described as severe “boring” or “piercing” pain, and occurs exclusively unilaterally?
Cluster
“SNOOP”ing for secondary headaches:
Systemic symptoms Neurologic s/s Onset sudden Onset late in life Pattern change
“Worst headache of my life” - must r/o:
Subarachnoid hemorrhage
The majority of migraines are with or without aura?
Without (85%)
Criteria for migraine without aura:
At least 5 attacks
Lasts 4-72 hrs untreated
Unilateral
Pulsating
N or V or both
Photophobia
Phonophobia
Criteria for migraine headache WITH aura
At least 2 attacks
Aura symptom (visual, sensory, speech, motor, retinal)
Aura lasts 5 to 60 mins
What gene mutation are migraines associated with?
CACNL1A4 on chromosome 19
What neurotransmitter is an important mediator of migraines?
Serotonin (5-HT)
APAP - use in migraines?
May be useful 1st choice drug for acute migraine in those with mild to moderate attacks OR in those with CI’s to NSAIDS / ASA
Butalbital - class?
Short acting barbiturate
In which combination is Butalbital a scheduled drug?
When combined with ASA and caffeine
Midrin - composed of?
APAP
Isometheptene
Dichloralphenazone
Midrin - clinical use?
Alternative choice for mild to moderate migraine attacks
Controlled (C-IV)
Midrin - CI’s?
Glaucoma
Severe renal or hepatic disease
HTN
MOAI’s
What OTC is a reasonable first-line tx for migraine attacks?
Excedrin MIgraine (APAP/ASA/caffeine)
NSAID’s - MOA (migraines)
Prevents neurogenically mediated inflammation in the trigeminovascular system
What is considered the DOC for mild to moderate migraine attacks?
NSAID’s
Which three NSAID’s have the most consistent evidence in the tx of migraine attacks?
ASA
Vit-M
Naproxen
Ergotamine - MOA:
Partial agonist activity at 5HT and D2 alpha-adrenergic receptors
Peripheral and cranial vasoconstriction
Ergotamine - pharmacokinetics:
Oral absorption is incomplete and erratic - administer with caffeine
Ergotamine - AE’s:
Ergotism - intense vasoconstriction -> ischemia
Ergotamine - pregnancy cat?
X - stimulates uterus
Ergotamine - drug interactions:
Don’t use within 24 hrs of a triptan
Potent CYP3A4 inhibitors
When to give Ergotamine?
At the first sign of a migraine attack
Dihydroergotamine - MOA:
Similar to ergotamine but with LESS POTENT A1-adrenergic vasoconstriction
Less n/v
Dihydroergotamine - clinical considerations:
Not for use as a monotherapy
Try when first-lines have failed
Add anti-emetic as nause/vomiting likely SE
Triptans - MOA:
5-HT1B/1D receptor agonist with add’l activity at 5-HT1F receptors
Cranial vasoconstriction, peripheral neuronal inhibition, inhibition of trigeminocervical complex
Triptans - clinical use:
Appropriate 1st line therapy for moderate to severe migraine
Triptans - AE’s:
Chest tightness, pressure, heaviness, or pain
Paresthesia, dizziness, somnolence
Limit use of triptans to no more than __ days per month
9
Triptans - CI’s:
Hx of ischemic heart disease, uncontrolled HTN, stroke
Triptans - monitoring:
Pt’s at risk for CAD should have first dose of triptan in the clinic with vitals and ECG monitoring
What is the clinic triad of symptoms of serotonin syndrome?
- Cognitive effects
- Neuromuscular dysfunction
- Autonomic dysfunction
Sumatriptan/Naproxen (Treximet) - MOA and clinical use:
Targets different vascular and inflammatory processes in a migraine
Combination provides superior relief than either component by itself
What partial Mu and Kappa agonist can be used off-label as a last resort for migraine tx?
Butorphanol (Stadol)
How do antiemetics help with migraines (neuronally):
They act on dopaminergic receptors (antagonist)
What is the antiemetic of choice for migraines?
Metoclopramide
Strategy to avoid MOH?
Limit migraine therapies to 2 days/week
What migraine med is totally contraindicated for pregnancy and breastfeeding?
Ergots
Proposed etiology of tension headaches?
Originate from myofascial factors and peripheral sensitization of nociceptors
Clinical presentation of tension headache - what makes it different from migraine headaches?
Lacks premonitory symptoms and aura
Bilateral, non-pulsatile pressure
Disability minor compared to migraine
Acute tx of tension HA’s:
APAP/NSAIDS
Muscle relaxants
Consider prophylaxis if tension headache frequency is more than __ per week
2
What is the tension HA prophylaxis DOC?
Amitriptyline at bedtime
What is the most severe of the primary HA’s?
Cluster
Typical pt for cluster HA’s:
Male, mid-thirties
When do most cluster attacks occur?
At night, in the spring and fall, occurring suddenly, with a rapid crescendo to excruciating pain
In order to Dx cluster HA, what must be present?
Ipsilateral symptom (lacrimation, rhinorrhea, eyelid edema, ptosis, etc)
What is a standard first line tx for cluster HA’s?
100% O2 via NRB @ 7-10L/min x 15-25mins
What Ha medicine is considered first line (after oxygen) for cluster HA’s?
Sumatriptan
What is the drug of choice for maintenance prophylaxis of cluster HA’s?
Verapamil (Calan)
What is 2nd line prophylaxis for cluster HA’s?
Lithium
What is DOC for transitional prophylaxis of cluster HA’s?
Prednisone
