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53 > 5. Headache, Migraine > Flashcards

5. Headache, Migraine Flashcards

1
Q

ICHD-3 classification: primary vs secondary headaches

A

primary: TTH, migraine
secondary: (due to other sinister conditions) trauma to head/neck, infection, psychiatric disorders etc

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2
Q

Red flag for secondary headache (SNOOP10)

A
  • Systemic sx (eg fever
  • Neoplasm in hx (abnormal growth/ cancer)
  • Neurologic deficit
  • Onset of headache sudden/ abrupt
  • Old age (>50yo)
  • Pattern change or recent onset of headache
  • Positional headache
  • Precipitated by sneezing, coughing, exercising
  • Papilledema (swelling of optic nerve due to elevated intracranial pressure) - need equipment to check
  • Progressive headache with atypical presentation
  • Pregnancy
  • Painful eye with autonomic features (may suggest cluster headache)
  • Post-traumatic onset of headache
  • Pathology of immune system (eg HIV, immunocompromised)
  • Painkiller overused or new drug at onset of headache
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3
Q

characteristics of TTH
- pain location
- pain quality
- pain intensity
- effect on activities
- other sx
- duration

A
  • pain location: Bilateral
  • pain quality: pressing/tightening, nonpulsatile
  • pain intensity: mild to moderate
  • effect on activities not aggravated by routine daily activity
  • other sx: no prodrome sx/ aura, pericranial/ cervical (neck) muscle tenderness
  • duration: 30mins - 7d
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4
Q

characteristics of migraine
- pain location
- pain quality
- pain intensity
- effect on activities
- other sx
- duration

A
  • pain location: Unilateral/ bilateral
  • pain quality: pulsating/throbbing
  • pain intensity: moderate to severe
  • effect on activities: aggravated by/ cause avoidance of daily activity
  • other sx: N/V, sensitive to light/sight, aura
  • duration: 4-72hrs
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5
Q

characteristics of cluster headaches
- pain location
- pain quality
- pain intensity
- effect on activities
- other sx
- duration

A
  • pain location: Unilateral (around eye/ along face)
  • pain quality: variable
  • pain intensity: severe - very severe
  • effect on activities: restlessness on agitation
  • other sx: cranial autonomic sx
  • duration: 15-180mins
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6
Q

classification of TTSH

A
  • Infrequent episodic TTH = <1 episode per mth
  • Frequent episodic TTH = 1-14 days per mth
  • Chronic TTH = ≥15 days per mth
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7
Q

Identify modifiable lifestyle factors that may contribute to headache frequency and severity

A

TTH triggers: physical/emotional stress, straining/head held in a position for too long, alcohol, caffeine, cold/flu/ sinus infection, dehydration, hunger

  • identify triggers using a headache diary
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8
Q

Goal of tx of TTH

A

pain relief, prevent progression to chronic TTH

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9
Q

pharmacological agents for ACUTE TTH

A

paracetamol (+/- caffeine), aspirin, NSAIDs (ibuprofen, naproxen, diclofenac, ketoprofen)

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10
Q

pharmacological agents for PROPHYLATIC TTH

A

(for chronic TTH) amitriptyline (TCA - 1st line), mirtazapine, venlafaxine

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11
Q

Non-pharmacological tx for TTH

A

CBT (cognitive behaviour therapy), relaxation, physical and occupational therapy, lifestyle modification (sleep hygiene)

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12
Q

patho and sx of premonitory/prodrome phase

A
  • Patho: activation of hypothalamus and neuropeptides (contribute to sx in prodrome phase)
  • sx: fatigue, cognitive difficulties, mood changes, food cravings, neck pain, yawning
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13
Q

patho and sx of aura phase

A
  • Patho: cortical spreading depression
  • sx: visual aura, sensory/speech disturbances, motor symptoms
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14
Q

patho and sx of headache/ictal phase

A
  • Patho: neuropeptides implicated in the sensitisation of central and peripheral trigeminovascular system → creating state of hypersensitivity and contributing to both pain and non-pain sx
  • sx: headache, N+/-V, photophobia, phonophobia (fear of loud sounds)
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15
Q

patho and sx of postdrome phase

A
  • patho: unclear
  • sx: tired/weary, difficulty concentrating, neck stiffness
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16
Q

patho and sx of interictal phase

A

patho: some regions of the brain remain abnormally active after headache cessation

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17
Q

dx of migraine with or w/o aura

A

see notes

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18
Q

criteria for episodic migraine

A

≥5 migraine attacks lasting 4-72hrs

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19
Q

criteria for chronic migraine

A

> 3 months with ≥15 MHD of which ≥8 MMD

20
Q

management of migraine

A

identify triggers, headache diary, adopt healthy lifestyle (regular eating habits, good sleep hygiene, regular exercise)

21
Q

acute tx goals

A
  • rapid and consistent freedom from pain and bothersome sx
  • restore ability to function
  • minimal need for repeat dosing or rescue medications
  • optimal self care and reduce use of resources (eg A&E)
  • minimal or no adverse events
  • cost effective tx
22
Q

migraine specific drugs (established efficacy)

A
  1. Triptans
  2. Ergotamine derivatives
  3. Gepants (new agent)
  4. Lasmiditan (new agent)
23
Q

non migraine specific drugs (established efficacy)

A
  • NSAIDs: aspirin, celecoxib, diclofenac, ibuprofen, naproxen
  • Combination analgesic: acetaminophen + aspirin + caffeine
24
Q

migraine specific drugs (probably efficacy)

A

ergotamine, other forms of dihydroergotamine

25
non migraine specific drugs (probably efficacy)
NSAIDs (ketoprofen, ketorolac), IV magnesium, antiemetics (metoclopramide)
26
Principles of acute tx
- take acute tx as early as possible (more benefits) - stratified approach (more serious migraine use more potent meds like triptans) - avoid stepwise approach (start with mild agents) - antiemetics for pt with N/V sx (eg metoclopramide, domperidone) - choose appropriate formulations (NV take oral disintegrating tablets/parenteral)
27
MOA of triptan
selective agonist of 5HT 1B/1D receptors → vasoconstriction, inhibition of vasoactive peptides, inhibit nociception neurotransmission
28
SE of triptans
pressure on chest, nausea, distal paraesthesia (tingling/numbness), fatigue
29
CI of triptans
stroke/TIA, ischemic CAD, coronary artery vasospasm, uncontrolled HTN, peripheral vascular disease, GI ischemia
30
DDI of triptans
ergotamine/ergotamine containing within 24hrs, MAO-A inhibitors within 2 weeks
31
MOA of Ergotamines & Dihydroergotamine (DHE) - Cafergot
Ergotamine (main drug) - 5HT 1B/1D on intracranial vessels → vasoconstriction - inhibit norepinephrine uptake and partial agonist of alpha-adrenoceptors → prolonged vasoconstriction (risk of ischemic AE) Caffeine - adenosine receptor antagonist: vasoconstrict cerebral vasculature - enhance GI absorption of ergotamine by increasing solubility of ergotamines and decreasing gastric pH
32
SE of cafergot
N/V, cramps, insomnia, transient lower limb muscle pain
33
CI of cafergot
same as triptan (increase risk for vasospasm leading to cerebral ischemia and/or ischemia of extremities)
34
DDI of cafergot
triptans within 24hrs, CYP3A4 inhibitors (eg protease inhibitors - darunavir/atazanavir/ritonavir/fosamprenavir and macrolides)
35
CGRP mAbs and antagonist MOA
to block CGRP activity to treat migraine attacks
36
3 ways to block CGRP activity to treat migraine attacks
1. Gepants - CGRP receptor antagonist (bind to CGRP receptors) 2. Anti-CGRP antibodies - prevent CGRP interacting with receptor 3. Anti-CGRP receptor antibodies/ CGRP mAB (bind to CGRP receptors) - eg erenumab
37
SE and off target effect of CGRP blockade
constipation, nausea, Raynaud (decrease blood flow to fingers), hypertension, joint pain/ osteoporosis, nasopharyngitis
38
Criteria for initiation CGRP mAbs (erenumab)
- not as first line - must be prescribed by a licensed clinician - pt must be at least 18yo - failed other oral preventive meds (topiramate, valproate sodium, beta blocker, TCA - amitriptyline, SNRI - venlafaxine, duloxetine)
39
Criteria for continuing CGRP mAbs (erenumab)
reduction in mean MHDs of ≥50% compared to baseline (no CGRP mABs) - usually stopped in 1 year
40
medication overuse headache definition
meet all 3 criteria 1. Headache on ≥15 days per month in pt with a preexisting headache disorder 2. Regular overuse of acute and/or symptomatic headache drugs >3 months - ergotamine, opioids, triptans, combination of analgesics on ≥10 days/mth for >3 mths - simple analgesics (paracetamol, acetylsalicylic acid/aspirin, NSAIDs) ≥15 days/mth >3 mths 3. Headache cannot be better accounted for by another ICHD-3 diagnosis
41
when is prevention offered
based on degree of disability and MHD
42
Preventive tx goals
- reduce attack frequency, severity, duration and disability - improve responsiveness to and avoid use of acute tx - improve function and reduce disability - reduce reliance on ineffective acute tx - reduce overall cost - enable pt to manage their own disease (personal control) - improve QOL - reduce headache-related distress and psychological symptoms
43
medication effective for migraine prevention
Candesartan (ARB) Beta blockers (metoprolol, propanolol, timolol) Frovatriptan (for menstrual migraine prophylaxis) Topiramate Valproate sodium Erenumab (SC)
44
medication probably effective for migraine prevention
Amitriptyline Atenolol, Nadolol Lisinopril Memantine (rarely used) Venlafaxine
45
how to give an adequate trial of preventive tx
- oral tx: min 8 weeks at target therapeutic dose, cumulative benefits may occur over 6-12mths - injectable CGRP mAbs: - at least 3 mths for monthly administration - at least 6 mths for quarterly tx

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