Chapter 25: Headaches Flashcards
headache
Common symptom
Triggered by a variety of stimuli -Stress, fatigue, acute illness, and sensitivity to alcohol
Mild episodes -Relieved by over-the-counter drugs (e.g., aspirin, acetaminophen) -most will try OTC before coming to doc
severe headache
migraine, cluster, tensio
HA cause
Identifiable underlying causes
Severe hypertension, hyperthyroidism, tumor, infection, and disorders of the eye, nose, sinuses, and throat
No identifiable cause
Migraine
Cluster
2 ways HA drugs work
To abort an ongoing attack
Aspirin-like drugs, opioid analgesics, and migraine-specific drugs
To prevent attacks from occurring
Beta blockers, tricyclic antidepressants, and antiepileptic drugs
several can cause physical dependence
not all pt will response to same drug
migraine HA
Throbbing head pain of moderate to severe intensity
Nausea and vomiting
Sensitivity to light and sound
Highly debilitating
hormonal component and family hx is typical
36 mil in US have migraine
10% worldwide pop.
Females 43 % -65% of females will have first episode in late teens early 20s onset
Males 18%
60% say unilateral HA
40% have bilateral HA
2 forms of migrains
Migraine with aura
Preceded by visual symptoms (flash of light, zig zag pattern)
Only ~ 30% of pt
Migraine without aura is more common than with aura
Hyperalgesia –augmented response to painful stimuli
Can have pain response to normally inoculate stimuli
Most happen in the morning
Lkast bw 4-72 hr
Most have 1.5 attacks per month
Many Identify precipitating event
patho of migraine
Neurovascular disorder that involves the dilation and inflammation of intracranial blood vessels
Vasodilation leads to pain
Neurons of the trigeminal vascular system
Calcitonin gene–related peptide (CGRP) -Promotor of migraines
Serotonin (5-hydroxytryptamine [5-HT]) -Suppressor of migraines
factors than trigger migraine: emotions
Stress
Anticipation
Anxiety
Depression
Excitement
Frustration
factors that can trigger migraine HAL food
Tyramine (such as aged cheeses or Chianti wine)
Nitrates (such as cured meat products)
Phenylethylamine (such as chocolate)
Monosodium glutamate (such as Chinese food or canned soups)
Aspartame (such as diet sodas or artificial sweeteners)
Yellow food coloring
factors that can trigger migraine HA: drugs
Alcohol
Analgesics (excessive use or withdrawal)
Caffeine (excessive use or withdrawal)
Cimetidine (tagmet)
Cocaine
Estrogens (such as oral contraceptives)
Nitroglycerin
factors that can trigger migraine HA: weather
Low temperature and low humidity
High temperature and high humidity
Major weather change over 1 to 2 days
High or low barometric pressure
factors that can trigger migraine HA: other
Carbon monoxide
Hormonal changes
Flickering lights
Glare
Loud noises
Hypoglycemia
Change in altitude
migraine overview of tx
Aborting an ongoing attack:
Nonspecific analgesics: Aspirin-like drugs and opioid analgesics (e.g., butorphanol, meperidine)
Migraine-specific drugs: Serotonin1B/1D receptor agonists
Ergot alkaloids
Ubrogepant (ubervly) tx for acute migraine (not prevention) with or without aura in adults. Oral calcitonin gene related peptide receptor antagonist
Fda approved 2020
Preventing attacks from occurring
Serotonin1B/1D Receptor Agonists: Sumatriptan [Imitrex]
Mechanism of action:
Binds to receptors on intracranial blood vessels and causes vasoconstriction
Diminishes perivascular inflammation
Therapeutic use:
Aborting an ongoing migraine attack to relieve headache and associated symptoms
Pharmacokinetics:
Oral or intranasal administration
1st line for aborting HA
sumatripin ADR
Chest symptoms:
Transient “heavy arms” or “chest pressure” experienced by 50% of users
Coronary vasospasm:
Rare angina as a result of vasospasm
Teratogenesis
Others:
Vertigo, malaise, fatigue, and tingling sensations
Very bad taste when taken in intranasal form
pt to avoid sumatripin in
CVD, CAD, DM, HTN, smoker preg, pt
sumatripin: drug interactions and prep/admin
Drug interactions:
Ergot alkaloids, sumatriptan, and other triptans (all cause vasoconstriction)
Preparations, dosage, and administration
Oral -need higher dose dt low bioavailability
Nasal spray
SQ/IM dose can be lower than PO
2.5 hr half life
Other serotonin1B/1D receptor agonists
Naratriptan [Amerge]
Rizatriptan [Maxalt]
Zolmitriptan [Zomig]
Almotriptan [Axert]
Frovatriptan [Frova]
Eletriptan [Relpax]
Ergot alkaloids: ergotamine
Agonist activity at subtypes of serotonin receptors, specifically 5-HT1B and 5-HT1D receptors
Suppresses release of CGRP to block inflammation associated with the trigeminal vascular system
Second-line drug for stopping an ongoing migraine attack in patients who have not responded to a triptan
Risk for dependence
Don’t take daily or long term
Oral, SL, rectal
Half life of a couple hours
ADRs: N/T in digits, some N/V, some leg weakness
Ergot alkaloids: Ergotamine toxicity
ergotism
contraindications for ergotamine
Liver and renal impairment
CAD, PVD, HTN
Pregnancy (contractions)
People taking medications that inhibit CYP3A4 –increase drug to dangerous levels. See vasospasms, cerebral ischemia, peripheral ischemia
qualifies for preventative migraine therapy
Greater than 3 attacks a month that are very severe and/or don’t respond to abortive medications
preventative migraine therapy: beta blockers
Propranolol -preferred, timolol, atenolol, metoprolol, and nadolol
Reduce number and intensity in 70% of people
Takes a few weeks to see benefits
preventive migraine therapy: antiepileptic drugs
Divalproex [Depakote ER] -preferred, topiramate [Topamax], gabapentin [Neurontin], and tiagabine [Gabitril]
Decrease in number of migraines by 50% in 30-50% of people
preventative migraine therapy: TCA
Amitriptyline [Elavil]
Good for migraines and tension HA
See hypotension and anticholinergic SE
preventative migraine therapy: Estrogens and triptans for menstrually associated migraine
Estrogen gel and patches (e.g., Climara, Estraderm), frovatriptan, naratriptan, zolmitriptan, and naproxen sodium (550 mg 2/day for 6 -7 days) after menses is effective
Menstual asso
patches and gels
migraine HA preventive therapy: less effective agents
Calcium channel blockers: Verapamil and nimodipine
Botulinum toxin A
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers
Supplements: Riboflavin (vitamin B2) and coenzyme Q-10
Butterbur
cluster HA characteristics
Occur in a series or “cluster” of attacks
Each attack lasts 15 minutes to 2 hours
Severe, throbbing, unilateral pain near the eye
Lacrimation, conjunctival redness, nasal congestion, rhinorrhea, ptosis, and miosis on the same side of the headache
One or two attacks every day for 2 to 3 months
An attack-free interval of months to years separates clusters
No aura, no N/V
More debilitating, less common, no associating with family history
See more often in males –for every 1 female see 5 males
tx of cluster HA
Primary therapy directed at prophylaxis
Glucocorticoids (prednisone and dexamethasone) can do sub occipital injection of dex
Verapamil -1st line
Lithium -Require monitoring bc target level 0.4-0.8
O2 -7-10L/min for 15-20 min
can abort with sumptripin 6mg sq
tension-type HA characteristics
Most common form of headache
Moderate, nonthrobbing pain
Usually located in a “headband” distribution
May be episodic or chronic
tx of tension HA
Nonopioid analgesics: Acetaminophen
Nonsteroidal antiinflammatory drugs: Aspirin, ibuprofen, and naproxen
Analgesic-sedative combination: Aspirin and butalbital
Patient teaching about how to manage stress
medication overuse HA
Chronic headache that develops in response to frequent use of headache medicines
Resolved by withdrawing use of overused medicine
Almost all medicines used for abortive headache therapy can cause medication overuse headache
Risk of medication overuse headache can be decreased by limiting the use of abortive medicines and implementing nondrug measures
dont use HA meds for more than 2-3 wk
