Exam 2 Pharmacotherapy Headache Dr. Brown (resident) Flashcards
Which headache type has a throbbing presentation?
Migraines
Which type of headache causes a stabbing and burning pain around the eye?
Cluster headace
Which type of headache causes a squeezing or tight sensation around the head?
Tension-type headache
(most common)
Comorbidities that may present with headache
-depression/anxiety
-epilepsy
-stroke
-TBI (traumatic brain injury)
-sleep apnea
-obesity, tobacco use
Modifiable risk factors
Stress
-depression
-dietray triggers
-hormone levels (due to menstrual cycle -> may be treated with OC preventing periods)
-poor sleep habits
Medication that can cause headache
Vasodilation causing drugs -> affecting cranial blood vessels -> causing headache
-PDE-5 inhibitor
-Nitrates
-hydralazine (peripheral vasodialtor)
When is migraine considered episodic?
1-14 days per month
> 15 or more days per month -> chronic
How is migraine with aura classified?
-1+ fully reversible aura symptoms lasting +4 minutes or 2+ symptoms occurring in sequence
-the symptoms should not last more than 60 minutes
-headache onset is within 60 minutes of aura
How is migraine without aura classified?
-<2 characteristics:
Pain: unilateral/pulsating
Intensity: moderate-severe
-<1 symptom:
N/V
Photo or Sonophobia
What are the prodrome symptoms that occur before the migraine?
increased parasympathetic tone
-> lacrimation (flow of tears), nasal congestion, rhinorrhea, irritability, food cravings, mood swings, sensory sensitivity
onset up to 3 days before migraine
Treatment for acute migraine
-Mild-moderate: analgesics (tylenol, ibuprofen) and supportive care
-Moderate-severe: CGRP receptor antagonists, triptans, ditans, ergotamine
When is it appropriate to treat migraine prophylacticly?
-no guidelines that direct that
-use it if the patient has significant disability despite acute therapy
-epidsodes >2 per week (risk for medication overuse headache)
-ineffective rescue therapies or intolerable ADEs
-risk of neurologic damage with uncommon migraine types
What are the recommended drug therapies for ACUTE migraine based on the guidelines?
A level evidence
-Triptans: all available options and doses
for milder migraines:
-APAP (Tylenol) 1000mg (max 4g/d and not longer than 15 days due to overuse)
-Aspirin 500-1000mg - not preferred bc Salicylate
-ibuprofen 200-400mg
naproxen 500mg, diclofenac 50-100mg
-Dihydroergotamine 2mg nasal spray or 1mg inhaler
-Butorphanol 1mg nasal spray
What are the recommended drug therapies for PREVENTION of EPISODIC migraine based on the guidelines?
A level evidence
-valproic acid 500-1000mg/d
-Topiramate 50-200mg/day
-Propranolol 80-160mg/day
-Metoprolol 200mg/day
-Frovatriptan 2.5mg once or twice daily (for menstrual migraine) -> has the slowest onset and longest half-life
-evaluate patient comorbidites and side effects of drug
Which migraine prevention drug may be used in a bipolar patient?
Valproic acid
Which migraine prevention drug may be used in a patient who suffers from seizures?
Topiramate
Which migraine prevention drug may be used in a patient with HTN or heart failure?
ß-blockers (propranolol)
Which migraine prevention drug may be used in a patient with menstrual migraine?
Frovatriptan
Naratriptan
Zolmitriptan (nasal spray for patients with N/V)
or oral contraceptives
How should Frovatriptan be taken?
once or twice daily for 6 days
start 2 days prior to the period
2.5 mg/day
max 7.5 mg/day
What type of migraines conflict with the use of oral contraceptives?
avoid combined oral contraceptives (COC) in patients with migraine with aura
-> absolute contraindication
What are the recommended drug therapies for PREVENTION of EPISODIC migraine based on the guidelines?
B level evidence
-Amitriptyline
-Venlafaxine XR 150mg daily
-Nadolol
-Naratriptan
-Zolmitriptan
Which durg might be used for migraine prevention in patients with depression?
Amitriptyline (TCA)
Venlafaxine (SSRI)
What is the preferred first line therapy based on the guidelines?
CGRP antagonists
-> but still not recognized by insurance
->patients might try triptans first
Which drugs may be used for predictable migraine episodes?
Prophylaxis: make sure the patient is eligible -> >2 episodes per week, ineffective rescue therapy or intolerable ADE
-Erenumab (Aimovig)
-Rimegepant (Nurtec)
-> both CGRP receptor antagonist
maybe Frovatriptan in menstrual cycle -> CAUTIOS with CV risk bc it causes some vasoconstriction
Which drugs can be used for pain syndrome (headache)?
-Ibuprofen
prophylactics
-TCA: Amitriptyline
-SSRI: Venlafaxine
Treatment for mild migraine
Tylenol
NSAIDs
Treatment for patients who are otherwise healthy
Lasmiditan
Triptans
How is Lasmiditan different from Triptans?
it only blocks Serotonin-1F receptors
-> blocks neuropeptide release on the presynaptic receptor
-but does not cause vasoconstriction of the arteriole on the meninges
Which migraine treatment should be avoided in HTN patients?
-Erenumab (contraindicated in recent CV events, it may worsen HTN)
-Triptans
-Venlafaxine (contraindicated in HTN if > 150 mg, note: > 150 mg is needed to get enough norepinephrine effect for pain control)
Which migraine treatment should be avoided in patients with long QTc syndrome?
-Triptans (since causing vasoconstriction, more 1B, 1D receptor agonists???)
-TCA (side effect of cardiac conduction delay)
Which migraine treatment should be avoided in patients with a history of CVD?
Triptans
Ibuprofen
Rimegepant (Nurtec) -> block CGRP on blood vessels -> vasoconstriction
dihydroergotamine
Which migraine treatment should be avoided in patients with CKD or AKI?
CGRP antagonits
with CrCl < 15: ESRD patients (end-stage renal disease)
Ubrogepant
Rimegepant (Nurtec)
with CrCl < 30:
Atogepant
Zavegepant
-Naratriptan (contraindicated in CrCl < 15)
-Ibuprofen
Which migraine treatment should be avoided in patients with Liver dysfunction?
CGRP antagonists:
Ubrogepant: dose adjust
Rimegepant (Nurtec) - Contraindicated
Triptans:
Sumatriptan
Naratriptan
Eletriptan
Serotonin agonist:
Lasmiditan
Ergot alkaloid:
Dihydroergotamine
Which migraine treatment should be avoided in patients with low body weight?
Topiramate
-> weight loss is a side effect
Which migraine treatment should be avoided to avoid DDI?
CGRP antagonists
Ubrogepant - CYP 3A4 inhibitor
Rimegepant (Nurtec) - CYP 3A4 inhibitor
Atogepant - CYP 3A4 inhibitor
Dihydroergotamine: strong CYP 3A4 inhibitor, space 2 weeks from MAOIs, space 24h from Triptans
Triptans: avoid within 24h with other serotonergic drugs
Butorphanol: check interaction checker
Amitriptyline, Venlafaxine, Topiramate: check interaction chekcer
Which migraine treatment should be avoided to drug interactions with pregnant/lactation?
Valproic Acid
Topiramate
Venlafaxine
Lasmiditan!!!
Ibuprofen after 20 weeks
Which migraine treatment should be avoided in patients with GI conditions?
-Ibuprofen -> risk for GI bleeds
-Erenumab (Aimovig) -> can cause severe constipation
-Atogepant (Qulipta) -> ADR for constipation
-Triptans are contraindicated in IBD (ischemic bowel disease)
Which drug has a BBW for being a strong CYP 3A4 inhibitor?
Dihydroergotamine
Classification Cluster Headache
multiple short, severe/very severe occurrences
lasting 15 minutes to 3 hours
location: unialteral -> orbital (cavity of the eye), suborbital, temporal
1+ symptoms
-eye irritation, pinpoint pupils, eyelid dropping, eyelid swelling
autonomic:
-lacrimation
-nasal congestion
-rhinorrhea
-face sweating
How are episodic cluster headaches classified?
daily for weeks to months -> long pain-free intervals of about 2 years
How are chronic cluster headaches classified?
recurrence (daily headache) for more than a year
or
remission (pain-free) for less than a month
What are the treatment options for cluster headaches?
Guidelines Level A
-Sumatriptan 6mg SQ
-Zolmitriptan 5mg or 10mg nasal spray
-High flow oxygen (100% at 6-12 L/min)
Level B:
-other formulations
-Sphenopalatine ganglion stimulation
What are the prophylactic treatment options for cluster headaches?
Level A
-Suboccipital steroid injection (single or series;
monotherapy or add-on
What are the PROPHYLAXIS treatment options for cluster headaches?
Level B and C
-Civamide 50mcg nasal drops daily (not available in the US)
Level C: Possibly effective
-Lithium 900mg daily !!
-Verapamil 360mg daily !!
-Warfarin to INR 1.5-1.9
-Melatonin 10mg nightly
CGRP receptor antagonist:
-Galcanezumab (Emgality®) 300mg SQ for 3 months
How is tension headache classified? Name the characterisitcs
10 more occurrences lasting 30 minutes to 7 days
-> pressing/thightening
-> bilateral, hatband
-> not aggravated by physical activity
When is tension headache considered episodic?
1 or more occurences per month
frequent episodic: 1-14 days per month
When is tension headache considered chronic?
15 or more days per month
What is thought to cause tension headaches?
Pathopyhsiology
Peripheral Mediation
-> muscle contraction of the head -> activation of peripheral nociceptors
Central Sensitization
-> persistent peripheral activation -> sensitization of trigeminal nerve
Acute Treatment for tension headache
-Trigger management
-APAP 1000 mg or NSAIDs
-Aspirin 500 mg
-Caffeine-containing combinations (Level B)
Prophylaxis for tension headache
-Amitriptyline 25-75mg/day (Level A)
-Venlafaxine >150mg/day (Level B)
-Mirtazapine 30mg/day (Level B)
Which drug is NOT recommended for acute treamtent of tension headache?
triptans
muscle relaxants
opioids
Which drug is NOT recommended for prophylaxis treamtent of tension headaches?
botulinum toxin
SSRI
When should prophylaxis treatment for tension headaches be reevaluated?
every 6-12 months
How is Status Migrainosus classified?
continuous headache phase lasting >72 hours despite treatment
headache free phase is less than 4h (not including sleep)
How is “frequent use” in Medication Overuse Headache classified?
average >3 days per week for 3 months
-simple analgesics: max of 15 days !!!
NSAIDs, Aspirin, APAP
-complex analgesics: max of 10 days !!!
opioids, ergotamines, triptans
How long should the washout period last to get rid of the acute treatment dose from the system?
about 2 months
->may stay on prophylactic treatmentv (CGRP), doesn’t seem to contribute to overuse headache
Status Migrainosus treatment
- IV fluids
- IV prochlorperazine or IV metoclopramide for nausea
- NSAID, Tylenol 1g
- SC sumatriptan (space 24h between ergots)
- magnesium sulfate
- consider DHE (ergot) or dexamethasone 4-16 mg IV
When to refer Status Migrainosus patients
-Change in frequency, severity, intensity or associated symptoms of headache
-Systemic symptoms (ie, fever, weight loss, rash, chills, night sweats, and jaw claudication)
-Secondary risk factors (ie, pregnancy, cancer, HIV/AIDS, and immune-compromised state)
-Seizures or neurologic symptoms/signs
-New headache or change in headache in someone over age 50
-Thunderclap headache
-Positional component
-Pulsatile tinnitus
-Precipitated headache, specifically by cough, exercise, sexual activity or sleep
Treatment for N/V
Nausea:
Ondanestron
Vomitting:
Metoclopramide IV
Prochlorperazine IM
Non-pharmalogical headache treatment
Riboflavin
Magnesium
CBT, relaxing technique
TENS treatment
Herbals
Smoking cessation
ADE for valproic acid
-liver toxicity
-pancreatitis
-weight gain
-sedation
