HA Flashcards
What is a med overuse headache
Frequent or excess use of migraine medication causing a syndrome of self-sustaining HA-Medication cycle
How do you recognize a med overuse headache
gradual onset of an atypical daily or near daily headache with superimposed episodic migraine attacks
What meds are said to cause med overuse headaches more frequently
Simple and combo analgesics and opiates
Triptans (in men w/ high frequency of HA)
How often should you use Triptans
Max of 9 times per month!
What is a migraine headache
Recurring throbbing head pain
Unilateral
Lasts 4-72 hours
Associated N/V, photophobia, phonophobia, and sensitivity to movement
The pathogenesis of migraine headaches is related to
complex dysfunctions in neuronal and broad sensory processing
Pain and Sx are 2/2 neural suppression, and activation of subcortical structures
Migraine pain is 2/2
Activity within the trigeminovascular system (afferent fibers arising from trigeminal ganglia and projecting peripherally to innervate IC extracerebral blood vessels, dura, and large venous sinuses
What is the pathophys of a migraine
- Afferent fibers of trigeminal ganglia project centrally and terminate in the brain stem and upper cervical spinal cord
- Activating trigeminal sensory nerves= release of vasoactive neuropeptides (CGRP, neurokinin A, substance P)
- Neuropeptides interact with dural blood vessels= vasodilation and dural plasma extravasation= Neurogenic inflammation
Continues afferent input can result in
sensitization of these central sensory neurons= hyperalgesic state that responds to previously innocuous stimuli and maintains HA
What is 5-HT
a mediator of migraine HA, involved in the pathophys and Tx of migraine HA
Long story short pathophys of migraines
Vasodilation of extra-cerebral vessels= activation of perivascular trigeminal nerves= vasoactive neuropeptide release= neurogenic inflammation
Central pain transmission activates other brain stem nuclei= associated Sx
Goals of migraine Tx include
Long term: Reduce migraine frequency, severity, and disability
Acute: Treat rapidly, restore functional ability
Analgesics that can be used to Tx migraines are
Tylenol Excedrin migraine (APAP250/ASA250/caffeine65)
NSAIDs that can be used for migraine are
ASA
Ibuprofen
Naproxen sodium
Diclofenac
Serotonin Agonists that can be used to Tx migraines are
Triptans!
Sumatriptan: inject, PO, nasal spray
Zolmitriptan: PO, nasal spray
Adjunct: Metoclopramide (reglan), Prochlorperazine (compazine)
Other acute migraine meds include
Ergotamine Tartrate: oral w/ caffeine, sublingual, rectal suppository w/ caffeine
Dihydroergotamine: injection, nasal spray
(Ergo has more potent arterial effects)
What is Ergotamine/Dihydroergotamine
Non-selective 5-HT1 receptor AGONIST;
Constricts IC blood vessels and inhibits development of neurogenic inflammation in trigeminovascular system
Dopaminergic receptor agonist
How do Triptans work
Selective 5-HT1b/1d receptor AGONISTS
- Enhance IC vasoconstriction
- Inhibit vasoactive peptide release from trigeminal neurons
- Inhibit transmission through second order neurons ascending to thalamus
How do you dose Sumatriptan
Injection: 6mg subQ at onset. repeat after 1 hour if needed. MAX 12mg
PO: 25-100mg at onset, repeat after 2 hours if needed. MAX 200mg
Nasal: 5-20mg at onset, repeat after 2 hours if needed. MAX 40mg
How do you dose Zolmitriptan
oral tab: 2.5-5mg, repeat after 2 hr if needed. MAX 10mg
*Do NOT divide ODT
Nasal: one 5mg spray at onset, repeat in 2 hr if needed. MAX 10mg
How do you dose the other Triptans
Naratriptan: 1-2.5mg, repeat in 4 hr. MAX 5mg
Rizatriptan (ODT): 5-10mg, repeat in 2 hr. MAX 30mg
Almotriptan: 6.25-12.5, repeat in 2 hr. MAX 25mg
Frovatriptan: 2.5-5mg, repeat in 2hr. MAX 7.5mg
Eletriptan: 20-40mg, repeat in 2hr. MAX 80mg
With ergotamine administration, consider
pre-treatment with antiemetic when dosing oral tablet or rectal suppository
What do you need to remember about Dihydroergotamine nasal spray
You start with ONE spray in each nostril, can repeat after 15 min. max dose is four sprays total
Discard open ampules after 8 hours of being opened
Prime sprayer 4 times before using
Do not tilt head back, just put up nose and inhale
What is “Triptan Sensation”*
Tightness, Pressure, Heaviness, or Pain in chest, neck or throat
Usually at the nipple level and above
Applications and ADE of Sumatriptan are
Good for Migraine and Cluster HA
ADE: paresthesias, dizziness, chest pain, coronary vasospasm, serotonin syndrome
What is Serotonin syndrome
Hyperthermia, hyperreflexia, tremors, clonus, HTN, diarrhea, mydriasis, agitation, coma
Onset w/in hours of taking meds like SSRI, second gen antidepressants, tramadol, fentanyl, zofran, sumatriptan, MDMA, St. John’s wort, and ginseng
How od you treat serotonin syndrome
Sedation w/ benzos Paralysis intubation ventilation -Consider 5-HT2 block with cyproheptadine or chlorpromazine
What is Neuroleptic malignant syndrome
Hyperthermia and acute severe parkinsoniam 2/2 taking D2 blocking antipsychotics and Sumatriptan
How do you treat neuroleptic malignant syndrome
Diphenhydramine (parenteral)
Cooling
Sedation with benzos
What is malignant hyperthermia
hyperthermia, muscle rigidity, HTN, tachycardia 2.2 taking volatile anesthetics, Succinylcholine, and sumatriptan
How do you treat malignant hyperthermia
Dantrolene
cooling
When should you consider preventive migraine therapy
In the setting of recurrign migraines that produce significant disability despite acute therapy
Frequent attacks (>2x wk)
Sx therapies ineffective or CI, or w/ serious ADE
FDA approved migraine preventive meds are
Propranolol Timolol Divalproex sodium Topiramate *Need 2-3 months of therapy to assess efficacy! Noticeable in 1 month, best judgement after 6 months*
Prophylactic Tx should be continued at least
6-12 months after frequency and severity of HA have diminished
Then gradually taper or d/c prophylaxis
What are Erenumab, Fremanezumab, and Galcanezumab
CGRP MABs under review by FDA for use in migraine prevention by stopping CGRP’s vasodilatory and nociception effects
Log half lives mean you can take them once a month subQ
Ibuprofen can be used to prevent
Menstrual migraine onset!
Daily prolonged use can lead to med overuse HA and has potential toxicity
When should Frovitriptan be taken
in the perimenstrual period to prevent menstrual migraine
Riboflavin is beneficial only
after 3 months of use
Withdrawal of MIG99 is associated with
increased HA
Magnesium is more helpful in
migraine with aura and menstrual migraine
To be prophylactic, Frova Nara and Zolmitriptan should be taken
1-2 days before expected onset of HA and continued during the period of vulnerability
What is the MC and least studied primary HA
Tension headache
1 year prevalence is rising 31 to 86%
Pain in a tension headache is thought to arise from
myofascial factors and peripheral sensitization of nociceptors
Heightened sensitivity of pain pathways in the CNS
CBT treatment options for tension headaches are
Stress management
Relaxation training
Biofeedback
These treatment options offer inconsistent results, but are ok to use to treat tension HA
heat or cold pack US electrical nerve stimulation stretching, exercise massage acupuncture manipulations ergonomic instruction trigger point injection occipital nerve block
What are the recommended Tension HA meds
Acetaminophen (alone or with caffeine)
Acute mild-mod: NSAIDs (ASA, Diclofenac, Ibu, Naprozen, Ketoprofen, Ketorolac
High dose NSAID
(ASA or APAP) + (Butalbital or codeine)
How long can you take acute medications for tension HA
Butalbital: no more than 3 days
Combo analgesics: no more than 9 days
NSAIDs: no more than 15 days
There is no evidence to support these meds in treating tension HA
Skeletal muscle relaxers
Preventive therapy for Tension HA is
TCA
SSRI IF also with depression
Chronic tension: Topiramate and Gabapentin
-Botox injection into pericranial muscles NOT recommended
-Limited studies on SNRI’s (Mirtazapine, Venlafaxine)
What is the most severe primary HA disorder
Cluster HA
Excruciating, unilateral head pain occurs in a series lasting weeks-months (cluster periods), separated by remission periods lasting months-years
What is generally the modulator of cluster headaches
The hypothalamus (ipsilateral grey area is activated) Hypothalamus then activates trigeminal autonomic reflexes= ipsilateral pain and cranial autonomic features
What is a hallmark of cluster HA
Circadian rhythm of painful attacks
MC episodic cluster HA (occur for 2 weeks-months, then LONG pain free period)
Cluster HA is often accompanied by
Cranial autonomic Sx:
conjunctival injection, lacrimation, nasal stuffiness, rhinorrhea, eyelid edema, facial swelling, miosis or pitosis
(resolve with resolution of HA)
Difference between migraine and cluster patients
Migraine retreat to a dark room
Cluster sit and rock or pace around the room clutching their head
Abortive therapy for a cluster HA is
Oxygen! standard acute Tx is 12L 100% O2 for 15-30 min using nonbreather facial mask
- Triptans injections (or sprays) > orals (except Zolmitriptan)
- IV dihydroergotamine or Ergotamine tartrate
Prophylactic therapy for cluster headaches is
Verapamil* (takes 2-3 weeks)
Lithium (can cause lethary, nausea, diarrhea, abd discomfort)
Corticosteroids (Prednisone 5 days, then taper)
Misc: Intranasal lidocaine, hyperbaric oxygen, subQ octreotide
