HA

Question 1

HA

Answer 1

<2% office and <4% ER visits have serious pathology

Question 2

classifications of HA’s

Answer 2

primary (not caused by secondary pathology ; includes migraines, tension and cluster)
secondary (caused by secondary pathology ; includes HTN, infn, tumors, etc)

Question 3

red flags of secondary HA’s

Answer 3

change or progression of pattern
first/worst HA 
abrupt awaking from sleep
abnormal neuro findings
neuro symptoms > 1 hr
new HA in pt's < 5 or > 50
HA triggered by exertion, sex or Valsalva

Question 4

tension HA

Answer 4

mild-mod dull ache
lacks: signs of serious underlying condition, visual disturbances, bruxism or pain/fever/stiff neck/recent trauma
self-tx: OTC acetaminophen (MC), Aspirin, ibuprofen, others

Question 5

tension HA tx

Answer 5

limit analgesics to 2-3 times/week
prevents med-overuse HA
may be augmented with sedating antihistamines (diphenhydramine, promethazine)

Question 6

if all other tx is inadequate for tension HA, try:

Answer 6

acetaminophen or aspirin + caffeine and butalbital
may precipitate chronic daily HA
use < twice weekly
caution about sedation, limit alcohol

Question 7

cluster HA

Answer 7

most painful of primary HA
may have aura, phonophobia (56%), photophobia (43%) or osmophobia (23%)
recurrent bouts of near daily attacks (key ft)
may last for weeks or mo’s
many attacks begin with REM sleep
dx’ed by hx

Question 8

precipitants of cluster HA attack

Answer 8

hypoxia (as may occur with sleep apnea), vasodilators (nitroglycerin), alcohol or CO2

Question 9

dx criteria for cluster HA

Answer 9

unilateral orbital, supraorbital or temporal
accompanied by >/= 1 of following: ipsilateral conjunctival injection/lacrimation, ipsilat nasal congestion or rhinorrhea, ipsilat eyelid edema/forehead/facial sweating, ipsilat mitosis/ptosis, sense of restlessness or agitation (93% of pt’s)

Question 10

cluster HA tx

Answer 10

acute attacks must be aborted or subdued
prophylaxis to suppress remaining cluster HAs
O2 (7 L/min x 15 min) is tx of choice for abortive!!
O2 + sumatriptan is underprescribed for abortive

Question 11

what is not effective in cluster HA prophylaxis?

Answer 11

oral sumatriptan

Question 12

migraine HA

Answer 12

despite effective therapies, often underdosed and undertx’ed
about 1/2 of pt’s stop medical care secondary to dissatisfaction
pain usually unilaterally, throbbing, temporal, incapacitating and minimized in dark, quiet location
many experience prodromal symptoms

Question 13

migraine HA classification

Answer 13

based on clinical ft’s:
aura or w/o aura
aura includes visual distortions that are + or -

Question 14

positive aura

Answer 14

scintillations (sparks), teichopsia (luminous appearance), photopsia (flashes)

Question 15

negative aura

Answer 15

visual field defects

Question 16

triggers of migraines

Answer 16

food (alcohol, caffeine, chocolate, MSG, tyramine and nitrate containing food), behavioral/physiologic, enviro (flickering lights)

Question 17

goal of therapy for acute migraine

Answer 17

treat rapidly
sedatives no longer widely used
acetaminophen mono therapy NOT recommended

Question 18

goals of therapy for Lon-term migraine

Answer 18

red the freq and severity of attacks

avoid escalation of meds

Question 19

mild-mod migraine or unresponsive severe attacks use:

Answer 19

oral NSAIDs, combo analgesics containing caffeine,
isometheptene combos (midrin)

Question 20

mod-severe migraine or mild-mod migraine unresponsive to NSAIDs

Answer 20

migraine specific meds or combo tx (APC = aspirin + APAP + caffeine)

Question 21

approaches to tx’ing migraine

Answer 21

step-care approach
stratified-care approach
results: recent data found stratified to be superior

Question 22

principles of triptan therapy in migraine HA tx

Answer 22

try one for 2-3 HA episodes before changing
if one is ineffective, try another
match drug characteristics to pt’s needs
several “newer” triptans offer no adv

Question 23

migraine prophylaxis

Answer 23

consider if: >/= 2 attacks/mo with disability >/= 3 days/mo, CI’s to or failure of abortive therapy, use of abortive therapy > 2x/week, or presence of uncommon migraine conditions (hemiplegic migraine or prolonged aura)