HA Flashcards
HA
<2% office and <4% ER visits have serious pathology
classifications of HA’s
primary (not caused by secondary pathology ; includes migraines, tension and cluster)
secondary (caused by secondary pathology ; includes HTN, infn, tumors, etc)
red flags of secondary HA’s
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
tension HA
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
tension HA tx
limit analgesics to 2-3 times/week
prevents med-overuse HA
may be augmented with sedating antihistamines (diphenhydramine, promethazine)
if all other tx is inadequate for tension HA, try:
acetaminophen or aspirin + caffeine and butalbital
may precipitate chronic daily HA
use < twice weekly
caution about sedation, limit alcohol
cluster HA
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
precipitants of cluster HA attack
hypoxia (as may occur with sleep apnea), vasodilators (nitroglycerin), alcohol or CO2
dx criteria for cluster HA
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)
cluster HA tx
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
what is not effective in cluster HA prophylaxis?
oral sumatriptan
migraine HA
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
migraine HA classification
based on clinical ft’s:
aura or w/o aura
aura includes visual distortions that are + or -
positive aura
scintillations (sparks), teichopsia (luminous appearance), photopsia (flashes)
negative aura
visual field defects
triggers of migraines
food (alcohol, caffeine, chocolate, MSG, tyramine and nitrate containing food), behavioral/physiologic, enviro (flickering lights)
goal of therapy for acute migraine
treat rapidly
sedatives no longer widely used
acetaminophen mono therapy NOT recommended
goals of therapy for Lon-term migraine
red the freq and severity of attacks
avoid escalation of meds
mild-mod migraine or unresponsive severe attacks use:
oral NSAIDs, combo analgesics containing caffeine, isometheptene combos (midrin)
mod-severe migraine or mild-mod migraine unresponsive to NSAIDs
migraine specific meds or combo tx (APC = aspirin + APAP + caffeine)
approaches to tx’ing migraine
step-care approach
stratified-care approach
results: recent data found stratified to be superior
principles of triptan therapy in migraine HA tx
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
migraine prophylaxis
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)