HA & Migraine Flashcards
What are the 3 types of headaches?
- tension-type HA
- migraine
- cluster HA
What are the features of TTH based on:
- pain location
- pain characteristics
- pain intensity
- effect on activities
- other sx
- duration
- pain location: bilateral
- pain characteristics: pressing / tightening
- pain intensity: mild-moderate
- effect on activities: not aggravated by routine activities of daily living
- other sx: none
- duration: 30min-7D
What are the features of migraine based on:
- pain location
- pain characteristics
- pain intensity
- effect on activities
- other sx
- duration
- pain location: unilateral / bilateral
- pain characteristics: pulsating / throbbing
- pain intensity: moderate-severe
- effect on activities: aggravated by / causes avoidance of routine activities of daily living
- other sx: N/V, photophobia, phonophobia, aura
- duration: 4-72h
What are the features of cluster HA based on:
- pain location
- pain characteristics
- pain intensity
- effect on activities
- other sx
- duration
- pain location: unilateral (around eye/along face)
- pain characteristics: variable
- pain intensity: severe to very severe
- effect on activities: restlessness / agitation
- other sx: cranial autonomic sx in the same side as HA (red, water, swollen eye, nasal congestion, runny nose, sweating)
- duration: 15-180min
Red flags for HA?
SNNOOP10
- systemic sx including fever
- neoplasm
- neurologic deficit / dysfunction
- onset is sudden
- older age >50y
- pattern change / recent onset of HA
- positional HA
- progressive HA with atypical presentation
- precipitated by sneezing, coughing or exercise
- papilledema
- painful eye with autonomic features
- pregnancy / puerperium
- post-traumatic onset of HA
- pathology of immune system (e.g. HIV, immunocompromised)
- painkiller overuse / new drug at onset of HA
Classification of TTH?
- infrequent episodic: 30min-7D (<1 episode/m, at least 10 HA episodes but <12D/y)
- frequent episodic: 30min-7D (1-14D/m, at least 10 HA episodes for >3m, ≥12D but <180D/y)
- chronic: hours to days or unremitting (≥15D/m, for 3m, ≥180D/y)
Phases of migraine? How long does each phase occur?
- prodrome: a few hours to days (≤48h)
- aura: 5-60min
- HA: 4-72h
- postdrome: ≤48h
Triggers of TTH? (7)
- physical / emotional stress
- activities that cause the head to be held in one position for a long time
- alcohol (binge then withdraw)
- caffeine (withdrawal sx)
- cold / flu / sinus infx
- dehydration
- hunger
Acute tx of TTH?
- paracetamol (alone or with caffeine), aspirin
- NSAIDs (ibuprofen, naproxen, diclofenac, ketoprofen)
Prophylactic tx for TTH?
1st line: amitriptyline, nortriptyline
2nd line: mirtazapine, venlafaxine
Non-pharm for TTH?
- HA diary
- CBT, biofeedback, relaxation, stress management
- PT/OT
- lifestyle (sleep hygiene, proper posture)
What is considered medication overuse HA?
- HA on ≥15D/m
- regular overuse of acute +/ symptomatic HA drugs for >3m
–> paracetamol / aspirin / NSAIDs on ≥15D/m
–> ergotamines / opioids / triptans on ≥10D/m
–> combi of analgesics on ≥10D/m
Classification of migraine by frequency?
- episodic: ≥5 migraine attacks lasting 4-72h in a lifetime
- chronic: >3m with ≥15 HA days, including ≥8 MMD
MMD: monthly migraine day: ≥2 migraine characteristics, or with photophobia/phonophobia/N/V during HA if no aura
What are some aura sx for migraine?
- visual (zigzag lines, rainbow)
- sensory or speech disturbance
- motor sx
Acute tx for migraine?
1st line
- paracetamol
- NSAIDs (ibuprofen, naproxen, diclofenac, ketoprofen)
- aspirin
2nd line
- triptans (e.g. sumatriptan, zolmitriptan, eletriptan) if not relieved by OTC analgesics
3rd line
- triptans + naproxen sodium
Others
- ergotamine + caffeine
- opioids
- ditans & gepants (not in SG) e.g. erenumab (CGRP receptor antagonist)
Triptans MOA?
5HT1B and 5HT1D receptor agonist -> decrease trigeminal neuron activity -> vasoconstriction of cerebral blood vessels + inhibit vasoactive peptide release by trigeminal neuron -> inhibit nociception
CI of ergotamine + caffeine?
- CVD, CHD, uncontrolled HTN
- cerebrovascular disease
CI of triptans?
- CHD, arterial HTN
- MI, ischaemic stroke
- Raynaud’s disease
- pregnancy & lactation
- concurrent adm with serotonergic agents
Does migraine occur with or without aura?
Can occur with or without aura
What triggers migraine attacks?
- hormones (menstrual cycle, ovulation)
- diet (alcohol, caffeine)
- behaviour (irregular meal times, lack sleep, stress, too much exercise)
- env (bright/flashing lights, loud noise, strong odour)
- meds (COC, HRT, nitroglycerin, histamine)
Nonpharm for migraine?
- relaxation, CBT
- acupuncture
- eliminate triggers
What can be used for N/V a/w migraine?
Anti-emetics: metoclopramide, domperidone
If response to sumatriptan is inadequate, what else can be added for therapy?
Naproxen sodium (3rd line of acute tx)
When can preventive tx be considered for migraines?
- ≥4 migraine days per month
- attacks have a substantial impact on their lives despite appropriate use of acute meds
- frequency of migraine attacks puts them at risk of medication overuse HA
How long should preventive tx be tried for one drug before saying it is ineffective?
≥ 2 months
What outcome shows that preventive med is effective for migraine?
Migraine attack frequency or number of HA days/month reduced by ≥50%
When should drug be weaned off for preventive tx?
After 6-12m of successful preventive tx
Preventive tx options for migraine?
1st line
- BB (propranolol, metoprolol, atenolol)
- antidepressants (amitriptyline, nortriptyline)
2nd line
- ARB (candesartan)
- ASM (topiramate)
3rd line
- CGRP monoclonal antibodies (erenumab) if all else fails
Others
- ASM (sodium valproate)
- botox
- CCB (flunarizine)
