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Therapeutics P3 Fall > Headache > Flashcards

Headache Flashcards

1
Q

Migraine Definition

A
  • Unilateral pain with pulsating quality and is moderate - severe
  • may present with N/V, phonophobia, or photophobia
  • 4-72hrs
  • aggravated by physical activity
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2
Q

Migraine Aura vs TIA

A

Migraine Aura
- + visual sx
- gradual onset
- sequential progression
- repetitive attacks of identical nature
- flurry of attacks midlife
- duration < 60 min
- Headache follows 50%

TIA
- visual loss
- abrupt onset
- simultaneous occurrence
- duration < 15 min
- headache uncommon accompaniment

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3
Q

Treatment for Mild-Moderate Migraine

A
  • NSAIDs
  • Acetaminophen
  • Caffeinated analgesic combos
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4
Q

Treatment for Moderate - Severe or refractory Mild-Mod Migraine

A

Migraine specific agents:
- Triptans
- DHE
- Gepants or Ditans if triptans are not tolerated

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5
Q

Refractory Mod-Severe Migraine Treatment

A
  • Combo triptans and NSAIDs
  • Gepants
  • Ditans
  • Combo analgesics with codeine or tramadol (if used infrq)
  • Opioids (if used infrq)
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6
Q

When would a non-oral formulation aid migraine treatment?

A
  • fast onset migraine
  • migraine associated with n/v
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7
Q

Emergency Department treatment for severe migraine

A
  • IV/IM dexamethasone
  • SQ sumatriptan
  • IV prochlorperazine + diphenhydramine
  • IV metoclopramide + diphenhydramine
  • IV DHE + antiemetic
  • IV valproate
  • IV/IM ketorlac
  • IV magnesium
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8
Q

Butalbital/APAP/Caffeine (Fioricet)

A

Indication: tension type HA (but also used in migraine)

ADE: CNS depression, stomach upset, high risk of medication overuse headache

BBW: hepatotoxicity (APAP)

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9
Q

Butalbital / ASA / Caffeine (Fiorinal)

A

CIII

Indication: tension type HA (but also used in migraine)

ADE: CNS depression, stomach upset, high risk of med overuse headache

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10
Q

Triptans

A

Indication: acute treatment of moderate-severe migraine
- administer early to improve treatment response

ADE: Flushing, chest pain, palpitations, dizziness, fatigue, xerostomia, serotonin syndrome

Counseling points:
- limit use to < 10 days/month
- caution in elderly
- may combine with NSAIDs (Treximet -> sumatriptan/naproxen)

CI:
-Hemiplegic migraine, ischemic heart disease / CVD, Wolff-Parkinson-White syndrome, stroke/TIA, uncontrolled HTN, use within 24h of an ergotamine or different triptan, MAOIs (with rizatriptan, sumatriptan, and zolmitriptan only)

Agents:
- Almotriptan
- Eletriptan (Relpax)
- Frovatriptan (Frova) (longest t1/2)
- Naratriptan (Amerge)
- Rizatriptan (Maxalt)
- Sumatriptan (available PO, nasal spray, or SQ)
- Zolmitriptan (zomig)

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11
Q

Lasmiditan (Reyvow)

A

C5

Use: acute treatment of migraine with or without aura in adults

ADE: CNS depression, serotonin syndrome, decreased HR, HTN, palpitations, dizziness, N/V

Counseling points:
- must wait at least 8 hrs after dosing before driving / operating heavy machinery
- Onset of action: 30-60min

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12
Q

Gepants (agents)

A

-Atogepant
- Rimegepant
- Ubrogepant

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13
Q

Rimegepant (Nurtec)

A

PO ODT

Use: acute and preventive treatment of migraine in adults
- acute = 1 dose
- preventative = QOD dosing

ADE: abdominal pain, dyspepsia, nausea

Counseling: avoid use in hepatic / kidney impairment
- CrCl </= 15 mL/min

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14
Q

Ubrogepant (Ubrelvy)

A

PO tablet

Use: acute treatment of migraine w/wo aura in adults

ADE: nausea, drowsiness, xerostomia

Counseling:
- may repeat dose after 2 hrs (MDD 200mg)
- dose reduction CrCl < 30
- CI in CrCl < 15
- admin with high fat meals delays Tmax and Cmax

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15
Q

Ergotamine (Ergomar)

A

Use: acute treatment of moderate-severe migraine

ADE: N/V, ECG changes, HTN, ischemia, vasospasm, numbness, paresthesia, gangrene, cardiac valvular fibrosis, ergotism

Counseling:
- SL tablets
- avoid in pregnancy
- do not use within 24hrs of triptans, other serotonin agonists, or ergotamine-containing agents
- CI: potent CYP3A4i (protease inhibitors, macrolide abx, azole antifungals)

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16
Q

Dihydroergotamine (DHE, Migranal, Trudhesa)

A

Use:
- injection : acute treatment of cluster HA
- injection and nasal spray: acute treatment of migraine w/wo aura

ADE: fewer ADE than ergotamine

Counseling:
- avoid in pregnancy
- do not use within 24hrs of triptans, other serotonin agonists, or ergotamine-containing agents
- CI: potent CYP3A4i (protease inhibitors, macrolide abx, azole antifungals)

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17
Q

Topiramate (Topamax)

A

Use: prevention of migraine headache in pats > 12

ADE: cognitive dysfunction, CNS effects, kidney stones, metabolic acidosis, angle-closure glaucoma, oligohidrosis/hyperthermia, suicidal ideation, weight loss, paresthesia

Counseling:
- Hydrate or die-drate
- avoid in pregnancy

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18
Q

Valproic Acid (Divalproex sodium, sodium valproate)

A

Use: migraine prevention

ADE: CNS effects, hematologic effects, hepatotoxicity, encephalopathy, TEN-SJS, DRESS, pancreatitis, suicidal ideation

BBW: hepatotoxicity, pats with mitochondrial disease, fetal risk (avoid in pregnancy), pancreatitis

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19
Q

Beta blockers in Migraine

A

Agents: propranolol, timolol

Use: migraine prevention

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20
Q

TCAs in migraine treatment

A

Agents: Amitriptyline, nortriptyline

Use: migraine prevention

ADE: anticholinergic effects, CNS depression, cardiac conduction abnormalities, ortho hypo, serotonin syndrome

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21
Q

Venlafaxine (Effexor)

A

Use: migraine prevention

ADE: CNS depression, weight loss, anorexia, increased blood pressure, hyponatremia, acute angle closure glaucoma, serotonin syndrome

BBW: suicidality

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22
Q

Atogepant (Qulipta)

A

Use: migraine prevention

ADE: constipation, nausea, drowsiness, fatigue, weight loss

Counseling:
- not recommended in hepatic impairment
- dose reduction in CrCl < 30

23
Q

Eptinezumab (Vyepti)

A

CGRP MOAB

Target: CCRP ligand

Use: migraine prevention

Admin: IV every 3 months

ADE: infusion reactions, nasopharyngitis, nausea

24
Q

Erenumab (Aimovig)

A

CGRP MOAB

Target: CGRP receptor

Use: migraine prevention

Admin: SQ every month

ADE: injection site reactions, constipation

25
Q

Fremanezumab (Ajovy)

A

CGRP MOAB

Target: CGRP ligand

Use: migraine prevention

Admin: SQ every month or every 3 months

ADE: injection site reaction

26
Q

Galcanezumab (Emgalty)

A

CGRP MOAB

Target: CGRP ligand

Use: migraine prevention

Admin: SQ every month

ADE: injection site rxns

27
Q

Peripheral nerve blocks

A

Greater occipital nerve block
- Lidocaine and/or bupivacaine and/or methylprednisolone

28
Q

Non-pharm migraine treatments

A
  • stress reduction
  • dietary changes
  • trigger avoidance
  • dietary changes
  • trigger avoidance
  • magnesium
  • Vitamin B2
  • feverfew
  • butterbur
  • neuromodulation devices
29
Q

Treatment for Menstrual Migraine

A
  • Frovatriptan
  • Naratriptan
  • Zolmitriptan
  • Magnesium
  • Estrogen - containing contraceptives (avoid in patients with aura)
30
Q

Migraine treatment in CVD/Stroke pats

A
  • gepants
  • Lasmiditan
31
Q

Migraine treatment in pregnancy

A
  • APAP
  • avoid NSAIDs 3rd trimester
32
Q

Tension type headache

A

At least 2 of the following
- bilateral location
- pressing or tightening (non-pulsating) quality
- mild or moderate intensity
- not aggravated by routine physical activity

30min - 7 days
no N/V
no more that 1: photophobia or phonophobia

33
Q

Tension headache acute treatment

A
  • simple analgesics (NSAIDs, APAP)
  • combo analgesics containing caffeine
  • combo analgesics with butalbital or codeine (not preferred)

COUNSEL ON MED OVERUSE HA

34
Q

Tension headache preventive treatment

A
  • Antidepressants: TCAs, mirtazapine, venlafaxine
  • Anticonvulsants: gabapentin, topiramate
  • Trigger point injections
35
Q

Cluster Headache definition

A

severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 min
occurring with a frq between 1 QOD - 8 per day
restlessness/agitation

36
Q

Cluster Headache Acute Treatment

A
  • Oxygen
  • SQ or intranasal sumatriptan
  • intranasal zolmitriptan
37
Q

Cluster Headache Prevention

A
  • Verapamil (gold standard)
  • Glucocorticoids
  • Galcanezumab
  • Lithium
  • Topiramate
  • Greater occipital nerve blocks
38
Q

Hemicrania Continua Definition

A

Unilateral headache
present for > 3 months w/exacerbations
restlessness / agitation
responds absolutely to therapeutic doses of indomethacin

39
Q

Hemicrania Continua Treatment

A

INDOMETHACIN

Alt:
-onabotulinumtoxin A
- occipital nerve stimulation
- vagus nerve stimulation
- peripheral nerve blocks

40
Q

Traumatic Brain Injury HA

A

often resemble clinical features of migraine/tension - like headaches

associated post-concussive sx: fatigue, dizziness, insomnia, difficulty concentrating seizures, depression, anxiety

onset within 7 days of head trauma

41
Q

Pseudotumor cerebri (idiopathic intracranial HTN)

A

increased intracranial pressure -> headache, papilledema, vision loss

primarily effects overweight females of childbearing age

may be medication induced:
- growth hormone
- tetracyclines
- retinoids

42
Q

Pseudotumor Cerebri Treatments

A
  • withdrawal offending agent
  • weight loss
  • carbonic anhydrase inhibitors (Acetazolamide, Topiramate)
  • furosemide
  • migraine preventive meds
43
Q

Brain Tumor HA definition

A

varying features dependent on tumor type and location

commonly presents as tension-like

pain may either be bilateral or on the side of the tumor

associated neurologic symptoms: seizures, fatigue, cognitive dysfunction, focal weakness

44
Q

Reversible Cerebral Vasoconstriction Syndrome (RCVS)

A

Thunderclap headaches
multifocal narrowing of cerebral arteries
Neurologic deficits related to brainstem edema, stroke, or seizure
Meds associated: SSRIs, triptans, ergots, cyclophosphamide, tacrolimus, nasal decongestants, illicit drugs

45
Q

Subarachnoid headache

A

Sudden / thunderclap onset (worst of my life)
N/V
Photophobia
Neck stiffness
focal neurologic deficits
brief loss of consciousness

LIFE THREATENING EMERGENCY

46
Q

Medication Overuse Headache

A

HA occurring on at least 15 days / month in a patient with a pre-existing HA disorder

regular overuse for > 3 months of one or more HA drugs

47
Q

Anti-migraine ergot overuse

A

> /= 10 days/month

48
Q

Triptan overuse

A

> /= 10 days/month

49
Q

Opioid overuse (in headache)

A

> /= 10 days/month

50
Q

Non-opioid analgesic overuse

A

> /= 15 days/month

51
Q

Butalbital overuse

A

> /= 5 days/ month

52
Q

Substance Withdrawal Headache

A

Caffeine: > 20mg / day for > 2 weeks
Opioids: > 3 months
Many more: estrogen, TCAs, SSRIs

53
Q

Headache Red Flags (SNOOP)

A

Systemic symptoms (fever, myalgia, weight loss)
Systemic disease (malignancy, AIDS)
Neurologic symptoms / signs
Onset sudden
Onset after 40 years
Pattern change

Therapeutics P3 Fall (21 decks)

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