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
Fremanezumab (Ajovy)
CGRP MOAB Target: CGRP ligand Use: migraine prevention Admin: SQ every month or every 3 months ADE: injection site reaction
26
Galcanezumab (Emgalty)
CGRP MOAB Target: CGRP ligand Use: migraine prevention Admin: SQ every month ADE: injection site rxns
27
Peripheral nerve blocks
Greater occipital nerve block - Lidocaine and/or bupivacaine and/or methylprednisolone
28
Non-pharm migraine treatments
- stress reduction - dietary changes - trigger avoidance - dietary changes - trigger avoidance - magnesium - Vitamin B2 - feverfew - butterbur - neuromodulation devices
29
Treatment for Menstrual Migraine
- Frovatriptan - Naratriptan - Zolmitriptan - Magnesium - Estrogen - containing contraceptives (avoid in patients with aura)
30
Migraine treatment in CVD/Stroke pats
- gepants - Lasmiditan
31
Migraine treatment in pregnancy
- APAP - avoid NSAIDs 3rd trimester
32
Tension type headache
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
Tension headache acute treatment
- simple analgesics (NSAIDs, APAP) - combo analgesics containing caffeine - combo analgesics with butalbital or codeine (not preferred) COUNSEL ON MED OVERUSE HA
34
Tension headache preventive treatment
- Antidepressants: TCAs, mirtazapine, venlafaxine - Anticonvulsants: gabapentin, topiramate - Trigger point injections
35
Cluster Headache definition
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
Cluster Headache Acute Treatment
- Oxygen - SQ or intranasal sumatriptan - intranasal zolmitriptan
37
Cluster Headache Prevention
- Verapamil (gold standard) - Glucocorticoids - Galcanezumab - Lithium - Topiramate - Greater occipital nerve blocks
38
Hemicrania Continua Definition
Unilateral headache present for > 3 months w/exacerbations restlessness / agitation responds absolutely to therapeutic doses of indomethacin
39
Hemicrania Continua Treatment
INDOMETHACIN Alt: -onabotulinumtoxin A - occipital nerve stimulation - vagus nerve stimulation - peripheral nerve blocks
40
Traumatic Brain Injury HA
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
Pseudotumor cerebri (idiopathic intracranial HTN)
increased intracranial pressure -> headache, papilledema, vision loss primarily effects overweight females of childbearing age may be medication induced: - growth hormone - tetracyclines - retinoids
42
Pseudotumor Cerebri Treatments
- withdrawal offending agent - weight loss - carbonic anhydrase inhibitors (Acetazolamide, Topiramate) - furosemide - migraine preventive meds
43
Brain Tumor HA definition
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
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
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
Subarachnoid headache
Sudden / thunderclap onset (worst of my life) N/V Photophobia Neck stiffness focal neurologic deficits brief loss of consciousness LIFE THREATENING EMERGENCY
46
Medication Overuse Headache
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
Anti-migraine ergot overuse
>/= 10 days/month
48
Triptan overuse
>/= 10 days/month
49
Opioid overuse (in headache)
>/= 10 days/month
50
Non-opioid analgesic overuse
>/= 15 days/month
51
Butalbital overuse
>/= 5 days/ month
52
Substance Withdrawal Headache
Caffeine: > 20mg / day for > 2 weeks Opioids: > 3 months Many more: estrogen, TCAs, SSRIs
53
Headache Red Flags (SNOOP)
Systemic symptoms (fever, myalgia, weight loss) Systemic disease (malignancy, AIDS) Neurologic symptoms / signs Onset sudden Onset after 40 years Pattern change