Headache Flashcards
Migraine Definition
- Unilateral pain with pulsating quality and is moderate - severe
- may present with N/V, phonophobia, or photophobia
- 4-72hrs
- aggravated by physical activity
Migraine Aura vs TIA
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
Treatment for Mild-Moderate Migraine
- NSAIDs
- Acetaminophen
- Caffeinated analgesic combos
Treatment for Moderate - Severe or refractory Mild-Mod Migraine
Migraine specific agents:
- Triptans
- DHE
- Gepants or Ditans if triptans are not tolerated
Refractory Mod-Severe Migraine Treatment
- Combo triptans and NSAIDs
- Gepants
- Ditans
- Combo analgesics with codeine or tramadol (if used infrq)
- Opioids (if used infrq)
When would a non-oral formulation aid migraine treatment?
- fast onset migraine
- migraine associated with n/v
Emergency Department treatment for severe migraine
- IV/IM dexamethasone
- SQ sumatriptan
- IV prochlorperazine + diphenhydramine
- IV metoclopramide + diphenhydramine
- IV DHE + antiemetic
- IV valproate
- IV/IM ketorlac
- IV magnesium
Butalbital/APAP/Caffeine (Fioricet)
Indication: tension type HA (but also used in migraine)
ADE: CNS depression, stomach upset, high risk of medication overuse headache
BBW: hepatotoxicity (APAP)
Butalbital / ASA / Caffeine (Fiorinal)
CIII
Indication: tension type HA (but also used in migraine)
ADE: CNS depression, stomach upset, high risk of med overuse headache
Triptans
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)
Lasmiditan (Reyvow)
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
Gepants (agents)
-Atogepant
- Rimegepant
- Ubrogepant
Rimegepant (Nurtec)
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
Ubrogepant (Ubrelvy)
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
Ergotamine (Ergomar)
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)
Dihydroergotamine (DHE, Migranal, Trudhesa)
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)
Topiramate (Topamax)
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
Valproic Acid (Divalproex sodium, sodium valproate)
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
Beta blockers in Migraine
Agents: propranolol, timolol
Use: migraine prevention
TCAs in migraine treatment
Agents: Amitriptyline, nortriptyline
Use: migraine prevention
ADE: anticholinergic effects, CNS depression, cardiac conduction abnormalities, ortho hypo, serotonin syndrome
Venlafaxine (Effexor)
Use: migraine prevention
ADE: CNS depression, weight loss, anorexia, increased blood pressure, hyponatremia, acute angle closure glaucoma, serotonin syndrome
BBW: suicidality
Atogepant (Qulipta)
Use: migraine prevention
ADE: constipation, nausea, drowsiness, fatigue, weight loss
Counseling:
- not recommended in hepatic impairment
- dose reduction in CrCl < 30
Eptinezumab (Vyepti)
CGRP MOAB
Target: CCRP ligand
Use: migraine prevention
Admin: IV every 3 months
ADE: infusion reactions, nasopharyngitis, nausea
Erenumab (Aimovig)
CGRP MOAB
Target: CGRP receptor
Use: migraine prevention
Admin: SQ every month
ADE: injection site reactions, constipation
Fremanezumab (Ajovy)
CGRP MOAB
Target: CGRP ligand
Use: migraine prevention
Admin: SQ every month or every 3 months
ADE: injection site reaction
Galcanezumab (Emgalty)
CGRP MOAB
Target: CGRP ligand
Use: migraine prevention
Admin: SQ every month
ADE: injection site rxns
Peripheral nerve blocks
Greater occipital nerve block
- Lidocaine and/or bupivacaine and/or methylprednisolone
Non-pharm migraine treatments
- stress reduction
- dietary changes
- trigger avoidance
- dietary changes
- trigger avoidance
- magnesium
- Vitamin B2
- feverfew
- butterbur
- neuromodulation devices
Treatment for Menstrual Migraine
- Frovatriptan
- Naratriptan
- Zolmitriptan
- Magnesium
- Estrogen - containing contraceptives (avoid in patients with aura)
Migraine treatment in CVD/Stroke pats
- gepants
- Lasmiditan
Migraine treatment in pregnancy
- APAP
- avoid NSAIDs 3rd trimester
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
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
Tension headache preventive treatment
- Antidepressants: TCAs, mirtazapine, venlafaxine
- Anticonvulsants: gabapentin, topiramate
- Trigger point injections
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
Cluster Headache Acute Treatment
- Oxygen
- SQ or intranasal sumatriptan
- intranasal zolmitriptan
Cluster Headache Prevention
- Verapamil (gold standard)
- Glucocorticoids
- Galcanezumab
- Lithium
- Topiramate
- Greater occipital nerve blocks
Hemicrania Continua Definition
Unilateral headache
present for > 3 months w/exacerbations
restlessness / agitation
responds absolutely to therapeutic doses of indomethacin
Hemicrania Continua Treatment
INDOMETHACIN
Alt:
-onabotulinumtoxin A
- occipital nerve stimulation
- vagus nerve stimulation
- peripheral nerve blocks
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
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
Pseudotumor Cerebri Treatments
- withdrawal offending agent
- weight loss
- carbonic anhydrase inhibitors (Acetazolamide, Topiramate)
- furosemide
- migraine preventive meds
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
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
Subarachnoid headache
Sudden / thunderclap onset (worst of my life)
N/V
Photophobia
Neck stiffness
focal neurologic deficits
brief loss of consciousness
LIFE THREATENING EMERGENCY
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
Anti-migraine ergot overuse
> /= 10 days/month
Triptan overuse
> /= 10 days/month
Opioid overuse (in headache)
> /= 10 days/month
Non-opioid analgesic overuse
> /= 15 days/month
Butalbital overuse
> /= 5 days/ month
Substance Withdrawal Headache
Caffeine: > 20mg / day for > 2 weeks
Opioids: > 3 months
Many more: estrogen, TCAs, SSRIs
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
