Headache

Question 1

Medication Overuse HA

Answer 1

• caused by freq use of ha medications-> withdrawal symptoms (escalating use or a large amount of HA)
  offending agents:
  -Barbiturates, acetaminophen, ASA, nsaids, ergotamines

avoid by limiting to 2-3x per week for abortive therapy

Question 2

Migraine triggers

Answer 2

increased/decreased sleep
dehydration
stress
emotional letdown
skipping meals
alcohol
meds
weather changes
smoking
strong perfumes
chocolate
caffeine
cheese
hormone changes
loud noise
physical activity

Question 3

Goals of migraine tx

Answer 3

Primary goal: prevent, or have consistent/rapid relief with minimal AE

Other goals: minimize disability, emotional distress, enable pt to participate in ADL, manage HA w/out doc visit

Question 4

Acute migraine tx overview

Answer 4

Mild Mod:
-Acetaminophen
-NSAIDS

Mod-Severe:
-triptans
-triptans w/ NSAIDS
-ergotamine
-calcitonin gene-related peptide receptor antagonists (CGRP)
- non-preferred: butalbital products and opioids

Adjunctive:
antiemetics
-hydroxyzine
-promethazine
-Metoclopramide
Antihistamines
Transcranial Magnetic stimulators

Question 5

Overview of attacks

Answer 5

Prophylactic:
- BB, antidepressants, Topiramate, Verapamil, CRPG

During an acute attack:
1. Triptans
2. Dihydro-ergotamine
3. Analgesics

Question 6

Mild to moderate migraine

Answer 6

1. Acetaminophen
   -AE: Liver issues, unintentional overdose
2. NSAIDS
   -AE: GI bleeding, renal impairment, cardiac issues
   AVOID IN PREGO

Question 7

Triptans

Answer 7

Imitrex (sumatriptan) and Relpax (eletriptan)
MOA: activates SEROTONIN receptor in intracranial bv -> VC & reducing release of Pro-inflamm neuropep

1ST LINE ABORTIVE THERAPY OF MILD TO SEVERE MIGRAINES
can redose w/in 24 hrs

ae:
- htn, cardiac events, pain and pressure sensations in chest, neck, throat, jaw, dizzy, mailase

Contra:
-ischemic heart dz
-stroke
-uncontrolled htn
-MAOIs= mono amine oxidase inhibitors
-serotonin syndrome

Interactions:
1. CANNOT ADMINISTER W/IN 24 HRS OF AN ERGOTAMINE DERIVATIVE
2. CANNOT ADMINISTER W/IN 2WKS OF A MAOI

WARNINGS IN ELDERLY

Question 8

Serotonin Syndrome

Answer 8

CAN B LETHAL
pts taking Triptan w/ Serotonin antidepressant
Triad:
1. Mental status changes
2. Autonomic instability
3. Neuromuscular abn (hyperreflexia, myoclonus)

RF: taking >1 serotonergic agent (MAOI + SSRI, SNRI, Linezolid, Antiemetic)

Causative agent:
-Tryptophan, oxitriptan, amphetamines, MDMA (ecstasy), cocaine, Mirtazapine, tramadol, dextromethorphan, SSRI, SNRI, Fentanyl, LSD, ALL MAOI, Lithium

Question 9

Ergotamine derivatives aka Ergots

Answer 9

Ergotamine (Ergomar) and dihydroergotamine (D.H.E)
Non-selective 5-HT1 (serotonin) receptor agonists
MOA: partial agonist and/or antagonist activity against tryptaminergic, dopaminergic, and alpha-adrenergic receptors depending upon their site= contrict peripheral and cranial blood vessels -> produce depression of central vasomotor centers

AE: Extreme NVD, paresthesias, chest tightness, “ergotism”- cold, numb, painful extremities, diminished peripheral pulses and claudication

Contra:
PREGNANCY/LACTATION
RENAL AND LIVER FAILURE
CORONARY, CEREBRAL, OR PERIPHERAL VASCULAR DZ
UNCONTROLLED HTN
SEPSIS

cant use w/in 24 hrs of a Triptan B4 or after

Question 10

Ditans - new class

Answer 10

Lasmiditan (Reyvow)
MOA: block neurogenic inflam in dura and simulation of the trigeminal nucleus caudalis

AE: dizzy, paresthesia, sedation (SPECIFIC WARNING NOT DRIVING MOTOR VEHICLE OR OPERATE HEAVY MACHINERY W/IN 8 HRS DUE TO DROWSINESS), n/v

Question 11

Small-molecule CGRP Antagonists (“Gepants”)

Answer 11

Rimegepant (Nurtec) and Atogepant (Qulipta)
CGRP- role in trigeminovascular pain transmission and neurogenic inflam
efficacy like triptans and lasmiditan-> better tolerated

MOA: block backing CGRP receptors-> VC and decrease in neurogenic inflam

USEFUL FOR ACUTE MIGRAINE AND CHRONIC MIGRAINE PROPHYLAXIS
-Nurtec and Qulipta

only for acute tx- Ubrogepant (Ubrelvy) mod to severe migraine

AE:
Nausea- Rimegepant (Nurtec)= long half life (11 hrs)
Nausea, xerostomia, somnolence- ubrogepant (Ubrelvy) = short (5-7 hrs)

lots of interactions
avoid use in hepatic or renal impairment

Question 12

Opioid and opioid derivatives

Answer 12

inadequate evidence to tx migraine
Probably effective: codeine + acetaminophen or tramadol + acetaminophen
Established efficacy= Butorphanol (nasal spray)

reserve use for pts w/ infrequent mod to severe HA:
-contra to conventional therapies
or
-“rescue” med after failure to conventional therapies

Question 13

Chronic migraine prophylaxis

Answer 13

1. Ant-calcitonin gene-related peptide (CGRP) antagonist
2. Topiramate (Topamax)- anticonvulsant
3. Timolol, propanolol (non-selective beta blockers)
4. Divalproex (Depakote)

possible effectiveness:
antidepressants: amitriptyline
Anticonvulsants: valproic acid
NSAIDS
Triptans
Lisinopril
Candesartan
Verapamil

Question 14

Calcitonin Gene-related peptide (CGRP) antagonist monoclonal ab

Answer 14

Eptinezumab (Vyepti)- infusion
Erenumab (Aimovig)- inj
Fremanezumab (Ajovy)- inj
Galcanezumab (Emgality)- inj

limitations: access and cost
no known med interactions

AE: injxn sit rxn, hypersensitivity, nasopharyngitis, constipation

cardiovasc warnings: Fremanezumab, galcanezumab

Question 15

Adjunctive migraine therapies

Answer 15

Antiemetic: pretx b4 oral adn non-oral meds
-Metoclopramide (Reglan)
-Prochlorperazine (Compro)
-Hydroxyzine (Vistaril)
-Promethazine (Phenergan)
-Chlorpromazine, droperidol = first gen antipsychotics

Question 16

Non pharm tx for migraine

Answer 16

ice to head
rest/sleep in a dark quiet environ
identify and avoid triggers
behavioral triggers
-relaxation
-biofeedback
-cognitive therapy

Question 17

Tension HA and cluster HA

Answer 17

Tension HA: analgesic (NSAID, acetaminophen, aspirin)-> NSAID preferred
-simple analgesic +- Caffeine
-acetaminophen, aspirin, NSAIDS (diclofenac, ibuprofen, naproxen, ketoprofen, ketorolac)

Cluster HA: Triptans + inhaled oxygen-> first line abortive therapy