Headache

Question 1

What is the general mechanisms of analgesics for headache treatment?

Answer 1

COX inhibition (COX2 preferred)

Question 2

What is the trifecta combination used in analgesic medications to treat headaches?

Answer 2

Acetaminophen, aspirin, caffeine

Question 3

What two general headache conditions are analgesics used to treat?

Answer 3

Acute moderate migraine and acute tension headaches

Question 4

A patient has many contraindications for migraine medications but is having an acute migraine. The doctor quickly administers medication. The whiny patient becomes sleepy. What medication did the doctor use? What is an important consideration when using this med?

Answer 4

Barbiturates; Limit the use to 2-3 times per week!

Question 5

A patient with a history of very few migraines wakes up with an acute migraine. The doctor administers medication. What med was administered? What drugs within this class would be suggested for pregnant women? Maximally, how many times per week would you administer this medication for migraines?

Answer 5

• Opioids
• Codeine or meperidine (with caution)
• 2x/week

Question 6

A patient chronically using a particular drug for acute migraines develops chronic daily headaches from the drug. What drug was this patient using? What other conditions is this drug used to treat?

Answer 6

Corticosteroids

-Prolonged headache syndromes (chronic daily headache); Rescue treatment for cluster headaches

Question 7

What are the possible mechanisms of Ergotamines and DHE?

Answer 7

Vasoconstriction and 5HT agonist in trigeminovascular pathway

Question 8

What are Ergotamine and DHE both used to treat? What are the advantages of DHE over Ergotamine?

Answer 8

Acute treatment of migraine headaches; DHE less likely to cause rebound headache and nausea

Question 9

What are other therapeutic uses of DHE?

Answer 9

Acute treatment of cluster headaches; short-term prevention of cluster headaches (along with steroids)

Question 10

What are the overlapping side effects of ergotamine and DHE? What are the contraindications for use?

Answer 10

• Side effects:Nausea (less likely for DHE), dizziness, paresthesia, chest pain, abdominal cramps
• Contraindications: Women planning pregnancy, uncontrolled HTN, sepsis, renal/hepatic failure, vascular disease

Question 11

I’m a fancy fresh intern in the ED and my patient is having an acute migraine. I have ergotamine in one hand and DHE in the other and I need to inject one of them into my patient, STAT! Which one can I inject?

Answer 11

DHE! BOOM!

Question 12

What is oxygen used to treat and what can occur when oxygen is stopped?

Answer 12

Acute treatment for cluster headaches; Headache rebound!

Question 13

My patient tells me that he “can’t poop” and that the room is spinning. What drug did I likely prescribe? To what class does it belong? What is this drug class used to treat?

Answer 13

• Verapamil: Calcium Channel Blocker
• Migraine Prevention, Particularly useful in prolonged/disabling aura, complicated migraine syndromes, long-term prevention of cluster headaches

Question 14

I want to prevent my patient’s migraines with a Beta Blocker. Which Beta Blockers are FDA approved? Now my patient has asthma! What drugs are now contraindicated? In what other conditions are these drugs contraindicated?

Answer 14

• Propanolol and Timolol
• Asthma: Propanolol, timolol, nadolol, atenolol
• Contracindicated: Diabetes, CHF, Raynaud’s

Question 15

What do TCAs and SSRIs treat?

Answer 15

Migraine and tension headache prevention

Question 16

What are the three SSRIs that you need to know about and what are their side effects?

Answer 16

Fluoxetine, paroxetine, sertraline

-Weight gain, sexual dysfunction, headache

Question 17

What are the unfortunate side effects of beta blockers?

Answer 17

Drowsiness, depression, decreased libido, hypotension, memory disturbances

Question 18

What are the 3 TCAs and what are their side effects?

Answer 18

Amytriptyline**, protriptyline, nortriptyline

-Dry mouth, constipation, weight gain, cardiac toxicity, orthostatic hypotension

Question 19

What in the world would you use Onabotulinum toxin for? How does it work? What are some pesky side effects?

Answer 19

• Migraine Prevention: Unknown mechanism! (possible decreased afferent stim of trigeminovasc system or downreg of sensory and parasymp receptors)
• Side Effects: Injection site pain, headache, neck weakness, ptosis

Question 20

To what class does Sumatriptan belong?

Answer 20

Triptans!

Question 21

What is the mechanism of action of Sumatriptan?

Answer 21

Selective 5HT1b-d agonist; penetrates CNS -> constrict extracerebral intracranial vessels -> inhibition of trigeminovascular system

Question 22

My patient is having an acute migraine! Darn! What would be the “premier” treatment? How would I administer it? What other conditions is this drug used to treat? In what instances would you not use this drug?

Answer 22

• Sumatriptan (also effective for: Photo/phonophobia, N/V, Acute Cluster Headache) -Injection!
• Contraindicated in Vasc Disease, Uncontrolled HTN, complicated migraine

Question 23

What are the side effects of Sumatriptan?

Answer 23

Flushing, tingling, dizziness, noncardiac chest discomfort

Question 24

Which two antiepileptic drugs can be used for migraine prevention?

Answer 24

Divalproex sodium ER and Topirimate