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Headache Flashcards

1
Q

1.What are the primary types of HA’s (3) and what are the sx’s and how would they display ?

  1. Secondary types? (3)
  2. What are some labs to rule out a secondary headache?
A
  1. Migraine (pain, nausea, and visual changes)
    -Tension (pain is like a band squeezing the head)
    -CLuster (pain is in and around one eye)
  2. Trauma, Vascular, CNS infection
  3. Thyroid function , serum chemistries, urine toxicology, lyme studies, CBC, ESR , HEAD CT
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2
Q

Migraine without Aura (Common Migraine)

  1. How many episodic attacks
  2. Lasting how long ?
  3. With any 2 of the following ? (4)
  4. Any 1 of the following DURING HA

Migraine WITH AURA (Classic migraine) :

  1. How many attacks not attributed to another disorder?
  2. Aura with >=1 of the following but NO MOTOR WEAKNESS : ?
  3. Headache begins during ___ or follows within ___
  4. > =2 of the following (3)
A
  1. > = 5 episodic attacks
  2. 4 hrs - 3 days (untx or unsuccessfully treated)
  3. Unilateral, pulsating, worsened or caused by movement , moderate or severe pain
  4. Nausea and or vomiting
    -Photophobia and or phonophobia
  5. > =2 attacks
  6. Fully reversible visual, sensory, or speech sx’s with positive or negative features
  7. Aura, 60 mins
  8. > =1 aura sx develops gradually over 5 min
    =1 aura sx is unilateral
    Individual aura sx’s lasts >= 5 mins but <= 60 mins
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3
Q

Migraine Triggers :

  1. SLeep?
  2. S
  3. Emotional let down
  4. Missing ___
  5. D
  6. A
  7. M
  8. W C
  9. S
  10. S P
  11. F
A
  1. Too much or too little sleep
  2. stress
  3. meals
  4. dehydration
  5. alcohol
  6. medications
  7. weather changes
  8. smoking
  9. strong perfumes
  10. foods/preservatives
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4
Q

NON-Pharm TX

  1. SEEDS
  2. Apply __
  3. Stop ___
  4. Caffeine limit to ?
  5. Alcohol limit to ?
  6. Improved ___
  7. Regulation of ___
  8. Lose ___
  9. Massage (for tension type)
A
  1. Sleep , exercise, eat, diary, stress relief
  2. ice
  3. smoking
  4. 8oz/day
  5. 1 bev per day
  6. hydration
  7. hormones
  8. weight
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5
Q

Migraine TX Overview
1) For abortive tx mild mod
2) for abortive tx mod- severe
3) for Prophylactic
4) Adjunctive

See chart for tx algorithm!

A
  1. NSAIDS, tylenol, combos
  2. Triptans, Dihydroergotamines , Selective serotonin AGONISTS, CGRP antags
  3. BB, anticonvulsants, antidepress, long acting triptans, anti CGRP MABS and CGRP antags
  4. Antiemetics
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6
Q

NSAIDS/APAP/COMBOS
1) WHat are some pros
2) Cons?

  1. Check chart for dosing!
A
  1. Effective for mild/mod pain , prophylaxis in predictable migraines (menstrual), Available OTC, quick onset
  2. Overuse headache , not effective for SEVERE migraines
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7
Q

Triptans
1) MOA?
2) Prevents peptide release that would lead to ?
3) Sumatriptan Oral dose?
4) SQ dose?
5) Nasal spray?
6) nasal powder?
7) Combo ?

A
  1. Serotonin receptor agonist (5HT1B and 1D)
  2. Vasodilation , neurogenic inflamm, pain
  3. 25-100 mg x 1, may repeat in 2 hrs (max 200 mg /day)
  4. SQ 6 mg, may repeat in 1 hr (max 12 mg/day)
  5. 5-10 mg , can repeat in 2 hrs (max 40mg/day)
  6. 22mg , may repeat in 2 hrs (max 44mg/day)
  7. Treximet (85 mg suma + Naproxen 500mg)
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8
Q
  1. Which triptans are available ODT?
  2. Available Nasal sprays ?
  3. Nasal inhaltions?

4.Sq?

5.What’s poor about Sumatriptans oral form ?

  1. Frovatriptan has a long half life, which may lower recurrecne at 24 hrs –> may be useful in ?
  2. Which triptan has a slightly faster onset ? –> Which drug does this interact with ?
  3. Which triptan has CYP3A4 interactions?
  4. For all the triptans, check for what kind of interactions?
A
  1. Rizatriptan, zolmitriptan (must handle with dry hands)
  2. Sumatript, zolmitriptan
  3. Sumatriptan
  4. Sumatriptan
  5. POOR BIOAVAIL
  6. prophylaxis or with slow onset HA , good for menstrual migraine prophylaxis
  7. Rizatriptan –> propanolol (start with 5 mg dose)
  8. Eletriptan
  9. MAO interactions
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9
Q

Triptan Major ADR’s and Precautions

  1. AE’s : F, D, C,S,N , R
  2. precautions : C,C, history of ___
    uncontrolled ___
    Concurrent ___ or ___
    Use of ____ within 2 weeks (Except eletriptan, frovatript, naratript)
    Concurrent ____ /___
    Preg category C!
  3. Triptans are best when taken at ?
A
  1. Fatigue, dizzy, chest discomfort, somnolence, nausea , rebound HA
  2. cad, CHF, MI
    - HTN
    -Ergotamine or DHE
    - MAOI’s
    -SSRI/SNRI
  3. Onset of pain rather than onset of aura
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10
Q

Triptan Non-Responders
1) What are some alts?
2) Switch to ?

A
  1. Just try a diff triptan !
  2. CGRP antag or lasmiditan
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11
Q

Lasmiditan (Reyvow)
1) MOA?
2) Dose?
3) ADE”s?
4) precautions?

A
  1. Selective 5HT1F agonist for acute migraine +/- aura in adults
  2. 200 mg PO everyday
  3. DIzzy , fatigue, sedation, burning/prickling skin sensation –> Dont drive or ooperate machinery for 8 hrs after taking med!!!!
  4. Decr in HR, incr in BP –> Doesnt constrict blood vessels and may role a role for pt’s with cardiovasc CI to triptans
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12
Q

Ubrogepant (Ubrelvy)
1) Bc it doesnt constrict blood vessels, it has a role for which set of pt’s?
2) MOA?
3) For what kind of migraines ?
4) Dose?
5) ADR’s? (3)
6) CI’s?

A
  1. Cardiovasc CI patients to triptans
  2. Oral (CGRP) antag
  3. Acute migraine +/- aura in adults
  4. 200 mg PO everyday
    -if CrCL 15-29, 50 mg PO daily –> if CRCL < 15 AVOID !!!!
    - If severe hepatic disease, dose adjust to 50 mg
  5. Nausea /Somnolence, dry mouth (Dose dependent )
  6. Strong CYP 3a4 inhibs (avoid or reduce dose)
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13
Q

Rimegepant (NURTEC ODT)
1) No BV constriction –> Can use in Cardio Pts
2) First fast acting ODT ___
3) can be used for ?
4) dosing ?
5) AE’s?
6) With concomitant use of moderate CYP 3A4 inhibs what should u do?

Zavegepant (Zavzpret)
1. what kind of drug
2. what kind of migraines
3. dose?
4. Ae’s?
5. Safe for pt’s with ?
6. avoid use of ___ or administer 1 hr AFTER this drug
7. AVoid use in CrCL < ___ and in severe hepatic impairment

A
  1. CGRP receptor antag
  2. acute migraine +/- aura in adults (+ PREVENTION!) –> sustained benefit for 2 days
  3. 75 mg ODT (max 1 pill per day) avoid if CrCL<15
  4. Nausea
  5. avoid 2nd dose of nurtec within 48 hrs
  6. nasal spray CGRP receptor antag
  7. acute migraines +/- aura, ideal for those w/nausea or who dont wanna swallow tabs
  8. 10 mg single spray in 1 nostril PRN (Max 10 mg/day)
  9. Dysgeusia and ageusia, N/V, Nasal discomfy
  10. HX of MI/CVA
  11. intranasal decongestants
  12. 30 mL/min
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14
Q

DHE (Dihydroergotamine)
1. what place in therapy ?
2. MOA?
3. Most effective given at ????
4. Migranal Nasal SPray has better effectiveness than INJECTIONS –> Dosing?

  1. DHE 45 (IV, IM or SQ)
    - Dose ?
    -Effective in tx of?
A
  1. SECOND LINE
  2. Non select 5HT1receptor AGONIST –> constricts intracranial vessels
  3. ONSET of migraine
  4. 1 spray (0.5mg) into each nostril at onset of aura , can repeat 1 spray each nostril in 15 min (max 3mg/day)
  5. 1 mg at onset, repeat every 1 hr prn (max 3 mg/day for IM/SQ and 2mg/day for IV)
  • Acute and INTRACTABLE migraine
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15
Q

ADR’s for DHE? :
N/V/D pre treat with ?
A
Transient
T
Incr ___
Peripheral
T!!!, L !!
G
D
Rebound ___
Nasal irritation
F, D, T

BBW FOR DHE?
INTERACTIONS?
Preg category X (FYI)

A

Anti emetic
angina
transient bradycardia
tachycardia
BP
peripheral numbness
TINGLING, LEG CRAMPS!
gangrene , dizzy, rebound HA, Fatigue, dry mouth, taste perversion

BBW : Serious/life threatening peripheral ischemia with potent CYP 3A4 inhibs
(CI with PI’s and macrolides)

BETA BLOCKERS, Triptans

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16
Q

Medication Overuse Headache (Rebound HA) : Adjunctive tx
1. Pt’s should limit medication to average of how many times a week?

  1. Migraines with med overuse causing rebound can be accompanied by ?
  2. Adjunctive tx : Pretx w/antiemetic –> Which 2 drugs are u gonna consider?
A
  1. 2 days/week
  2. N/V
  3. Metoclopramide (reglan) 10-20 mg PO, 15-30 mins before abortive medications

-Compazine 10 mg PO or 25mg rectal suppos then q4h prn

17
Q

Chronic Migraines
1. Headaches how often ?

  1. When should we consider preventative migraine tx?
  2. Define overuse
A
  1. HA>=15 days/month for >3 months AND >= 8 days of migraine sx’s
  2. based on number of HA days/months or degree of disability
    -CI to , failure or overuse of acute tx
    -ADE with acute tx option , and patient preference
  3. > 10 days/month for DHE, triptans, opioids, combo analgesics

> =15 days/month for non opioid analgesics, nsaids, and APAP

18
Q

Prophylaxis Reccs :
1) First line options? (7)
2) Second line ? (6)

A
  1. Divalproex, frovatriptan
    Metoprolol, propanolol , timolol
    Topiramate, ANti CGRP MABS and CGRP antags —> CGRP therapies now first line for prevention
  2. Amitriptyline, atenolol , nadolol
    naratriptan, venlafaxine, zolmitriptan
19
Q

Beta Blockers :
1) Prevent ___ or ___
2. does not reduce ___
3. Propanolol , Metoprolol, Timolol dose
4. AE’s ?

Antiepileptics :

Delayed Release Divalproex
1. FDA approved for
2. for which group of pt’s?
3. Preg categ X , and avoid use in ?

Topiramate
1. as effective as ?
2. preg categ D (dont use!)
3. Also dont use in the following

A
  1. Vasodilation , serotonergic effects
  2. aura
  3. 40 mg PO BID-TID
    50mg PO BID
    20-30mg PO daily
  4. Bradycardia, fatigue, hypotension, depression, decr exercise tolerance, nightmares, insomnia, and impotence
  5. Migraine prevention!
  6. < 65 yrs
  7. Liver disease
  8. amitriptyline and propanolol
  9. Glaucoma, kidney stones, liver disease
20
Q

Antidepressants : Amitriptyline
1. Dose?
2. MOA
3. ADR’s
4. CI?

ANtidepress : Venlafaxine
1. Dose ?
2. MOA?
3. When discontinuing, taper ____

A
  1. 10-25 mg QHS
  2. block 5HT re-uptake at central sites
  3. sedation, ortho hypo, anticholinergic in old peeps , weight gain, dry mouth
  4. Narrow angle glaucoma, cardiac arrhythmias, bipolar, uncontrolled epilepsy
  5. 37.5 mg PO daily x 3 days –> 75 mg daily x 3days –> 150 mg daily
  6. selective Serotonin/NE reuptake inhibitor
  7. taper slowly to avoid withdrawal sx
21
Q

Cluster HA :
Males > Females
1. Sx’s?
2. No __ and NO ___
3. What can precipitate?
4. usually self limiting and lasts ?
5. Tends to be “clustered” around same time each year and can last ??

A
  1. Usually unilateral. Deep, sharp pain usually centered around same eye. Lacrimation, rhinorrhea, eyelid drooping
  2. aura. NV
  3. Smoking, alc, and naps
  4. 15mins-2 hrs
  5. days - weeks (can occur daily)
22
Q

Cluster HA -Abortive TX
1) what are the 2 regimens u can use?
2) What can you use for prophylaxis + tx? (Injection )

3) What are other prophylaxis regimens for cluster headaches? (3)

A
  1. O2 inhalation 6-12 L/min x 10-15 mins
    -rapid acting triptans (Sumatriptan SQ 6 mg at onset, zolmatriptan NS 5-10 mg at onset)
  2. Galcanezumab (EMGALITY) : 300 mg SQ at cluster onset and then monthly until end of cluster period
  3. Verapamil (preferred) initially 80 mg PO TID , Prednisone 40mg QDx2days then taper,
    Lithium 300 mg BID(second line)
23
Q

Tension HA : Most Common Type of HA

  1. Presentation
    -___ HA that worsens thruout day
    -location ?
    -can be associated with ?
    -can occur when ?
    -duration is more variable than ___
    -What can precipitate?
    -What can improve?
  2. ABortive therapy options? (3)
  3. Prophylaxis?
A
  1. DULL
    - variable, bandlike, starts at top or back of head then generalize
    - depression or anxiety
    -daily
    -cluster HA
    -Stress and fatigue
    -relaxation , alcohol
  2. Non opioid analgesics (APAP, nsaids, ASA, combo product with doxylamine)
    -Butalbital and codeine combos (should be avoided)
    -Sedatives/anxiolytics (Butalbital and diazepam)
  3. Amitriptyline 30-75 mg /day –> should taper down /discontinue after 3-4 months if effective

-Mirtazapine 30mg
-Venlafaxine 150 mg/day

Oncology Therapeutics (17 decks)

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