Headache Flashcards
primary headaches
migraine
cluster
tension
medication overuse headaches
secondary headaches (mass, edema, fluid)
blood/bleeds/clots
brain tissue
cerebral spinal fluid
other causes
red flags for headaches (SN3OOP8 DOG)
systemic symptoms
new onset
neoplasm history
neurologic deficits
older (≥50 or ≤ 5)
onset is acute
papilledema
positional
pattern change
progressive headache with an atypical presentation
pushing pain (valsalva maneuvers)
pregnancy or postpartum period
post traumatic onset of headache
pathology of immune system
drug over or misuse/coagulation
ocular
giant cell temporal arteritis
triggers for migraine
red wine, chocolate, cheese, genetics, hormone meds = oral contraception pills, stress
what causes aura in migraine
Cortico-spreading depression [CSD] theory
contraindication for migraine
NEVER use OCP with migraine with aura
which nerve is triggered causing the sensation of headache pain
CN 5 tirgeminal ganglion
migraine: A POUND
Aura
Pulsatile
One day duration
Unilateral (except pediatric population-bilateral)
Nausea
Disabling
Drugs for migraine
ergots and triptans
Pharmacologic Tx for migraine (MOA)
- decrease neuropeptide release
cause direct vasoconstriction
Triptans MOA
act on serotonin (5-HT) subclass 1B and 1D receptors found on blood vessels and neurons to inhibit the release of vasoactive neuropeptides, decreases trigeminal nerve CN 5 activation and causes vasoconstriction of the pain-sensitive blood vessels.
triptans contraindications
do not use if any cardiac like symptoms
serotonergic medication- serotonin syndrome
drug interaction of triptan with
warfarin: increased anticoagulation effects
antihypertensive
lithium
do not use with MAOIs
ergot alkaloids MOA
Agonists to 5HT receptors but are non-specific. Ergots have similar actions to the triptans but also interacts centrally with dopamine and adrenergic receptors, accounting for some of its side effects.
contraindication for ergots
contraindicated cardiac disorders, hypertension, sepsis, PVD, PUD, renal or liver disease,
contraindicated in pregnancy
Patients taking potent inhibitors of CYP3A4
Serotonergic medication: serotonin syndrome
Ergotism [intoxicate with ergot alkaloids] symptoms
Spasms
Seizures
Psychiatric symptoms
Gastrointestinal symptoms
Gangrene in hands/feed [vasoconstriction of limbs]
Tx of ergotism
Tx this with anticoagulants, vasodilators, low molecular weight dextran
acute management for migraine 1st line
Nonpharmacologic [e.g., dark room, rest, quiet, cold/heat to head]
Hydration [IV bolus fluids]
Anti-emetics [antiemetic/prokinetic agents (e.g., metoclopramide and domperidone) 1st line], also Antinauseants (e.g., dimenhydrinate)
Analgesics: Acetaminophen, ASA** or NSAIDS* [decrease inflammation/pain at the first sign of attack]
Triptan* nasal spray or IM
Pediatrics: Intranasal 2% lidocaine [off label]
acute management for migraine 2nd line
Ergots] nasal/IM/IV/SC
Dexamethasone glucocorticoids steroids
Occipital nerve blocks using anesthetics
migraine prophylactic treatment
Beta blockers
Anti-seizure medications
Tricyclic anti-depressant agents
SNRI Venlafaxine
Calcium channel blockers (ECG baseline required and careful titration of dose with close monitoring to cardiac symptoms )
Serotonin Modulators
Occipital nerve blocks using anesthetics
Botox
new medications for migraine
Anti-CGRP antibodies
atogepant
rimegepant
natural health products for headache
Butterbur (Petasites hybridus extract) Must be pyrrolizidine alkaloids (PA) free – liver toxic of PA
Magnesium citrate
Riboflavin (Vit B2)
Coenzyme Q 10
Melatonin [as effective as amitriptyline]
triggers for cluster headache
Sex: most common male at birth individuals
Genetic component/predisposition hypothalamic dysregulation
stress, smoking [tobacco/THC], wine [histamine/circadian rhythm disruption]
pathophysiology of clustered headache
hypothalamus mediated by a change in neurohumoral and behavioural rhythms can lead to:
Dysregulation of melatonin production (sympathetic pathway)
Triggering/activating the connections with the trigeminal nucleus (trigeminovascular pathway) and the superior salivatory nucleus (parasympathetic pathway) activating the trigeminal autonomic reflex
clinical manifestation of clustered headache
(A CLUSTER)
A-autonomic parasympthetic (rhinitis, lacrimation, conjunctival hyperemia, miosis, ptosis)
C- clustered (vary 5 min-3 hours per episode, multiple episodes)
L- lads (male)
U- unilateral orbital/supraorbital
S- stabbing/burning/sharp
T- teaching/assessment for suicidal ideation
E- exacerbations/remissions
R- restless/pacing/moving
1st line treatment acute clustered headache
O2
triptans nasal spary/IM
2nd line treatment for acute clustered headache
ergots nasal/IM/SC/IV
lntranasal lidocaine
1st line maintenance/prevention treatment for clustered headache
calcium channel blocker
anticonvulsive (topiramate, valproate)
bridging- prednisone to decrease the inflammation 50-80 mg with tapering over 2 weeks until the anticonvulsant are therapeutic
tension headache triggers
muscle tension
dehydration
stress
sleep deprivation
pathophysiology of tension headache
chronic stress response (elevation of glutamate, NMDA receptors activation, nitric oxide and COX enzymes)
precranial tension stimulate MSK vascular nociceptor neuron inflammation and pain in cerebral cortex
clinical manifestations of tension headache
bilateral
frontal & temporal
non-puslating
30 min-1 week
MUST have no nausea/vomiting, no phonophobia or photophobia, no aura
MUST not be worse with exertion
If they are more frequent/long = r/o OTC overuse of NSAIDs or Tylenol – rebound headaches.
2 types of tension headache
episodic ( at least 10 episodes < 15 days per month for at least 3 months)
chronic tension headache >15 days per month for a duration >3 months.
treatment for acute tension headache
avoid triggers
resting/dark/quiet
hydration
NSAIDS
Tylenol
Caffeine
treatment for chronic tension headache
1st line:
tricyclic antidepressants
cognitive behavioural therapy
massage therapy
physiotherapy
2nd line: other antidepressants
medication overuse headache
medication overuse defined as:
≥10 days/month for ergot derivatives, triptans, and combination analgesics; this also includes combinations of agents from different drug classes that are not individually overused
≥15 days for non-opioid analgesics: acetaminophen and NSAIDs
Giant Cell Temporal Arteritis
inflammation/vasculitis of the temporal artery +/- associated with history of Polymyalgia Rheumatica [PMR], geriatric population [headache is over the temporal area, usually unilateral, very sensitive to superficial touch/pain – brushing hair, light touch to temporal area creates pain, facial/jaw claudication/vasculitis s/s weakness or fatigue of the mastication muscles, difficulty/painful chewing,
visual changes [ophthalmic artery vasculitis] can lead to permanent blindness, ESR/CRP elevated
start prednisone and ER referral for temporal artery biopsy
triptan (best tolerated-2)
Almotriptan: [best tolerated than other triptans]
Naratriptan [best tolerated than other triptans]
Frovatriptan contraindications
oral contraceptives and propranolol may increase frovatriptan serum concentrations by 30–60%
Eletriptan contraindications
contraindicated within 72 h of potent CYP3A4 inhibitors, e.g., clarithromycin, itraconazole, ketoconazole, nelfinavir, ritonavir
rizatriptan contraindicated
do not use with MAOIs & caution with propranolol increases bioavailability
Sumatriptan contraindication
not with MAOIs
Zolmitriptan contraindication
do not use with MAOIs.
Maximum dose of 5 mg/24h if also taking CYP1A2 inhibitor (e.g., fluvoxamine, cimetidine
