headache Flashcards
examples of primary headache
migraine, tension type, or cluster and other trigeminal autonomic cephalgias
define secondary headache and give example
caused by an underlying medical disorder. medication overuse headache
examples of headache triggers
hormonal, environmental, emotional (stress, menstruation, weather, caffiene)
define chronic headache
occurs 15+ days/month for 3+ months
define status migrainosus
severe and debilitating migraines for 72+ hours
who is brain imaging recommended for diagnosis of migraine headache
pts with risk factors of intracranial pathology (acute onset, 55+, abnormal neuological exam)
localized neurological signs (numbness, tingling)
Frequent, prolonged, severe attacks
To classify tension headaches as episodic how often do they occur
3 days per month
to classify tension headaches as chronic how often do the occur
15+ times per month
What is the most common type of primary headache
tension
tension headaches are more common in which gender
female
what is the least common type of primary headache
cluster
cluster headaches are more common in which gender
male
cluster headaches pathophysiology
unsure. possibly hypothalamic dysfunction
Causes of cluster headaches
genetics
tobacco/alcohol use
how often are episodic cluster headaches
lasting weeks to months with remission
how often are chronic cluster headaches
1 year without remission or remission less than 1 month
frequency of cluster headaches
once every other day to 8 per day
Headache Alarm symptoms
acute onset of first or worst headache ever
accelerating pattern of headaches after initial subacute presentation
onset of headache after 50
headache assocaited with systemic illness (fever, N/V, neck stiffness, rash)
headache with focal neurological symptoms or papilledema
new onset headache in patient with cancer or HIV (immunocompromised)
how many attacks to diagnose migraine without aura
5+
how many attacks to diagnose migraine with aura
2+
how many attacks to diagnose tension type headache
10+ attacks on average < 1 per month
how many attacks to diagnose cluster headache
5+ attacks on average 1+/day more than half of the time
migraine without aura must have 2+ of these characteristics
pain increase or decrease with physical activity
unilateral
pulsating
moderate to severe intensity
migraine with aura must have 1+ of these characteristics with no motor weakness
visual symptoms (+/-) sensory symptoms (+/-) dysphasic speech, moerate or severe intensity
tension type headache must have 2+ of these characteristics
bilateral
nonpulsating
mild or moderate
cluster headache characteristics
unilateral
orbital, supraorbital, or temporal
sharp, stabbing, severe
migraine without aura must have 2+ of the following other symptoms
nausea vomiting photophobia phonophobia osmophobia
duration of migraine without aura
4 to 72 hours
migraine with aura must have 2+ of the following other symptoms
homonymous visual symptoms and/or unilateral sensory symptoms
1 aura develops 5+ minutes prior and/or a second aura develope in 5 minutes after HA start
duration 5-60 mintes
duration of migraine with aura
5-60 minutes
tension type headache must have 2+ of the following other symptoms
no nausea or vomitting AND either photophobia or phonophobia
duration of tension type headache
30 minutes to 7 days
cluster headaches must have 1+ of the following other symptoms
conjuntival injection and/or lacrimation
nasal congestion and/or rhinorrhea
eyelid edema
duration of cluster headache
15-180 minutes
goals of therapy for headache
reduce attack frequency, severity, and disability
reduce reliance on ineffective, poorly tolerated acute treatment medications (avoid overuse and dependence of analgesics)
improve QOL
avoid acute headache medication escalation
reduce headache related distress and psychological symptoms
reduce frequency and severity within a cluster series
delay or eliminate recurrent periods
non pharm treatment of headache
headache diary avoid exposure to triggers behavioral interventions reduce alcohol and tobacco use accupuncture psychological intervention relaxation techniques
medications that can trigger headache
nitrates, estrogen/oral contraceptives, nifedipine, ondansetron, indomethacin, cimetidine
what medications can cause headaches as withdrawl from overuse
analgesics, Benzos, decongestants
behavioral headache triggers
fatigue menstruation or menopause sleep excess or deficit stress vigorous physical activiy
environmental headache triggers
flickering lights high altitude loud noises strong smells tobacco smoke weather changes
food headache triggers
alcohol caffeine intake or withdrawl chocolate citrus fruits, bananas, figs, raisins dairy products fermented or pickled products MSG containing (asain, seasoned salt) Saccharin/aspartame (diet soda/food) Sulfites (shrimp) Tyramine (cheese, wine, organ meats) Yeast (breads)
Pharm treatment for mild-moderate migraine
APAP+ASA+ caffeine; NSAIDS
Pharm treatment for moderate-severe or when simple analgesics not effective
Triptans
Triptans used to treat migraines
almotriptan eletriptan frovatriptan naratriptan rizatriptan sumatriptan zolmitriptan
AEs of triptans
dizziness, warm sensation, chest fullness, nausea
RARE: ischemic event due to vasoconstriction
MOA of triptans
selective 5HT 1B/1D/1F agonists
vasoconstriction
inhibit inflammation
central inhibition of pain
Contraindications to all triptans
cardiovascular: ischemic heart disease, angina, mocardial infarction, myocardial ischemia, PVD
cerebrovascular: TIA, stroke
Uncontrolled HTN
within 24 hours of ergot derivatives
additional contraindication to eletriptan
use of CYP 3A4 inhibitors within 72 hours (azole antifungals, clarithromycin)
additional contraindication to naratriptan
CrCl < 15 and/or severe hepatic impairment
Almotriptan brand name
axert
eletriptan brand name
relpax
frovatriptan brand name
frova
naratriptan brand name
amerge
rizatriptan brand name
maxalt / maxalt MLT
sumatriptan brand name
imitrex
sumatriptan/naproxen brand name
treximet
zolmitriptan brand name
Zomig / Zomig ZMT
Almotriptan routes
oral
eletriptan routes
oral
frovatriptan routes
oral
naratriptan routes
oral
rizatriptan routes
oral
ODT
sumatriptan routes
subQ
oral
Sumatriptan/naproxen route
nasal spray
oral
Zolmitriptan routes
oral
ODT
nasal spray
almotriptan drug interactions
ergot derivative
eletriptan drug interactions
CYP 3A4
CYP 2D6
ergot derivatives
frovatriptan drug interactions
CYP 1A2
ergot derivatives
naratriptan drug interactions
CYPs, ergot derivatives
Rizatriptan drug interactions
Ergot derivatives
MAO-A Inhibitors
Sumatriptan drug interactions
ergot derivatives
MAO-A inhibitors
Zolmig drug interactions
CYP 1A2
ergot derivatives
MAO-A inhibitors
ergotamine alkaloids used in migraine
dihydroergotamine (DHE)
ergotamine
MOA of ergotamine alkaloids
typtaminergic, dopaminergic, alpha adrenergic receptors
vasoconstriction
AEs of ergotamines
nausea (give antiemetic)
Pregnancy category of ergotamines
X
Contraindications with ergotamines
Cardiovascular: ischemic heart disease, angina, MI, myocardial ischemia, PVD
Uncontrolled HTN
Use within 24 hours of triptans and other serotonin agonists, ergot-like agents
Severe hepatic/renal impairment
Sepsis
Pregnancy/nursing
How are opioids used for migraine
rescue therapy
when is butorphanol nasal spray used for migraine
when others are contraindicated
AEs of opioids
sedation drowsiness dizziness n/v constipatoin (nasal congestion/insomnia with nasal spray)
Which medications are not used in tension type headache
butalbital combos
opioids
benzos
tension headaches are typically treated how
nonpharm (ice pack/massage) and OTC (NSAIDS, APAP)
what is given for tension headache if nonpharm/OTC not effective
antidepressant with sedative effects (amitriptyline)
What routes are preferred for cluster headache
non-oral
What medications are recommended for cluster headache
sumatriptan subQ and zolmitriptan nasal spray
4 medications that can be used for cluster
triptans
oxygen
lidocaine/cocaine hydrochloride
octreotide
Medication overuse headache occurs how often
15+ days per month
what medications contribute to medication overuse headache
ergotamine triptans opioids combo analgesics simple analgesics
how long is a medication taken regularly before medication overuse headache
3+ months
How long after d/c medication will medication overuse headache resolve
within 2 months
how to manage medication overuse headache
aburpt stop better than taper
TCA
Who should get headache prevention
frequent, severe, or lead to significant disability
Migraines with neurologic focality
APAP/NSAIDs 2+ days/week
medications used to prevent migraines
beta blockers ACE/ARB Antidepressants Antiepileptics Triptans Alpha agonists
Which beta blockers are used for migraine prevention
propranolol metoprolol timolol atenolol nadolol
Which ACE/ARBs are used for migraine prevention
lisinopril
candesartan
Which antidepressants are used for migraine prevention
amitriptyline
venlafaxine
Which antiepileptics are used for migraine prevention
divalproex sodium
sodium valproate
topiramate
carbamazepine
Which triptans are used for migraine prevention
frovatriptan
zomitriptan
naratriptan
which alpha agonists are used for migraine prevention
clonidine
guanfacine
What medications are used to prevent tension headache
similar to migraine TCA muscle relaxants botulinum toxin (severe cases) intranasal capsacin suboccipital steroid injection verapamil lithium melatonin
What medications can be used to manage headache in pregnancy
APAP
antiemetics
opioids
corticosteroids
What headache medications are contraindicated in pregnancy
NSAIDs Triptans Ergotamines beta blockers calcium channel blockers antiepileptics
