Headache

Question 1

What are the 3 types of headaches?

Answer 1

Primary, Secondary, Medication overuse

Question 2

What are the types of primary headaches?

Answer 2

• Migraine
• Tension
• Cluster

Question 3

What are types of secondary headaches?

Answer 3

• Dental pain
• Subarachnoid hemorrhage
• Brain tumor

symptom of a secondary abnormality

Question 4

What is first line treatment for migraine?

Answer 4

Simple analgesics- NSAIDS, APAP, caffeine

Question 5

What are a/e of simple analgesics?

Answer 5

GI upset, somnolence, dizziness

Question 6

Use caution in what patients with simple analgesics?

Answer 6

• PUD
• Renal disease
• History of MI or stroke

Question 7

Why caution with opiods?

Answer 7

• rebound headaches

- addictive potential / dependence

Question 8

What about APAP alone?

Answer 8

ineffective in acute migraine treatment

Question 9

How does Triptan work?

Answer 9

Serotonin receptor agonist, results in vasoconstriction of intracranial arteries. It blocks pain pathway in brainstem

Question 10

Contraindications for Triptan?

Answer 10

• Uncontrolled HTN
• History of ischemic heart disease
• Cerebrovascular disease
• Combination with MAOI
• Pregnancy? (Cat C)
• SSRI

Question 11

Caution with what med and Triptan?

Answer 11

SSRI, small risk of serotonin syndrome

Question 12

Most triptans last how long?

Answer 12

3 hours

Question 13

Which triptan lasts a long time?

Answer 13

Naratriptan – 26 hours!

Question 14

A/E of triptans?

Answer 14

• chest symptoms “Triptan sensation” tightness, pressure, heaviness

Question 15

How do ergot alkaloids work?

Answer 15

non-selective serotonin agonist, causes vasoconstriction of intracrainial blood vessels

LAST LINE USUALLY

Question 16

Would you put patient on triptan & ergot alkaloid?

Answer 16

NO, both same mechanism

Question 17

A/E of ergot alkaloids?

Answer 17

• Ergotism (rare) psychosis with convulsions and gangrene in the toes

Question 18

What is ergot derivative?

Answer 18

LSD

Question 19

What is the common ergot?

Answer 19

DHE nasal spray

Question 20

Contraindications for ergot?

Answer 20

• Coronary / cerebral / PV disease
• Uncontrolled HTN
• Sepsis
• Hepatic and renal failure

Question 21

Risk with ergot meds?

Answer 21

Rebound headaches (like opioids)

Question 22

What are another types of med for migraines?

Answer 22

• Anti-emetics
• Corticosteroids
• Valproate (valporic acid, anti epileptic)

Question 23

What should you consider for status migrainosis?

Answer 23

• DHE (ergot)

- Valproate

Question 24

What is status migrainosis?

Answer 24

Migraine that has not broken in over 72 hours (usually classified if patient failed multiple therapies)

Question 25

Who should get migraine prophylaxis?

Answer 25

- 2 or more abortive therapies in a week - More than 15 migraines in a month - Contraindications or unsatisfied with abortive treatments

Question 26

Migraine prophylaxis options?

Answer 26

- Amitryptiline - Beta blockers (propranolol, timilol) - Calcium Channel Blocker (Verapamil) - Antiepilectics

Question 27

Who should not get Beta Blocker for migraine prophylaxis?

Answer 27

- Asthma - Depression GOOD for patent with HTN

Question 28

Who should not get amitriptyline for migraine prophylaxis?

Answer 28

- Mania GOOD for patient with depression

Question 29

Who should not get CCB prophylaxis?

Answer 29

- Depression GOOD for HTN, angina

Question 30

Who should not get anti-epileptics for migraine prophylaxis?

Answer 30

- Liver disease

Question 31

What is an uncommon migraine prophylaxis?

Answer 31

- Botox Blocks neuromuscular conduction by binding receptor sites on nerve terminals, prevents release of acetylcholine

Question 32

What is the most severe type of primary headache?

Answer 32

Cluster headache Treat with ABORTIVE + PROPHYLAXIS

Question 33

First line abortive treatments for cluster headaches?

Answer 33

- Oxygen (not patient friendly!) | - Triptans

Question 34

What else can you use for cluster headaches?

Answer 34

Ergotamine derivatives (DHE)

Question 35

What prophylactic treatment for cluster headaches?

Answer 35

- CCB (first line) - Lithium - Corticosteroids - Melatonin - Gabapentin / Topiramate

Question 36

Difficulty with CCB prophylaxis?

Answer 36

Takes full effect in 4-6 weeks

Question 37

Difficulty with lithium?

Answer 37

Monitoring, usually last line treatment

Question 38

What is most common type of headache?

Answer 38

Tension type

Question 39

Abortive treatment for tension?

Answer 39

- Analgesics: NSAIDS, APAP, ASA NSAIDS = mainstay of treatment

Question 40

What are other tension headache abortive?

Answer 40

- Combination products - Triptans - Muscle relaxants (not strong evidence)

Question 41

Potential triggers of medication overuse headaches?

Answer 41

- Narcotics - Triptans - Ergotamine - Benzos - Caffeine

Question 42

Classification for medication overuse?

Answer 42

15 or more days a month of headache

Question 43

First step for medication overuse HA?

Answer 43

Stop / decreasing amount of that medication

Question 44

Second line for medication overuse?

Answer 44

- Prednisone

Question 45

Third line for medication overuse?

Answer 45

- DHE