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Headache Flashcards

1
Q

Sinus HA

A

Pain is behind browbone and/or cheekbones

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2
Q

Cluster HA

A

Pain is in and around one eye

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3
Q

Tension HA

A

Pain is like a band squeezing the head

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4
Q

Migraine HA

A

Pain, nausea and visual changes are typical of classic form

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5
Q

Migraine criteria

A

5 attacks of

  • HA lasting 4-72hrs
  • Must be associated with N or V or photophobia/phonophobia

Must have 2 or the following

  • Unilateral
  • Pulsating
  • Moderately severe
  • Aggravated by physical activity
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6
Q

Acute therapy

A
  • Match agent to HA intensity
  • Prescribe an adequate dose
  • Consider the route
  • Avoid rebound (can have rebound headache with pain meds)

Goals:

  • Treat attacks rapidly and consistently without recurrence
  • Restore pt’s ability to function
  • Minimize use of back up and rescue medications (used at home when other treatments fail; permits pt to achieve relief w/o discomfort and expense of visit to physician’s office or ED)
  • Optimize self-care and reduce use of resources
  • Be cost effective for overall management
  • Have minimal or no adverse events
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7
Q

Nonpharmacologic Treatments

- Aimed at reducing stress

A
  • Acupuncture
  • Biofeedback
  • Message
  • Exercise
  • Regular sleep
  • Acupressure
  • Relaxation techniques
  • Diet changes
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8
Q

Abortive agents for self administration

A

Triptans

  • Sumatriptan (Imitrex)
  • Zolmitriptan (Zomig)
  • Rizatriptan (Maxalt)
  • Naratriptan (Amerge)
  • Eletriptan (Relpax)
  • Almotriptan (Axert)
  • Frovatriptan (Frova)

Dihydroergotamine (DHE)
Simple analgesics and NSAIDs
Compound preparations
Narcotics

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9
Q

I. Prodrome

A

Craving
Tired, yawning
Heightened perception
Fluid retention

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10
Q

II. Aura

A

Aura

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11
Q

III. HA

A 
Anorexia, N, V
Sleepy, yawning
Photophobia
Phonophobia
Osmophobia
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12
Q

IV. Postdromes

A

Limited food tolerance
Tired
Feeling high or low
Diuresis

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13
Q

Mild-moderate HA/migraines

A

OTC pain meds
Tylenol– worry liver
NSAIDs– worry ulcer

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14
Q

Caffeine

A
  • Most widely used psychoactive substance in the world
  • Methylxanthine
  • Competitively antagonizes adenosine receptors
  • Stimulant: tolerance rapidly develops
  • Withdrawal: HA, fatigue, sedation, N
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15
Q

Fiorinal/Fioricet

  • Fiorinal: Butalbital, aspirin, caffeine
  • Fioricet: Butalbital, acetaminophen, caffeine
A
  • INDICATION: tension HA
  • USE: migraine
  • ADR: N, abd pain, drowsiness, dizziness
  • Watch for over use, rebound HA, withdrawal (overuse- using more than 2x/weekly)
  • Preparations w/ codeine (CIII)
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16
Q

Triptans
- First line

  • Almotriptan (Axert): oral
  • Naratriptan (Amerge): oral
  • Eletriptan (Relpax): oral
  • Rizatriptan (Maxalt): oral, MLT
  • Frovatriptan (Frova): oral
  • Sumatriptan (Imitrex): subQ, nasal spray, oral
  • Zolmitriptan (Zomig): oral, ZMT, nasal spray
A
  • MOA: serotonin receptor agonist (5-HT1 receptor found on cranial arteries, basilar artery, dura mater vasculature); mediates vasoconstriction
  • Anti-migraine action: vasoconstriction, trigeminal inhibition, decreased pain transmission
  • INDICATIONS: Acute migraine w/ or w/o aura
  • USE: moderate/severe migraine, mild/moderate migraine that doesn’t respond to NSAIDs
  • ADR: coronary arter vasospasm, transient myocardial ischemia, MI, V tach, V fib; HTN; Paresthesias, fatigue, flushing; chest tightness; sweating
  • CONTRAINDICATIONS: basilar migraine; history, s/sx of ischemic cardiac, cerebrovascular, peripheral vascular syndromes; uncontrolled HTN; liver disease
  • DRUG INTERACTIONS: Serotonin drugs (will have elevated HTN), P450 drugs, antiemetics
17
Q

Central sensitization theory (Theory of how migraine works)

A
  • Pain
  • Allodynia
  • Hyperalgesia
  • May be due to activation of NMDA receptors
18
Q

Ergotamines

  • Ergomar (Ergotamine tartrate)
  • Cafergot (Ergotamine and caffeine)
  • DHE (dihydroergotamine)
A
  • Nonselective 5HT1 receptor agnoists
  • Direct stimulating effect on peripheral smooth muscle and cranial blood vessels–> vasoconstrictor
  • May have anti-inflammatory properties
19
Q

Dihydroergotamine (DHE)

A
  • MOA: binds 5HT, NE and DA receptors; stronger vasoconstrictor than nonhydrogenated ergotamines
  • INDICATION: acute migraine w/ or w/o aura; cluster HA
  • injection or nasal spray
20
Q

Ergotamines

  • INDICATION: abort or prevent vasulcar HA
  • NO CYP3A4 inhibitors (life threatening ischemia)
A
  • INDICATION: abort or prevent vascular HA
  • ADR: N/V (consider antiemetic pretreatment); abd pain, weakness, fatigue, paresthesias, myalgia, D, chest tightness
  • CONTRAINDICATION: renal/liver failure; vascular dz; uncontrolled HTN; pregnancy; breastfeeding; basilar or hemiplegic migraine
  • WARNING: Ergotism (st anthony’s fire)- HA, V/D, gangrene; Life threatening ischemia- Go administration with strong CYP3A4 inhibitors (macrolides and protease inhibitors), inhibitors increase ergot levels, can lead to cerebral or extremity ischemia
  • DRUG INTERACTIONS: other ergot, serotonin drugs; P450 3A4 inhibitors; vasoconstrictors
  • Caffeine potentiates effect and enhances absorption– vasoconstriction
  • oral, sublingual, rectal
21
Q

Options when self-administered therapy fails

A
  • IV DHE/prochlorperazine or metoclopramide
  • IV or IM lorazepam
  • IV divalproex
  • IM ketorolac
  • Steroids
  • IV chlorpromazine
  • Parenteral narcotics
22
Q

When to get head CT

A
  • Altered mental status
  • Worse headache ever
  • Late onset in life, when you’ve never had a headache and now first headache
23
Q

Prophylaxis

A
  • Avoid triggers: EtOH, skipping meals, OCP, no sleep , stress
  • Consider for pts with > 2 migraines weekly
  • Prescribe a dose suitable for an adequate length of time
  • Prescribe concomitant abortive medications
  • Avoid analgesic overuse
  • Encourage compliance
24
Q

Effective Prophylactic Therapy (Level A)

A

AED

  • Divalproex sodium (Depakote ER)
  • Topiramate (Topamax)
  • Sodium valproate

Beta blockers

  • Propranolol (Inderal)
  • Metoprolol (Lopressor, Toprol XL)
  • Timolol oral

Triptans
- Frovatriptan (Frova): menstrual migraine

25
Q

Natural medicines

A

Butterbur, Feverfew, Riboflavin, CoQ10, Capsicum, Guarana, Mate, Mg, Melatonin, Chasteberry, Fish oil, Willow bark, Peppermint oil, BoTox

26
Q

Butterbur

A
  • Petasites hybridus
  • Need to contain petasins
  • Look for PA free formulations (pyrrolizidine alkaloids, hepatotoxic)
27
Q

Migraine Prophylaxis length

A
  • Treat daily for 2-6 months
  • Continue for 3-6 months after HA diminish
  • Gradually taper and discontinue
28
Q

When prophylactic therapy fails

A
  • Confirm pt compliance
  • Determine if a positive response to therapy has been blocked by analgesic overuse, disrupted sleep, or other factors
  • Consider referral to a specialist
29
Q

Acute Migraine in Peds

A
  • Dosing by weight
  • Start with NSAIDs
  • Triptans: Sumatriptan, Rizatriptan, Zolmitriptan
30
Q

Peds Preventive therapy

A
  • AEDs
  • Antidepressants
  • Antihistamines
  • Antihypertensive (propranolol, clonidine)

Pharm (9 decks)

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