Headache Flashcards
what is a Medication-overuse HA or Rebound HA?
frequent or excessive use of acute migraine medications
HA returns as the med wears off
How many days per month can you take acute migraine therapies in order to avoid med-overuse ha’s?
fewer than 10 days per month
Presentation for migraine ha?
Recurring episodes of throbbing head pain
frequently unilateral
untx’d can last from 4-72 hrs
assoc w/ N/V and sensitivity to light, sound, and/or movement
Pathogenesis for migraine ha’s?
complex dysfunctions in neuronal and broad sensory processing
Activation of trigeminal sensory nerves triggers the release of vasoactive neuropeptides –> promote vasodilation and dural plasma extravasation –> neurogenic inflammation
sensitization of central sensory neurons, producing a hyperalgesic state that responds to previously innocuous stimuli and maintains the headache
OTC acute migraine therapies?
Analgesics- Acetaminophen, and aspirin/caffeine (excedrin migraine)
NSAID’s - Aspirin, Ibu, Naproxen, diclofenac
What are some Rx meds to tx acute migraines?
TRIPTANS
serotonin agonists (triptans
sumatriptan (imitrex)
Zolmitriptan
Metoclopramide and prochlorperazine
what are 2 older acute migraine therapies?
ergotamine tartrate and dihydroergotamine
ergot MOA for?
5-HT1 receptor agonists
Constrict intracranial blood vessels and inhibit the development of neurogenic inflammation in the trigeminovascular system
Triptan MOA?
Selective agonists of the 5-HT1B and 5-HT1D receptors
- normalization of dilated intracranial arteries through enhanced vasoconstriction
- inhibition of vasoactive peptide release from perivascular trigeminal neurons
- inhibition of transmission through second-order neurons ascending to the thalamus
appropriate 1st line therapy for pt’s w/mild to severe migraines?
TRIPTANS
what is the max daily dosage for sumatriptan alone? and a combination product of sumatriptan and naproxen?
200mg
combo = 85/500mg
what dose should you given of Rizatriptan if a pt is also on propranolol?
5mg (15mg/day max)
what medication should you given along with ergotamine tartrate?
pretreatment of anti-emetic
Patient education for nasal spray dihydroergotamine?
prime sprayer 4x before using
do not tilt head back or inhale through nose while spraying
discard open ampules after 8 hours
what 2 meds are useful for acute relief of migraine in office or ER setting?
metoclopramide (reglan)
prochlorperazine (compazine)
Triptan ADE’s
“triptan sensations”
tightness, pressure, heaviness, or pain in the chest, neck, or throat
MOA for sumatriptan
5-HT1D agonist
• causes vasoconstriction
• modulates neurotransmitter release
clinical applications for triptans?
migraine and cluster headache
P-kinetics for sumatriptan?
oral, inhaled, parental
duration = 2-4hrs
toxicities and interactions for triptans?
paresthesias, dizziness, CP and possible coronary vasospasm
triptans syndrome can cause…
serotonin syndrome:
neuroleptic malignant syndrome
malignant hyperthermia
therapy if pt gets serotonin syndrome??
Sedation (benzodiazepines), paralysis, intubation and ventilation
presentation of serotonin syndrome?
Hyperthermia, hyperreflexia, tremor, clonus, HTN, hyperactive bowel sounds, D, mydriasis, agitation, coma
onset w/in hours
presentation of neuroleptic malignant syndrome?
Hyperthermia, acute severe parkinsonism; hypertension, normal or reduced bowel sounds, onset over 1–3 days
tx for neuroleptic malignant syndrome??
Diphenhydramine (parenteral)
also, cooling if temp is very high, sedation w/ benzodiazepines
presentation of malignant hyperthermia?
Hyperthermia, muscle rigidity, HTN, tachycardia; onset w/in minutes
therapy for malignant hyperthermia?
dantrolene, cooling
what can be used for preventative therapy for migraine headaches?
Butterbur
FDA approved agents
- Propranolol, Timolol, Divalproex sodium, topiramate
when should consider preventative therapy for migraines?
in the setting of recurring migraines that produce significant disability despite acute therapy
- more than 2x per week d/t risk of med overuse HA
- sx. therapies ineffective or contraindicated
when do you see max benefits of therapeutic trial of preventative therapy?
by 6 mo’s of tx
prophylactic tx for migraines?
at least 6-12 mo’s after frequency and severity of ha’s have diminished
what are some prophylactic migraine therapies?
atenolol metoprolol nadolol *propranolol timolol
amitriptyline
venlafaxine
topiramate
valproic acid
*ibuprofen
ketoprofen
naproxen
frovatriptan
naratriptan
zolmitriptan
magnesium MIG-99 riboflavin melatonin butterbar
what drug is recommended for menstrual migraine prevention?
ibuprofen
frovatriptan - taken in perimenstrual period
Mechanism of pain in chronic tension-type ha?
myofascial factors and peripheral sensitization of nociceptors
central mechanism – heightned sensitivity of pain pathways in the CNS
nonpharm tx options for tension-type HA
CBT (stress, relax training, biofeedback)
heat/cold packs, U/S, massage, acupuncture, manipulations, trigger point injections
pharm tx’s for tension ha’s?
simple analgesics (acetominophen) or NSAID’s
high dose NSAIDs and combo of ASA or acetaminophen w/butalbital
Acute medications should be taken for episodic tension-type headache no more than
3 days (butalbital-containing)
9 days (combination analgesics)
or 15 days (NSAIDs) per month to prevent the development of chronic tension-type headache
preventative therapy for tension-type HA’s?
Similar to those for migraine headache
TCAs (tricyclic antidepressants)
cluster ha features?
excruciating, unilateral head pain that occur in series lasting for wks or mo’s (i.e., cluster periods) separated by remission periods usu lasting months or years
Activation of the ipsilateral hypothalamic gray area
hallmark of cluster ha’s
circadian rhythm of painful attacks.
cranial autonomic sx. assoc. w/cluster ha’s
Conjunctival injection Lacrimation Nasal stuffiness Rhinorrhea Eyelid edema Facial sweating Miosis/ptosis
Abortive therapy for cluster ha’s?
oxygen 100% by nonbreather facial mask 12L/min for 15 to 30 mins
triptan injections or sprays»_space; oral
Ergotamine Derivatives–> Clinically IV dihydroergotamine , or ergotamine tartrate
1st line prophylactic therapy for prevention of cluster ha’s?
Verapamil – given 2-3wks before benefit
Prophylactic therapy options for cluster ha?
verapamil
lithium
corticosteroids (prednisone)
also, intranasal lidocaine, hyperbaric oxygen, subQ octreotide
