Headache Flashcards
Headache disorder classifications:
- primary h/a disorder
2. secondary h/a disorder
Name 3 types of primary headache disorder
migraine, tension-type h/a’s, and cluster h/a’s
Which gender suffers from migraines more?
Females
Why are migraines a huge economic burden?
Bc they often affect ppl during the most productive yrs of life
What is the most accepted etiology of migraines?
complex dysfns in neuronal and sensory processing
Where does migraine pain START?
trigeminovascular system activity
Pathophysiology of migraines:
Trigeminal sensory nerves activate > vasoactive neuropeptides released > vasodilation of dural blood vessels > inflammation > pain impulses travel along trigeminovascular fibers > pain impulses arrive at trigeminal nucleus and higher cortical pain centres > continued pain input from afferent sensory fibers > hyperalgesic state > previously innocuous stimuli now cause h/a perpetuation
What’re the 4 phases assoc w/ the clinical presentation of migraine h/a’s?
premonitory sx’s, aura, migraine attack, postdrome
Distinguishing feature of premonitory phase of migraine h/a’s.
There’s no pain involved
Premonitory phase of migraine h/a synonyms:
prodrome, warning
Common sx’s of premonitory phase of migraine h/a’s?
- neurological (allodynia [pain from normally non-painful stimuli], phono/photophobia)
- psychological (anxiety, dep, euphoria)
- autonomic (polyuria, diarrhea)
- constitutional (neck stiffness, yawning, thirst)
How long before migraine attack do premonitory sx’s usually appear?
hours to days before h/a
how long before a migraine h/a do auras usually appear?
5-20mins
Sx’s of aura?
Often visual (flashes, colours appear brighter, blind spot, sig blindness)
sensory and motor sx’s are also possible
How long do migraine attacks usually last
4-72h
T or F: All migraine sufferers experience auras before their migraine attacks
F
What is the most important element in establishing a clinical dx of migraine?
a h/a hx
Shorthand way of dx’ing migraine:
POUND
- pulsatile
- one to three day duration
- unilateral
- N/V
- Disabling intensity of h/a
Red flag sx’s assoc w/ h/a (refer immediately):
- suspected stroke/TIA
- head trauma
- h/a gets worse
- memory loss
- suspected glaucoma (eye pain = major sx)
- sudden onset (seconds to 5 mins)
- worst h/a ever
- fever, neck stiffness, impaired level of consciousness accompany h/a
What’s the main goal when tx’ing migraines?
Getting the pt to return to normal activities within 2h’s of tx
Primary non-pharm approach to migraine tx:
Identify and avoid triggers
What approach to tx should be used when tx’ing acute migraines?
stratified approach
What’s the stratified approach to tx’ing migraines?
severity of migraine informs tx choice (i.e. drug is chosen based on how bad the migraine is/how disabled the pt is by it)
What are the advantages of using a stratified approach to acute migraine tx?
Works faster + lower numbers of initial tx failures
T or F: Opioids are first line for acute migraines.
F > weak evidence
What can be added if pt is experiencing N during an acute episode of migraine?
metoclopramide
Which drug classes have been shown to be the best for tx’ing acute migraines?
triptans, NSAIDs (inc. ASA), and acetaminophen
MOA of triptans
5HT-1B/1D agonists
vasoconstriction of meningeal blood vessels, inhibit vasoactive neuropeptide release by trigeminal nerves, and inhibit pain signal transmission
CI of triptans
Cerebrovascular/cardiac dz, HTN (since triptans constrict cerebral blood vessels), hemiplegic migraine
If s.o is experiencing N/V during an acute migraine, what route(s) of triptan should be used for triptan admin?
Nasal or SC
T or F: Serotonin syndrome is possible with triptans.
T (it’s a 5HT agonist)
When should triptans be taken?
At earliest onset of migraine pain
T or F: Taking a triptan before onset of pain (i.e. during premonitory or aura phases) is more effective than taking it during the acute migraine phase.
F
Which triptans are postulated to be the most effective in relieving acute migraine pain?
Eletriptan and rizatriptan
Why would rizatriptan be preferred over eletriptan in SK?
Rizatriptan (eletriptan is non-forumulary in SK)
Sumatriptan + naproxen combo tx has been shown to be better for acute migraine tx than either monotx.
T
What should triptans not be used with? Why?
dihydroergotamine (DHE) > additive vasoconstriction
Ergots - MOA
5-HT-1D agonists > vasoconstriction of intracranial blood vessels and inhibition of proinflam neuropeptide release
T or F: Ergots and triptans have similar MOAs
T
T or F: Ergots are first line for acute migraines
F (NSAIDs/triptans/acetaminophen are)
Regular intake of ergotamine or DHE can cause what?
Ergotism and gangrenous sx’s
When would dihydroergotamine be used?
moderate-sev migraine attacks or refractory h/a’s
Sumatriptan nasal spray vs. dihydroergotamine nasal spray: which is better for acute migraine tx?
sumatriptan nasal spray
Opioids: Place in tx for acute migraine?
None - they do not change the pathophys of acute migraines
MOA of antiemetics used for migraine-induced N/V?
D2 antagonists (reduces N), increases absorption of other meds, decreases gastric stasis
Which oral antiemetic is used for migraine-induced N/V?
metoclopramide
What can be used for acute migraines if triptans are CI’ed or not tolerated?
Metoclopramide + analgesic (NSAID)
T or F: Tx’s for migraines can end up causing migraines if used too much.
T (medication-overuse headache)
What are the diagnostic criteria for med-overuse h/a?
- h/a for ≥ 15 d/month in a pt w/ pre-existing h/a disorder
2. regular overuse for > 3 months of ≥ 1 drug that is used for h/a tx
T or F: In med-overuse h/a’s, analgesic overuse can lead to migraine h/a’s, whereas triptan overuse can lead to tension-type headaches
F
Other way around (analgesic > tension-type; triptan > migraines)
Which med classes are consistently linked to med-overuse h/a’s?
Opioids and barbiturates (hence another reason to avoid them to tx h/a’s)
What med class is MOH-protective? What is the caveat to its protective property?
NSAIDs > protective if used for < 10d/month
When should a migraine sufferer be admitted into hospital?
- status migrainosus - severely painful and lasting > 72h
- severe N/V that leads to dehydration
- detox from overuse of combo of analgesics, ergots, or opioids
What should be used for status migrainosus?
1L of NS bolus (PRN); if not effective…
sumatriptan (if triptans/DHE not tried yet) and/or ketorolac; if not effective…
metoclopramide; if not effective…
DHE + metoclopramide
When should DHE be taken if triptan taken previously?
12h after triptan dose
How long will migraine prevention tx take?
Several weeks for full effect
When is migraine prevention indicated?
When there’s sig disability or reduced QoL despite appropriate acute tx
When should preventative tx of migraines be tapered/stopped?
After 6-12 mths of benefit
When are preventative tx’s of migraines considered to be successful/beneficial?
when freq of attacks are reduced by ≥ 50%
OR
when number of days w/ headache/month is reduced by ≥ 50%
First line for migraine prophylaxis:
Beta blockers (propranolol, metoprolol, timolol) or TCAs (amitriptyline, nortriptyline)
1st line for severe migraine prophylaxis:
Anticonvulsants
Which anticonvulsants are recommended for severe migraine prophylaxis?
Valproate, topiramate
Which anticonvulsant is NOT recommended for severe migraine prophylaxis?
Gabapentin
CCB effectiveness in migraine prevention?
Limited data, so usually avoid
Botulinum toxin place in tx for migraine prophylaxis?
For chronic or episodic migraines
When must migraines occur in a woman’s cycle for them to be considered “menstrual migraines”?
2d before to 3d after menstrual bleeding
Prevention tx for menstrual migraines:
- NSAIDs
2. Triptans
What has chasteberry been used for?
Menstrual migraine
T or F: NHPs are usually used before Rx products wrt migraine tx
F
Pediatric tx options for migraines?
Similar to adults:
- NSAIDs
- Triptans
- Sumatriptan + naptroxen combo
Preventative tx for migraine in pediatrics is better supported compared to adults.
F
1st line migraine tx in preggos?
Non-pharm stuff
If meds req’d, what’s 1st line in preggos for migraine tx?
Acetaminophen
If meds req’d, what’s 2nd line in preggos for migraine tx?
ibuprofen, naproxen
What should we know about NSAID use in preggos for migraines?
Avoid in 3rd trimester
If meds req’d, what should we use if migraine is assoc w/ severe N in preggos?
Metoclopramide or prochlorperazine
If meds req’d, what’s used for prophylaxis in preggos?
propranolol, magnesium
1st line for migraine tx in lactating mothers?
acetaminophen
2nd line for migraine tx in lactating mothers?
ibuprofen (preferred NSAID)
What two meds are avoided when tx’ing migraines in preggos?
Ergot derivatives and triptans
What’s first line in preggos for migraine prophylaxis?
propranolol, Mg
T or F: Valproic acid/divalproex is CI in lactating mothers for migraine prophylaxis.
F (they’re compatible)
Sx’s of tension-type h/a’s
pain is bilateral, nonpulsatile, mild photophobia/phonophobia may occur, pericranial tenderness
1st line for tension h/a tx?
ibuprofen, naproxen, acetaminophen
What ISN’T helpful for tension h/a’s?
codeine products, muscle relaxants
Mainstay for tension h/a prophylaxis?
lifestyle measures
T or F: Caffeine combination products w/ simple analgesics are more effective for tension h/a’s than simple analgesic monotx.
T
What is a post-traumatic h/a?
a h/a that develops within 7 days of a. head injury, b. regaining consciousness post-injury c. d/c’ing med that prevented sensation of h/a following head injury
How should post-traumatic h/a’s be tx’ed?
Based on standard acute tx protocols (e.g. if it presents like a migraine, tx with migraine meds, etc.)
This type of h/a is aggravated by physical activity
Migraines
This type of h/a lasts 30 mins to 7d
Tension
Pressing and tightening pain is characteristic of which type of h/a?
Tension
Describe the pain experienced during a migraine
Throbbing, pulsating
N/V may accompany this type of h/a
Migraine
T or F: N/V may be present in both migraines and tension h/a’s.
F (not tension h/a’s)
How are simple analgesics (acetaminiophen, NSAIDs) used in migraines?
first line for mild-mod migraine attacks
How are simple analgesics used in tension h/a’s?
first line +/- caffeine
How are triptans used in migraines?
1st line for mod-severe attacks
How are triptans used in tension h/a’s?
usually no role
How is DHE used in migraines?
mod-severe pain if triptans fail/not an option
How is DHE used in tension h/a’s?
no role
How’re antiemetics used in migraines?
adjunctive role w/ simple analgesics or migraine specific tx for aborting migraine
How’re antiemetics used in tension h/a’s?
limited role
