Headache Flashcards
Acute nonpharmacologic treatments of tension type headache
- Heat
- Ice
- Massage
- Rest
- Biofeedback
What is the goal for limiting acute treatment of TTH?
- Less than 9 days/month
- Max of 2 doses/day
Initial monotherapy of TTH (outpatient)
What about inpatient?
- Oral ibuprofen (200 or mg)
- Naproxen (375 mg or 550mg)
- APAP 1000mg once
Inpatient centers may give one dose of ketorolac
Combination analgesic used for TTH
Excedrin (caffeine + APAP + ASA)
What is the most helpful tool to assess HA pattern and response to tx for migraine patients?
Headache diary
Non-pharm treatments of Migraines
Abortive: Relaxation techniques, ice massage
Prophylactic: Regular exercise, relaxation techniques, stress management, biofeedback, acupuncture, PT, diet
Why are many oral agents ineffective in migraines?
Poor absorption secondary to migraine-induced gastric stasis
When are migraine specific agents indicated?
- Moderate to severe migraine symptoms and in those whose HA’s respond poorly to NSAIDs
- Use non-oral route if early S/S with N/V
What medication classes are used for Mild-Moderate migraines?
- NSAIDs +/- APAP
- ergots
- “Triptans” ***
- “gepants”
- “ditans”
What drug is used as an acute adjunctive tx for patients with N/V?
- IV dopamine antagonism
- metoclopramide, prochlorperazine, promethazine
Which class of medications is an agonist on many serotonin receptors? Which drug is most commonly used?
- Ergots
- Dihydroergotamine
What is a common scenario in which we use Ergots?
May work for patients who have not previously responded to triptans
Dihydroergotamine is associated with what ADR’s?
N/V/D common
What are the ‘triptan’ drugs?
Sumatriptan *** Zolmitriptan *** Rizatriptan Almotriptan Eletriptan Naratriptan Frovatriptan ***
What is the end result of triptans agonizing serotonin receptors
Vasoconstriction of cranial arteries
What is a pearl about the use of Frovatriptan?
- Takes 2 hours to work and then has a 25 hour half life
- Good for patients with slow onset of symptoms
What is the clinical indication for the -triptans? What route is most effective?
- Moderate to severe acute migraine with or without aura
- SQ route is most effective (especially when patients have N/V)
What is a special indication for a sumatriptan injection?
Cluster headaches
In what patients are the triptans generally avoided in?
- Ischemic CVA/HD
- Ischemic CAD/PAD
- Ischemic bowel
- Uncontrolled HTN
- Raynaud’s
- Pregnancy
If triptans are an option for someone with cardiac RF, what must you do?
Cardiac eval before use
Triptan metabolism
- Sumatriptan and zolmitriptan are metabolized by MAO enzymes
- Avoid MAOI
Which drugs cannot be administered within 24 hours of triptans
Ergots due to enhanced vasoconstricting effects
What drug (which is commonly used for migraine prophylaxis) increases the concentration of triptans?
Propranolol
What are the ADRs associated with the three forms of sumatriptan?
- PO –> well tolerated with mild nausea
- SQ –> Burning sensation
- Intranasal –> Unpleasant aftertaste
What is the proposed mechanism of ‘gepants’
-small molecule CGRP antagonists to decrease pain signaling
What are the two ‘gepant’ drugs?
Rimegepant
Ubrogepant
What is the one “ditan” drug presented to us
Lasmiditan
What is a pearl about -gepants and -ditans?
Less effective than triptans but can be used in patients with vascular disease
What are the devices approved for acute treatment of migraines?
- Transcranial magnetic stimulation device
- Remote electrical neuromodulation device (band on arm)
- Transcutaneous electrical nerve stimulation (cyclops)
- Vagus nerve stimulation device
