Headache Flashcards
What are the signs and symptoms necessary to meet the diagnostic criteria for migraine headache?
At least 2 of POUND –> pulsatile, one-day duration, unilateral, nausea/vomiting, disabling intensity
At least 1 of –> nausea/vomiting, photophobia or phonophobia
Describe an aura as it relates to migraine headaches.
Positive symptoms (flashing lights, slots, lines) or negative symptoms (loss of vision, blind spot, numbness) that occur within 60 minutes of the headache’s onset
Describes the general pathophysiology associated with all headaches.
Long thought to have a vasodilatory component. But recently discovered to also be caused by a range of pro-inflammatory factors.
How is chronic tension headache disorder defined?
Headache at least 15 days per month
What are 4 risk factors for tension headache disorder?
Coexisting migraine disorder, depression, anxiety, poor stress management
Describe the typical clinical presentation of tension headache syndrome.
Dull, non-pulsatile tightness or pressure of mild to moderate severity that is usually bilateral
T/F: Migraine is the most severe headache disorder.
False: cluster headache disorder is most severe
Describe the clinical presentation of cluster headache disorder.
Unilateral, deep, excruciating non-pulsatile pain usually in or near the orbital region.
Describe the typical duration interval of cluster headache disorder.
Attacks occur daily for weeks or months followed by long (sometimes years) pain-free intervals
Describe the term secondary headache, list some common causes, and describe generally how they are treated.
Headache is a symptom of some other abnormality such as infection, stroke, tumor, hypertension, or hypoxia. The headache is resolved by treating the underlying cause.
Describe the concept of medication overuse headache.
Headache for 15+ days per month with regular overuse of headache drugs for 3+ months
What are the long term goals in management of a headache disorder?
Reduce frequency, severity, and disability
Prevent recurrence
Improve quality of life
What are the short term goals in management of a headache disorder?
Treat migraines rapidly and effectively
Minimize use of rescue meds
Cause minimal or no AEs
What medications are used to abort a headache once the symptoms have started?
APAP, NSAIDs, triptans, ergotamines, getants, ditan, opioids (rare)
What medications are used as prophylaxis for headache disorder and in what comorbid conditions might they ne most beneficial?
Predictable pattern: NSAIDs or triptans
HTN or angina: beta-blockers
Depression or insomnia: TCAs or SNRIs
Seizure or bipolar disorder: anticonvulsant or beta blockers if anticonvulsants ineffective
What medications are considered to be first line in prophylaxis for headache disorders?
Beta blockers
Which beta blocker is specifically approved for prophylactic use in headache disorder?
Propranolol
What is true about dosing of anticonvulsants in headache prophylaxis?
Used in lower doses than for seizure disorders
Describe the use of calcitonin gene-related peptide (CGRP) antagonists.
Block CGRP receptor just like getants do. But these medications are used for prophylaxis where getants are used to abort headaches.
Why are CGRP antagonists not commonly used in headache prophylaxis?
High cost
All four CGRP antagonist medications end in what suffix?
-umab
T/F: Some CGRP medications are available PO.
False: all are given by injection
In what patients would you not want to use a beta blocker as prophylaxis?
Asthma, COPD, bradycardia, AV nodal blocks
What are the simple analgesic treatment options in the treatment of a headache?
APAP and NSAIDs
Describe the mechanism of action of APAP and NSAIDs.
APAP: Inhibits synthesis of prostaglandins primarily in the CNS
NSAIDs: Inhibits synthesis of prostaglandins systemically by blocking COX-1 and COX-2
What is the primary AE of APAP use?
Hepatotoxicity: monitor LFTs and avoid alcohol
What are the primary AEs associated with NSAID use?
Dyspepsia, N/V, somnolence, dizziness
What are the warnings/precautions to consider before prescribing NSAIDs?
Pregnancy, elderly, renal impairment, peptic ulcer disease, HTN, bleeding disorders
When considering NSAIDs for headache disorders, what strategy is employed to avoid medication overuse disorder?
Limit NSAID use to fewer than 10 days per month
What NSAIDs are commonly used in the treatment of headache disorder?
Aspirin, Ibuprofen, Naproxen, Diclofenac, Ketorolac
What is unique about the use of ketorolac for headache use disorder?
Limit to use for no more than 5 consecutive days
What are the three combination products used in the management of headache disorder
Excedrin: APAP, ASA, and caffeine
Fiorinal: ASA, caffeine, and butalbital
Fioricet: APAP, caffeine, and butalbital
What is the mechanism of action of triptans?
Selective serotonin receptor agonists causing vasoconstriction and inhibition of vasoactive peptides
Why are triptans not used as antidepressant medications?
There are many serotonin receptors. Triptans agonize two specific receptors that are not related to depression.
What are the AEs associated with triptans?
Chest pain, somnolence, dizziness, flushing
What drug interactions are associated with use of triptans?
Do not use within 24 hours of ergotamines
Do not use within 2 weeks of MAOIs
Caution with serotonergic agents (SSRIs, SNRIs, tramadol, linezolid, ondansetron)
What are the warnings/precautions to consider before prescribing triptans?
Contraindicated in coronary artery disease Uncontrolled HTN Cerebrovascular disease Hemiplegic and basilar migraines Postmenopausal women and men > 40
When is the best time to take a triptan medication?
At the onset of pain
T/F: All triptans have roughly the same efficacy in all patients.
False: patients may respond to some triptans but not others
T/F: Adding an NSAID or APAP to a triptan has greater efficacy for headache disorders.
True: triptans work better than NSAIDs or APAP alone. But adding either to use of a triptan increases efficacy
Which triptans may be used if the patient has severe nausea or vomiting associated with their headache and why?
Sumatriptan: can be given nasally or SubQ
Zolmitriptan or Rizatriptan: can be given as an orally dissolving tablet
What is the mechanism of action of ergotamine medications?
Non-selective serotonin agonist that causes vasoconstriction and blocks inflammation
What are the common AEs associated with ergotamine medications?
Abdominal pain, muscle pain, N/V (most common), weakness, fatigue, chest tightness
What is the black box warning for ergotamine medications?
Severe peripheral ischemia –> cold/numb extremities, peripheral paresthesia, diminished peripheral pulses
What drug interactions are associated with use of ergotamine medications?
Do not use within 24 hours of triptans
What are the warnings/precautions to consider before prescribing ergotamine medications?
Hepatic/renal failure, sepsis, vascular disease, uncontrolled HTN, pregnant or nursing women
What are two key considerations when prescribing an ergotamine?
High risk of rebound headache and pretreat with an antiemetic
What is the mechanism of action of getants?
Calcitonin gene related peptide receptor antagonist
What are the AEs associated with use of getants?
Drowsiness, nausea, xerostomia
T/F: The getants have a lot of drug interactions.
True: inhibits CP-450 enzymes
What are the warnings/precautions to consider before prescribing getants?
Hepatic or renal impairment
Why are getants not commonly used in headache disorders?
Cost
What is the mechanism of action of ditan?
Selective serotonin receptor agonist that treats pain without vasoconstriction
What are the AEs associated with use of ditan?
Dizziness, N/V, chest discomfort, palpitations
What drug interactions are associated with ditan use?
Other serotonergic agents
What are the warnings/precautions to consider before prescribing ditan?
Hepatic or renal impairment and the elderly
Why is ditan not commonly used in headache disorders?
Cannot drive or operate machinery for 8 hours after ingestion
