Headache Flashcards
Headaches
One of the most common medical complaints.
Can be triggered by a variety of stimuli
Mild, episodic versus severe, re-current debilitating headaches
Want to identify between no identifiable cause and an identifiable cause.
Primary Headaches
Migraine with or without aura Tension-type Cluster headache Chronic daily Childhood Periodic Syndrome Abdominal migraines
Unilaterail in most, gradual in onset, patient prefers dark, duration 4 to 72 hours, nausuea, vomiting, photophopia, aura
migraine
bilateral, pressure or tightness which waxes and wanes, patient may remain active or may need to rest, duration 30 minutes to 7 days
tension type
always unilateral, usually begins around the eye or tempole, pain beings quickly and reaches a crescendo in minuts, 15 minutes to three hours, lacrimation and redness of the eye, stuffy nose, pallor, sweating
cluster
Secondary headaches
Trauma Cranial/cervical vascular disorder Substance use (substance withdrawal) Infection Metabolic disturbance Systemic problem Neck/sinus/teeth/eye/nose Anxiety Neuralgias/other headaches
Headache preceded by visual symptoms (flashes of light, a blank area in the field of vision, zigzag patterns).
Migraine with aura
Migraine patho
Neurovascular disorder that involves the dilation and inflammation of intracranial blood vessels
Vasodilation leads to pain
Neurons of the trigeminal vascular system
Calcitonin gene–related peptide (CGRP)
Serotonin (5-hydroxytryptamine [5-HT])
Goals of Acute Treatment of Migraine
Rapid and consistent freedom from pain and associated symptoms without recurrence
Restored ability to function
Minimal need for repeat dosing or rescue medications
Optimal self‐care and reduced subsequent use of resources
Minimal or no adverse events
Goals of Migraine Prevention
Reduce attack frequency, severity, duration, and disability
Improve responsiveness to and avoid escalation in use of acute treatment
Improve function and reduce disability
Reduce reliance on poorly tolerated, ineffective, or unwanted acute treatments
Reduce overall cost associated with migraine treatment
Enable patients to manage their own disease to enhance a sense of personal control
Improve health‐related quality of life
Reduce headache‐related distress and psychological symptoms
Contraindication to, failure, or overuse of acute treatments, with overuse defined as:
10 or more days per month for ergot derivatives, triptans, opioids, combination analgesics, and a combination of drugs from different classes that are not individually overused
15 or more days per month for nonopioid analgesics, acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs [including aspirin])
Medication Choice for Prophylaxis
Side-effect profile Comorbid conditions Medication interactions Evidence-based efficacy Patient preference
Start the drug at a
low dose.
Increase the dose gradually until therapeutic benefit develops, the maximum dose of the drug is reached, or side effects become intolerable.
Give the chosen medication an adequate
trial in terms of duration and dosage.
Clinical trials suggest efficacy is often first noted at four weeks and can continue to increase for three months.
Avoid overuse of acute
headache therapies including analgesics, triptans, and ergots.
Opioids and barbiturates should not
be used for the acute or preventive treatment of migraine.
Opioid use can contribute to development of chronic daily headache and can interfere with other preventive therapies.
Address patient expectations and
consider patient preferences when deciding between drugs of relatively equivalent efficacy.
Discuss the rationale, dosing, and likely side effects for a particular treatment.
Discuss expected benefits of therapy and how long it will take to achieve them. Preventive migraine therapy requires a sustained commitment on the part of the patient and provider to achieve benefit.
If the headaches are well controlled, slowly
taper the drug if possible.
Many patients experience continued
relief with either a lower dose or cessation of the medication.
Treatment failure – switch to
switch to a different class of medication
Educate about
lifestyle measures
Women of childbearing potential must be
warned of any potential risks.
Select a pharmacological agent
that will treat both disorders
Establish that the co-existing
condition is not a contraindication for the selected migraine therapy
Establish that the treatments being used
Establish that the treatments being used
Be aware of pharmacological agents
being used to treatment migraines and other conditions do not interact
Aborting an ongoing attack
Nonspecific analgesics Aspirin-like drugs and opioid analgesics Opioid analgesics (e.g., butorphanol, meperidine) Migraine-specific drugs Serotonin1B/1D receptor agonists Ergot alkaloids
Anti-emetics – important
adjuncts to migraine therapy
Metoclopramide [Reglan] – preferred*
Prochlorperazine
Preventing attacks
from occurring
Beta-blockers
Tricyclic antidepressant
Anti-epileptic drugs
Tension-Type Headache
Most common type
Moderate, non-throbbing, usually located in a “headband distribution”
Can be associate with scalp tingling and a sense of tightness or pressure in the head and neck
Precipitating factors: eye strain, aggravation, frustration, and daily stressors
Can have depressive symptoms
Episodic or chronic
Chronic – 15 or more days per month for at least 6 months
Tension-Type Headaches - acute attack
Acute attack of mild to moderate intensity – acetaminophen or NSAIDs or an analgesic-sedative combination
Tension-Type Headaches - Prophylaxis
Prophylaxis – amitriptyline [Elavil] – tricyclic anti-depressant – at bedtime – can cause anti-cholinergic side effects, pose a risk for cardiotoxicity at high doses
Tension-Type Headaches - Manage
Manage stress – cognitive coping skills, information on relaxation techniques
tension acute treatment
aceteiminophen
aspririn
nsaid
tension prophylaxis
amitriptyline
other TCA
venlafaxine XR
Cluster Headaches
Occur in a series or “cluster” of attacks
Each attack lasts 15 minutes to 2 hours
Severe, throbbing, unilateral pain near the eye
Lacrimation, conjunctival redness, nasal congestion, rhinorrhea, ptosis, and miosis on the same side of the headache
One or two attacks every day for 2 to 3 months
An attack-free interval of months to years separates clusters
Cluster acute treatment
Oxygen – administered via a non-breathing facial mask with a flow rate of at least 12 L/min, patient is in a sitting, upright position for 15 minutes. Can increase to 12 L/Minutes.
Sumatriptan
Intranasal lidocaine (small # of studies showed effectiveness) Ergots – effective if started early in the attack.
Cluster prophylaxis
Verapamil – agents of choice* (episodic and chronic cluster headaches).
Corticosteroids (bridging treatment, long-term use – risk of long-term side effects of prolonged systemic glucocorticoid use).
Second-line therapy - lithium – evidence for use is limited – narrow therapeutic index.
Topamax – add-on medication, add to verapamil.
Greater occipital nerve blockade
**Limit to the cluster cycle, discontinue when cycle is over.
Menstrual Migraine
Migraine that routinely occurs within 2 days of the onset of menses through three days after the onset of menstrual bleeding
Can also have migraines at other times of the month.
Important trigger is the decline in estrogen levels that precedes menstruation
Menstrual Migraine Treatment
Abortive treatment – triptans, NSAIDs, triptans + NSAID.
Preventative treatment – lifestyle modifications, cyclic prophylaxis
NSAIDs, triptans, magnesium
Hormone-based interventions
Medication Overuse Headaches
Chronic headache that develops in response to frequent use of headache medicines
Resolved by withdrawing use of overused medicine
Almost all medicines used for abortive headache therapy can cause medication overuse headache
Risk of medication overuse headache can be decreased by limiting the use of abortive medicines and implementing nondrug measures
Analgesics, triptans, ergotamine (not dihydroergotamine), caffeine
