Headache and Lower Back Pain Flashcards
Sumatriptan - Dose and Route
50 mg orally, max dose 300 mg
Sumatriptan - MoA
Serotonin 5-HT1D/1B agonist
Sumatriptan - Advers effects
Chest tightness Weakness Somnolence Dizziness Abnormal tingling and burning sensation(paresthesias)
Sumatriptan - Contraindications
Contraindicated for patients with history of angina pectoris, myocardial infarction or other coronary diseases
Increased blood pressure(should not be given to patients with uncontrolled hypertension)
Administration with ergot drugs
Sumatriptan - Interactions
MAO inhibitors, or within 24 h of adm of an ergot agent.
SSRI –> serotonin syndrome
Ergotamine - Dose and route
2mg orally, max dose 5mg
Ergotamine - MoA
Serotonin 5-HT1D/1B agonist
Ergotamine - Adverse effects
Nausea Vomitting Diarrhea Muscle cramps Cold skin Paresthesias Vertigo
Ergotamine - Contraindications
Pregnancy
Coronary heart disease
Administration with triptan agents and beta-blockers
Ergotamine - Interactions
Synergistic adverse effects with triptan agents
Drugs for migraine prevention
Propranolol - beta blocker
Amitriptyline - tricyclic antidepressant
Topiramate - anticonvulsant
Amitriptyline - MoA
TCA, inhibits neuronal reuptake of serotonin and noradrenaline
Amitriptyline - Dose and route
10-75 mg at night orally
Amitriptyline - Adverse effects
Drowsiness
Tremor
Anticholinergic effects (dry mouth, blurred vision, urinary retention)
Amitriptyline - Contraindications
Combination with MAOIs
Hypersensitivity to TCAs
History of MI
Topiramate - Dose and route
50 mg x 1 orally
Topiramate - MoA
Block voltage-sensitive Na2+ channels, augumentation of GABA activation of GABAa receptors, and blockade of two types of excitatory glutamate receptors, kainate receptors and AMPA receptors
Topiramate - Adverse effects
Ataxia
Dizziness
Drowsiness
Cleft palate
Topiramate - Contraindications
Hypersensitivity, use cautiously during pregnancy, lactation, or hepatic and renal disease
Propranolol - Dose and route
40mg x 2 orally
Propranolol - MoA
Nonselective beta blocker
Propranolol - Adverse effects
Cold extremities
Bradycardia
Hypotension
Diarrhea
Propranolol - Contraindications
COPD
Diabetes
AV block
Migraine - Diagnosis
At least 2 of the following: - Unilateral pain - Throbbing pain - Aggrevation by movement - Moderate or severe intensity Plus at least 1 of the following: - Nausea/Vomiting - Photophobia and phonophobia
Headache diary: helpful in making diagnosis, and assessing frequency of disability. 8 or more ep per month and at least 15 total days of headache per month –> chronic migraine
MR: suspicion of another underlying disease
General evaluation of acute headache
Palpation of cranial arteries
Evaluate cervical spine by the effect of passive movement of head
Imaging, LP
Investigation of cardiovascular and renal status by BP monitoring and urine exam
Eyes- fundoscopy, intraocular pressure
Psychological state
According to the position of the headache:
Temporal: Giant cell arteritis
Facial: sinusitis
Instant onset: ruptured aneurysm
Non- pharmocologic treatment of migraine
Avoid triggers, healthy diet, regular exercise, regular sleep pattern, avoid excessive alcohol and caffeine, avoid acute changes in stress level
Neuromodulation: single pulse transcranial magnetic stimulation (sTMS)
Noninvasive vagus nerve stimulation (nVNS)
Migraine - Treatment
First try NSAIDs; most effective when taken early in the attack
- Acetaminophen
- Naproxen
Chronic:
Drugs for prevention
Botulinum toxin
Acetaminophen - Dose
1g 4 times daily
Acetaminophen - MoA
COX-3 inhibitor
Who should get preventive treatment for migraine?
Increased frequency of migraine attack, unresponsive/poorly responsive to treatment, pts with 4 or more attacks a month.
Tension headache - Diagnosis
Pain: bilateral tight, bandlike discomfort, persist for hours or days, builds slowly.
If you have headache without nausea, vomiting, photoponia/phobia, throbbing, aggregation with movement –> tension
May be episodic, if 15 days or more a months –> chronic
Tension headache - Treatment
Elimination of triggers + exercise, mediation/yoga, acupuncture
Acetaminophen
If it coexist with migraine give triptans
Chronic:
Doxepine: 50 mg PO
Amitriptyline - Dose
10 mg PO once daily
Lower back pain - Diagnosis
Is it:
Unspecific back pain
Nerve root pain/Radiculopathy
Specific back pain
Pain referred to the back: Abdominal palpation, Goldflam’s sign
Palpation of the spine
Pain from hip may be confused with spine pain: internal/external rotation of leg (with knee and hip flexed)
Straight leg raising sign (SLR)/Lasague’s sign
Crossed SLR, Reverse SLR
Neurologic exam: search for focal atrophy, weakness, reflex loss, diminished sensation in legs
Ask if pts experiences pain during rest or activity
Lab tests:
Risk factors or nonspecific pain
- CBC, ESR, urinalysis
- X-ray, MRI, CT: anatomic definiton of spine disease
- EMG and nerve conduction studies: assessment of PNS
No risk factors:
no diagnostic test necessary
Lower back pain - Causes
Lumbar disk pain Cauda Equina syndrome Spinal Stenosis Trauma Osteoporosis, Ostoarthritis, Osteomyelitis, RA, PsA, Ankylosing spondylitis Vertebral metastasis Psychiatric
Lower back pain - Treatment
Acute (<3months):
Acetaminophen
Cyclobenzaprine
Physical therapy, massage, acupunture, traction, Ice/heat
Chronic (>12weeks): Treat underlying cause Acetaminophen Duloxetine Exercise therapy, Physical therapy, Spinal manipulation massage
Low back pain with radiculopathy
In addition to pain killers: Glucocorticoids; Prednisolone,
Surgery
Cyclobenzaprine - Dose
5 mg X3 PO
Cyclobenzaprine - MoA
Antispastic agent, muscle relaxant
Cyclobenzaprine - Adverse effect
Drowsiness, Tiredness, headache, dizziness
Cyclobenzaprine - Interaction
MAOI –> HTN
Benzodiazepine –> excessive sedation
Cyclobenzaprine - Contraindication
HF, arrythmia, hyperthyroidsm
Duloxetine - Dose
60 mg PO
Duloxetine - MoA
SNRI
Duloxetine - Adverse effects
Nausea, dry mouth, tiredness, drowsiness, constipation
Duloxetine - interaction
Inhibits Cyp2D, and increases serum levels of antipsychotics and TCA
Duloxetine - Contraindication
MAOI –> Serotonin syndrome
Prednisolone - Dose
80mg first two days, then 40 mg for 2 days, then 20mg last 2 days
