Headache - Block 2 Flashcards
What are examples of primary HA?
- Migraine
- Tension
- TAC
What are the causes of secondary HA?
- Trauma or injury to the head and/or neck (e.g., SAH)
- Cranial and/or cervical vascular disorder
- Non-vascular intracranial disorder
- A substance or its withdrawal
- Infection (e.g., meningitis)
- Disorder of homoeostasis
- Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure
- Psychiatric disorder
What are the causes of migraines?
Polygenic:
1. Activation of subcortical structures
2. Neural suppression
3. Activation of trigeminal systems
Migrain pain and sx
What is the cause of migrain pain?
The trigeminovascular system is considered to be the anatomical and physiological substrate from which nociceptive transmission originates
What are the types of migraines?
- Migrain without aura
- Migrain with aura
- Chronic migraine
What are the diagnosis of migraine without aura?
At least five attacks that meet the following four criteria:
1. Headache lasting 4–72 hours
2. Headache with at least two:
* Unilateral location
* Pulsating quality
* Moderate or severe pain intensity
* Aggravation
- HA accompanied by one of the following:
* N/V
* Photophobia/phonophobia
What are sx of a typical aura?
Visual: flashing lights, zig zag lines, loss of vision
Sensory: tingling or numbness across different body parts
Speech: difficulties with word formation and comprehension
What are the sx of hemiplegic migraine?
Visual: flashing lights, zig zag lines, loss of vision
Sensory: tingling or numbness across different body parts
Speech: difficulties with word formation and comprehension
Motor: temp weakness, unilateral of the arms, hands, legs, feet, tongue, or face
What is the presentation of migraine with aura?
At least two attacks that meet the following criteria:
One or more of the following fully reversible aura symptoms:
* Visual
* Sensory
* Speech, language, or both
* Motor
* Brain stem
* Retinal
At least three of the following six characteristics:
* At least one aura symptom spreading gradually over a period ≥5 minutes
* Two or more aura symptoms occurring in succession
* Each aura symptom lasting 5–60 minutes
* At least one unilateral aura symptom
* At least one positive aura symptom
* Headache accompanying the aura or following the aura within 60 minutes
What are the presentations of chronic migraines?
≥15 days/month for >3 months that fulfill the following criteria:
* least 5 attacks
* ≥8 days/month for >3 months
What does a comprehensive HA history contains?
- Age at onset
- Attack frequency and timing
- Duration of attacks
- Precipitating or aggravating factors
- Ameliorating factors
- Description of neurologic symptoms
- Characteristics of the headache pain (quality, intensity, location, and radiation)
- Associated signs and symptoms
- Treatment history
- Family and social history
- Impact of headaches on daily life
What is goals of treating acute migrains?
- Treat migraine attacks rapidly and consistently without recurrence
What is the goal for treating chronic migraines?
Reduce migraine frequency, severity, and disability
What is nonpharm for acute migraines?
Ice to the head and periods of rest or sleep, usually in a dark, quiet environment
What is the non pharm for prevention of migraines?
- Avoid triggers
- Wellness programs
- Behavioral interventions
What should a HA diary contain?
- Frequency
- Severity
- Duration of attacks
- Response to med
- Potential trigger factors
What are food triggers for migraines?
- Alcohol
- Caffeine/caffeine withdrawal
- Chocolate
- Fermented and pickled foods
- Monosodium glutamate (eg, in Chinese food, seasoned salt, and instant foods)
- Nitrate-containing foods (eg, processed meats)
- Saccharin/aspartame (eg, diet foods or diet sodas)
- Tyramine-containing foods
What are environmental triggers?
- Glare or flickering lights
- High altitude
- Loud noises
- Strong smells and fumes
- Tobacco smoke
- Weather changes
What are behavioral triggers?
- Excess or insufficient sleep
- Fatigue
- Menstruation, menopause
- Sexual activity
- Skipped meals
- Strenuous physical activity (eg, prolonged overexertion)
- Stress or poststress
What are acute pharm tx for migraines?
Nonspecific: analgesics, NSAIDs, antiemetics, CS
Migrain specific: ergots, triptans
What are acute migraine tx most effective?
At onset of migraines
When should NSAIDs and analgesics be used for migrains?
- mild-to-moderate migraine attacks
- severe attacks that have been responsive in the past
Types of Analgesics used for migraines?
- Aspirin
- Diclofenac
- Ibuprofen
- Naproxen
- acetaminophen + aspirin + caffeine
- APAP
What is med overuse HA?
A pattern of increasing headache frequency and drug consumption
How do you tx med overuse HA?
Discontinuation of the offending agent -> gradual decrease in headache frequency and severity -> return of the original headache characteristics
How do you avoid the development of med-overuse HA?
Limit use of acute migraine therapies to fewer than 10 days per month
Appropriate first-line therapy for patients with mild-to-severe migraine and also for rescue therapy when nonspecific medications are ineffective?
Serotonin Receptor Agonists (Triptans)
Examples of tripans?
Sumatriptan (Imitrex)
zolmitriptan (Zomig)
naratriptan (Amerge)
rizatriptan (Maxalt)
almotriptan (Axert)
frovatriptan (Frova)
eletriptan (Relpax)
MOA of triptans?
- Vasoconstriction
- Inhibition of vasoactive peptide release from perivascular trigeminal neurons
- Inhibition of transmission through second-order neurons ascending to the thalamus
Triptans
ADR, CI
ADR: paresthesias, fatigue, dizziness, flushing, warm sensations, and somnolence
* “Triptan sensations” - tightness, pressure, heaviness, or pain in the chest, neck, or throat
CI: ischemic heart disease, uncontrolled HTN, CVD, hemiplegic and basilar migraine, pregnancy
What are you ergot tx?
Ergotamine tartrate and dihydroergotamine: mod-severe migraine attacks
MOA of ergots?
Nonselective 5-HT1 receptor agonists:
1. Constrict intracranial blood vessels
2. Inhibit the development of neurogenic inflammation in the trigeminovascular system
Ergot
Dosage forms, CI, ADR
Form:
* Ergotamine: Oral and rectal preparations contain caffeine -> enhance absorption and potentiate analgesia
* Dihydroergotamine: intranasal and parenteral
CI: Renal or hepatic failure; coronary, cerebral, or peripheral vascular disease; ischemic heart disease; uncontrolled hypertension; and sepsis; and in women who are pregnant or nursing
ADR: N/V, abdominal pain, weakness, fatigue, paresthesias, muscle pain, diarrhea, and chest tightness
When should antiemetics be used for migraines?
15 - 30 minutes before ingestion of oral abortive migraine medications
Types of antiemetics for migrains?
Metoclopramide: reverse gastroparesis and improve absorption from the GI tract during severe attacks
Dopamine antagonist drugs are used monotherapy for the treatment of intractable headache:
* Prochlorperazine (IV, IM, or rectal) and metoclopramide (IV)
* Chlorpromazine and droperidol
ADR of antiemetics?
Drowsiness, dizziness, EPS, QT prolongation and torsades de pointes
When should opiate analgesics be used for migraines?
moderate-to-severe infrequent headaches in whom conventional therapies are contraindicated, or as “rescue medication”
What are other meds used for migraines?
- CS: status migrainous
- IV valproate
- Mag sulfate
- Isometheptene: not available
What are newer agents for migraines?
Calcitonin Gene-Related Peptide (CGRP) Antagonists:
* Ubrogepant (Ubrelvy)
* Rimegepant (Nurtec ODT)
Serotonin (5-HT)1F receptor agonists:
* Lasmiditan (Reyvow) – C-V substance
Calcitonin Gene-Related Peptide (CGRP) Antagonists
CI, DDI
CI: Rimegepant - severe renal and hepatic impairment
DDI: CYP3A4 substrate
Serotonin (5-HT)1F receptor agonists
CI, ADR
CI: severe hepatic impairment
ADR: DZ, CNS depression, seratonin syndrome
When should preventive migraine tx be considered?
- Patient preference to limit the number of attacks
- Uncommon migraine variants that cause profound disruption and/or risk of permanent neurologic injury (eg, hemiplegic migraine, basilar migraine, and migraine with prolonged aura)
- Symptomatic therapies that are ineffective or contraindicated, or produce serious side effects
- Frequent attacks occurring more than twice per week with the risk of developing medication-overuse HA
- Recurring migraines that produce significant disability despite acute therapy
What are med for migraine prevention?
- propranolol, timolol
- divalproex sodium
- topiramate
- erenumab-aooe
- fremanezumab-vfrm
- galcanezumab-gnlm
- epitnezumab-jjmr
- rimegepant
- atogepan
How long should preventative trial last for migraines?
2-3 months: Some reduction in attack frequency can be evident by the first month of therapy -> Maximal benefits are usually observed by 6 months of treatment
What happens if you overuse acute HA med?
Interferes with the effects of preventative tx
Ex of antiepileptics for migraines?
Valproate/divalproex
Topiramate
Valproate/divalproex
ADR, CI
ADR: N/V, Alopecia, tremor, asthenia, somnolence, and weight gain
CI: pregnancy, pancreatitis, hepatotox
Topiramate
ADR, CI
ADR: Paresthesia, fatigue, anorexia, diarrhea, weight loss, hypesthesia, difficulty with memory, language problems, taste perversion, and nausea
CI: Kidney stone hx, cognitive impairments
Antidepressants for migraines?
Amitriptyline (TCA) and venlafaxine (SNRI)
Amitriptyline
ADR?
Anticholinergic effects, increased appetite, weight gain
Venlafaxine
ADR?
- Nausea, vomiting, and drowsiness
- Increased risk for serotonin syndrome when used with triptans
β-Adrenergic Antagonists for migraines?
Metoprolol, propranolol, and timolol - atenolol, nadolol, nebivolol, and pindolol
β-Adrenergic Antagonists
ADR, CI
ADR: Drowsiness, fatigue, sleep disturbances, vivid dreams, memory disturbance, depression, impotence, bradycardia, and hypotension
CI: CHF, PVD, AV conduction disturbances, asthma, depression, diabetes
Calcitonin Gene-Related Peptide Antagonists types?
OTC migraine prophylaxis?
- Petasites, an extract from the butterbur plant (Petasites hybridus)
- Riboflavin (vitamin B2)
- Feverfew (Tanacetum parthenium)
- Magnesium
Prevention tx for menstrual migraines?
NSAIDs: ibuprofen, ketoprofen, naproxen
Triptans: Frovatriptan, Naratriptan, Zolmitriptan
What causes tension HA?
Peripheral pain mechanisms are most likely to play a role in episodic tension-type headaches,whereas central pain mechanisms play a more important role in chronic tension-type headache
What are the types of tension HA?
Infrequent episodic tension-type headache: Fewer than one episode per month
Frequent episodic tension-type headache: Episodes on 1-14 days/month
**Chronic tension-type headache: ** 15 or more days/month, perhaps without recognizable episodes
Diagnosis of episodic tension HA?
- Last from 30 min to 7 days: 4-6 hr
- Pressing or tightening (non-pulsating) quality
- Band-like, “vise”like, tight
- No more than one of photophobia or phonophobia
- No nausea or vomiting
Presentation of chronic tension HA?
- Lasting hours to days, or unremitting
- Pressing/tightening (non-pulsating)
- Not >1 of photophobia, phonophobia, mild nausea
- Neither moderate or severe nausea nor vomiting
Nonpharm for tension HA?
- CBT
- Massage
Acute tx for tension HA?
Simple analgesics (alone or in combination with caffeine)
Prevention tx for tension HA?
TCAs
Prevalence of cluster HA?
Male
Tobacco smokers
Presentation of cluster HA?
- 15-180 min
- Lacrimation
- Nasal congestion
- Miosis/ptosis
- Restlessness
- from once every other day to eight times per day
- Constanyly moving/restless
Abortive tx for cluster?
- Oxygen
- Triptans (Sumatriptan and zolmitriptan - IN and SC preferred)
- Ergotamine derivatives
Prophylactic tx for cluster HA?
- Verapamil – 1st line
- Lithium
- CS
- Intranasal lidocaine
- Subcutaneous octreotide
- Neurosurgical interventions
- Vagal nerve stimulation and sphenopalatine stimulation
When should you reassess new tx?
6 months
