Headache Disorders Flashcards
migraines, TTH, and trigeminal autonomic cephalalgias are classified as
primary headache
secondary headaches are _______
symptoms from organic disease
what is classified as episodic infrequent TTH
<1/mth for no greater than 10 attacks/yr
what is classified as episodic frequent TTH
up to 14 attacks/ mth
what is classified as chronic TTH
15 days or more per mth for >6mths
onset of TTH is
any age, but less in those >50yrs
TTH may be precipitated by
mental stress and tension, smoking, fatigue, prolonged poor body posture (ex- excessive computer use)
TTH lasts
30min-7hrs
TTH headaches have at least 2 of the following qualities (4) + both of the following
bilateral
pressing/ tightening (nonplusing)
mild/ mod intensity
not aggravated by routine physical activity
both: no N/V, either photophobia or phonophibia
migraine RFs
family hx (strong predictor), females
migraines
1. with aura are more prevalent than without
2. onset is always <50yrs and are more common in F
3. may be triggered by a TTH
4. are only diagnosed after having at least 2 attacks if aura is present
5. 2,4
5
what is the diagnostic criteria of migraines without aura
At least 5 attacks fulfilling criteria B-D
HA lasting 4-72hrs (untreated or successfully tx)
HA has at least 2 of the following characteristics: unilateral location, pulsating quality, mod or severe pain intensity, aggravation by or causing avoidance of routine physical activity
During HA at least one of the following: N and/or V, photophobia and phonophobia
Not attributable to another disorder
how many attacks must happen for migraines without aura to be dx
5
how long do migraines without aura last
4-72hrs
a migraine with aura has at least 2 of the following characteristics (4)
unilateral location
pulsating quality
mod or severe pain intensity
aggravation by or causing avoidance of routine physical activity
how many attacks does a pt need to have to dx migraine with aura
2
each aura sx lasts
5-60min
what are the classifications of cluster headaches? describe them
episodic CH: has remission inbetween
chronic CH: with no significant remission
onset of cluster HA is usually
any age, more commonly 28-30yrs
how many cluster HAs must happen before dx
5
how long do cluster HAs last
15-180min
a headache is pulsating, unilateral, and lasted 2 days. what kind of HA is this
1. TTH
2. migraine
3. cluster
2 (4-72hrs)
a headache is unilateral right above the eye, causes agitation, and lasts 20 minutes. what kind of HA is this
1. TTH
2. migraine
3. cluster
3
what are some red flags of headaches (list 3)
onset >50yrs or <5yrs, severe + abrupt onset of HA “thunderclap”, ↑ freq or severity, sig changes in pattern (atypical), other sx like stiff neck, reduced consciousness, fever, sick appearance, new onset HA during pregnancy (refer), cluster headache
generally, HA should be prophylaxed if
they’re frequent- using analgesia >15m/mth or 2d/wk
severe and disabling
short lived- esp with cluster HA
what are the principles of HA prophylaxis
use long acting for adherence, in cluster HA- start chronic prophylaxis while on transitional prophylaxis, if pt is attack free for 6-12mths- consider tapering the dose
when can you consider tapering dose of HA prophylaxis
if pt is attack free for 6-12mths
1st line TTH tx
NSAIDs
2nd line TTH tx
caffeine + NSAIDs
what should be avoided in trying to treat TTHs
acetaminophen with or without codeine (increased risk of dependency + MOH)
do TTH generally require prophylaxis?
no- usually mild- mod + short duration
when might prophylaxis be considered fro TTH
if attacks are severe enough to limit ADL
frequent (>2-3/wk)
analgesics are CI, ineffective, or overused
what is commonly used for TTH prophylaxis
amitriptyline (TCAs), may also use venlafaxine and mirtazapine
HA response to amitriptyline is usually seen in
2-3wks
2 forms of care for migraines
stratified vs stepped acre
what is the stratified care model for migarines
Migraine attack
Mild disability = simple analgesic
Mod- severe disability = triptan
describe the stepped care across vs within migraines attacks model
across: Migraine attack → simple analgesics (≥ 3 consecutive attacks with no/ insuff response) → migraine attack → triptans
within: Migraine attack → simple analgesic (within same attack with no/ insuff response) → triptan
if triptans are not effective/ CI/ not available for migraine tx, what should be used?
ditan or gepant
compare ASA and NSAIDs to triptans in efficacy
less effective
compare ergotamine and caffeine to triptans in efficacy
less effective
NSAIDs, acetaminophen, ASA use should be limited to ____ to avoid MOH
<15d/mth
butalbital combination analgesics use should be limited to ___ to avoid MOA and risk of dependency
<10d/mth
what is 1st and 2nd line migraine tx
1st line: NSAIDs, APAP, ASA
2nd line: triptans
when are triptans indicated in migraines
mod-severe migraines
when analgesics + NSAIDs are ineffective and used too frequently
triptan AEs
fatigue, dizzinses, drowsiness, paresthesias, N, abdominal pain, chest discomfort
absolute CIs to triptns
IHD or any cardiac like sx, stroke or TIA, peripheral vascular disease like ischemic bowel disease, basilar or hemiplegic migraine, use with ergot derivatives and MAOi
5 relative CIs to triptns
uncontrolled HPTN, pregnancy or BF, smoking
Caution when coadmin with SSRis and SNRIs d/t ↑ risk of serotonin sx
triptans should not be used within 24hrs of antoher
triptan or ergot
triptans should not be used within ____ of another triptan or ergot
24hrs
triptans should be used ____ to avoid MOH
<10d/mth
how soon can you repeat a sumatriptan dose
2hrs
PO sumatriptan dose is usualy
25-100mg
rank the onset speed of sumatriptan formulations
SC >INH >PO
sumatriptan ___ is v effective for severe migraines and acute cluster HAs
SC
which triptan has the lowest SEs
naratriptan
what is the slowest osnet triptan
naratriptan
which triptan is good for relief of nausea
rizatriptan
________ increases bioavailability of rizatriptan
propranolol
what is 3rd line migraine tx
triptans + NSAIDs
4th line migraine tx
ergot derivatives
what is a dihydroergotamine
an ergot derivative for migraines
ergot derivates AEs
AEs: N/V (v common = give antiemetics prior to IV dose), chest discomfort, fatigue, dizziness, drowsiness, cramps, paresthesias, vasoconstriction
what can be given with DHE to relieve N/V
Metoclopramide 10mg IV or prochlorperazine 5mg IV can be given pre IV
how many days can ergot derivatives be used for
<10d
what tx should be avoided for migraine tx
opioids
butalbital
codeine or tramadol combo analgesics should be used when
NSAIDs or triptans are CI/ poorly tolerated
as rescue meds
what are GEPANTs
calcitonin gene related peptide receptor antagonists
ubrogepant and rimegepant are
GEPANTs
GEPANTs are effective within
2hrs in mod-severe migraine
lasmiditan is a
ditan
how long for lasmiditan to kick in
2hrs in mod-sevre migraine
what is a major advantage of lasmiditan
it’s not a vasoconstructor
AEs of lasmiditan
temporary driving impairment (no driving for 8hrs post dose)
when should migraines be prophylaxed
attacks severe enough to limit ADL, frequent, ≥3x attacks/ mth that are resistant to therapy, migraine meds are CI or failed
6 classes for migraine prophylaxis
ACEi/ARBs
antiseizure meds
BB
CCB
calcitonin gene related peptide antibody
TCAs
when are calcitonin gene related peptide antibodies used for migraine prophylaxis
only when other agents are ineffective
TCAs are preferred for migraine prophylaxis when
pt has depression/ insomnia
migraines in the ER are treated with
Sumatriptan SC, metoclopramide IV, prochlorperazine IV, opioids, DHE, meperidine, ketorolac IM/IV (only NSAID parenteral), corticosteroids (IV dex 6-10mg, associated with reduced HA recurrence for up to 3d)
why is abortive tx difficult in cluster HAs
challenged by short nature. By the time PO kicks in, it’s already gone
3 first line abortive tx in cluster HAs
O2, sumatriptan SC, zolmitriptan IN
when is response expected in using O2 to treat cluster Hs
30min
1 spray of zolmitriptan nasal spray is effective within
30min
sumatriptan SC is effective within
20min
4 drugs for cluster prophylaxis
verapamil
lithium
topiramate
melatonin
which migraine med classes should not be used >10d/mth
opioids, triptans, ergots, butalbital combos
treatment for menstrual migraine
triptan BID starting 2 days prior to onset of menses, continuing for 5-7 days
add NSAIDs BID (starting 2 days before period, continue for 5-6d)
how to treat TTH in pregnnacy
some actually report improvement due to pregnancy (hormones
tx with APAP prefered
NSAIDs fine bewteen 20-30wks
how to tx acute migraines in preg + how to prophylax
acute :analyesics, possibly sumatriptan
prophylaxis: low dose propranolol, Mg, possibly amitriptyline
how to treat acute cluster HA in preg women
tx with oxygen, may use SC/IN sumatriptan
how to prophylax cluster HA in preg women
verapamil or prednisone, gabapentin as alt
what headaches drugs to avoid in alctation
ergots, barbiturates, opioids
