Headache Disorders Flashcards
Differentiate an aura from a TIA…
in terms of symptoms
aura is a positive visual symptom and a headache typically follows
TIA is associated with vision loss and headache is uncommon
Differentiate an aura from a TIA…
in terms of onset
auras have gradual onset with a sequential progression of symptoms
TIA is abrupt onset with simultaneous occurrence of symptoms
Differentiate an aura from a TIA…
in terms of duration
auras can last up to 60 minutes
TIAs usually last under 15 minutes
What are differentiating characteristics of a migraine?
more common gender?
type of pain?
duration?
additional symptoms?
females
UNILATERAL, PULSATING moderate to severe pain aggravated by physical activity
lasts 4-72 hours
+/- N and/or V
+/- photophobia AND phonophobia
+/- aura
When is preventative migraine therapy indicated? (5 reasons)
- attacks interfere w/ daily routine despite acute therapy
- frequent attacks (min > 2/mo, lower end of frequency has to be more debilitating)
- CI, failure or overuse of acute therapy
- ADR w/ acute therapy
- pt preference
Migraine classification definitions…
episodic migraine:
chronic migraine:
less than 14 days/mo
15 or more days/mo for 3 months; HA 4 hours or more of each day
What are the two migraine specific NSAIDs?
- diclofenac potassium oral solution (Cambia)
- celecoxib oral solution (Elyxyb)
What agents/classes are used in acute migraine therapy? (7)
What ones are for refractory? (+1)
What ones are LAST LINE? (+2)
- APAP
- NSAIDs
- triptans
- rimegepant (Nurtec)
- ubrogepant (Ubrelvy)
- zavegepant (Zavzpret)
- ergots
refractory: lasmiditan (Reyvow)
LAST LINE: Fioricet, Fiorinal
What are the similarities & differences between Fioricet and Fiorinal?
BOTH: bubtalbital, caffeine AND…
Fioricet: APAP (only CIII when codeine is added)
Fiorinal: ASA (CIII)
What is the benefit for using an NSAID oral solution for acute migraine therapy?
FASTER onset!
What is the main class ADR for triptans?
VASOCONSTRICTION!
- flushing , chest pain, palpitations
Which triptan contains a sulfa group?
almotriptan
Which triptans are CI in severe hepatic impairment?
- naratriptan (Amerge)
- eletriptan (Relpax)
Which triptan is CI with potent CYP3A4 inhibitor use in last 72 hours?
eletriptan (Relpax)
Which triptans have the longest & second longest half life?
- frovatripin (Frova) - 26 hours
- naratripran (Amerge) - 6 hours
Which triptans are CI with MAOIs?
- rizatriptan (Maxalt, RizaFilm)
- sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)
- zolmitriptan (Zomig)
Which triptans have ODT formulations?
- rizatriptan (Maxalt, RizaFilm)
- zolmitriptan (Zomig)
Which triptans have intranasal formulations?
- sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)
- zolmitriptan (Zomig)
Which triptans have subQ formulations?
sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)
Which triptans have the fastest & second fastest onset of action?
- sumatriptan subQ
- sumatriptan intranasal
What triptan has the lowest oral bioavailability?
sumatriptan (Imitrex, Onzetra, Sumavel, Tosymra, Zembrace)
What triptan has the lowest incidence of chest pain/tightness?
almotriptan
What triptan has the highest incidence of CNS ADR?
Why?
eletriptan (Relpax)
most lipophilic, increased BBB penetration
What is the CI for lasmiditan (Reyvow)?
severe hepatic impairment
What is the frequency of dosing for lasmiditan (Reyvow)?
MDD of 1 because no efficacy with repeated dosing
What is a significant ADR of lasmiditan (Reyvow)?
profound CNS depression (8 hours between dosing and driving)
What agents/classes are used in preventative migraine therapy?
- atogepant (Quilipta)
- rimegepant (Nurtec)
- antiepileptics
- beta blockers
- TCAs
- SNRI
- CGRP mAbs
OTC
1. magnesium
2. riboflavin (B2)
3. feverfew
4. butterbur
Which gepant is used for both acute and preventative migraine therapy?
rimegepant (Nurtec)
What CI do all gepants have?
severe hepatic impairment
renal impairment
RIM & UBO -> CrCl < 15
ATO & ZAV -> CrCl < 30
Which gepant has the fastest onset of action?
zavegepant (Zavzpret)
Which gepant comes as an intranasal spray?
zavegepant (Zavzpret)
Which gepant comes as an ODT?
rimegepant (Nurtec)
What is the rimegepant (Nurtec) dosing when used for migraine prevention?
75 mg every other day
What gepant can you repeat the PRN dose after 2 hours if needed?
What other gepants are used for acute migraine therapy?
Can you repeat the doses of these other gepants?
If so how many times/how long between?
ubrogepant (Ubrelvy)
NO NO NO
MDD of 1 for both rimegepant (Nurtec) & zavegepant (Zavegepant)
What is the common ADR associated with gepant use?
GI related: nausea, constipation, abdominal pain, dyspepsia
What specific ADR does zavegepant (Zavzpret) that differs from the other gepants?
taste disturbances & nasal discomfort
What is the class ADR causing many CI for ergots?
VASOCONSTRICTION
What monitoring is needed while using ergots?
liver & renal fxn
cardiovascular status
What is the indication for ergotamine (Ergomar)?
acute migraine therapy
What an important ADR consideration for ergotamine (Ergomar)?
**Think: What patients should you avoid it in?
WORSENS N/V!!
How is ergotamine (Ergomar) supplied?
sublingual tablet
also has combo w/ caffeine as PO and PR
How is dihydroergotamine (DHE) supplied?
intranasal, IV, IM, or subQ
What is the indication for dihydroergotamine (DHE) injection & intranasal formulations?
What is the indication for dihydroergotamine (DHE) injection only?
acute migraine therapy
acute cluster HA therapy
What is the benefit of using dihydroergotamine (DHE) over ergotamine (Ergomar)?
less ADR than ergotamine
What substance increases ergotamine (Ergomar) levels?
grapefruit juice
What is required when initiating therapy with dihydroergotamine (DHE)?
1st dose has to be given in a facility
+/- ECG for patients w/ CAD risk factors
What is true of Migranal vs Trudhesa?
BOTH are brands of dihydroergotamine (DHE)
Migranal contains caffeine
Which AEDs are used for preventative migraine therapy?
- topiramate (Topamax, Trokendi Xr, Quedexy Xr)
- valproic acid (Divalproex Sodium, Sodium Valproate)
When can you assess the effectiveness of gepants as preventative migraine therapy?
8 weeks
When can you assess the effectiveness of beta blockers as preventative migraine therapy?
2-3 months
When can you assess the effectiveness of AEDs as preventative migraine therapy?
2-3 months
What are some ADR of topiramate (Topamax, Trokendi Xr, Quedexy Xr)?
List 6!
cognitive dysfunction
nephrolithiasis
oligohidrosis
hyperthermia
suicidal ideation
weight loss
What is an important counseling point for topiramate (Topamax, Trokendi Xr, Quedexy Xr)?
HYDRATION!!!
What preventative migraine therapy is associated with a risk of SJS/TEN & DRESS?
valproic acid (Divalproex Sodium, Sodium Valproate)
What are the BBWs for valproic acid (Divalproex Sodium, Sodium Valproate)?
- hepatotoxicity
- patients w/ mitochondrial diseases
- teratogenicity
- pancreatitis
What beta blockers are indicated for preventative migraine therapy? (2)
What about off label ones? (3)
propranolol & timolol
metoprolol, atenolol & nadolol
Which 3 beta blockers are more lipophilic and have better BBB penetration in migraine therapy?
propranolol, timolol & metoprolol
What TCAs are indicated for preventative migraine therapy?
amitriptyline
nortriptyline
What is the common ADR of TCAs?
anticholinergic ADR!!
When can you assess the effectiveness of TCAs and SNRIs as preventative migraine therapy?
2-3 months
What is the BBW for TCAs & SNRIs as preventative migraine therapy?
suicidality
Which SNRI can be used for migraine preventative therapy?
venlafaxine (Effexor)
What mAbs are used for preventive migraine therapy?
Which ones target the CGRP receptor?
Which ones target the CGRP ligand?
- Vyepti (eptinezumab)
- Aimovig (erenumab) RECEPTOR
- Ajovy (fremanezumab)
- Emgality (galcanezumab)
the rest target the ligand
What CGRP mAbs are used given subQ?
How often are they administered?
When can you assess effectiveness?
- Aimovig (erenumab)
- Ajovy (fremanezumab)
- Emgality (galcanezumab)
MONTHLY
after 3 months
What CGRP mAbs are used given IV?
How often are they administered?
When can you assess effectiveness?
- Vyepti (eptinezumab)
- Ajovy (fremanezumab)
every 3 months
after 6 months
Which CGRP mAb has the highest rates of antibody development?
Vyepti (eptinezumab)
Which CGRP mAb can also be used for preventative cluster HA therapy?
Emgality (galcanezumab)
What are peripheral nerve blocks indicated for in terms of migraine therapy?
ACUTE therapy for…
SEVERE/PROLONGED attacks
or
REFRACTORY/CI to standard therapy
Which agents are used in migraine peripheral nerve blocks?
Which one CANNOT be used in pregnancy?
lidocaine
and/or
bupivacane
and/or
methylprednisolone CI pregnancy
How is magnesium dosed for preventative migraine therapy?
400 mg Mag Ox BID
What ADR are associated with magnesium therapy?
diarrhea, N/V (titrate dose)
hypermagnesemia
What needs to be avoided when choosing butterbur as preventative migraine therapy?
products NOT labeled as PA free
What are the symptoms associated with hypermagnesemia?
hypotension, N/V, bradycardia
How are neuromodulation devices used in migraine therapy?
ACUTE & PREVENTATIVE therapy
How is botox used in migraine therapy?
How often & when is affect assessed?
BBW?
PREVENTATIVE for CHRONIC migraine
every 3 months; after 3 treatments
spreading of toxin effect
What are the preferred acute & preventative therapies for migraine during pregnancy?
acute: APAP
preventative: magnesium or riboflavin (B2)
What are the preferred acute & preventative therapies for migraine in patients with cardiovascular/cerebrovascular disease?
acute: APAP, gepants, lasmiditan (Reyvow)
preventative: gepants
What agents are specifically used to treat menstrual migraine?
(can really use almost any migraine therapy)
- frovatriptan (Frova)
- naratriptan (Amerge)
- zolmitriptan (Zomig)
- magnesium
- combined hormonal contraceptives
What is the caveat for use of combined hormonal contraceptives for menstrual migraine therapy?
CONTRAINDICATED in migraine w/ aura
estrogen increases stroke risk!!!
What is the dosing of frovatriptan (Frova) for menstrual migraine?
KNOW START & TOTAL DAYS
2.5 mg PO QD-BID
START 2 DAYS BEFORE MENSES
6 DAYS TOTAL
What is the dosing of naratriptan (Amerge) for menstrual migraine?
KNOW START & TOTAL DAYS
1mg PO BID
START 2-3 DAYS BEFORE SYMPTOM ONSET
5-6 DAYS TOTAL
What is the dosing of zolmitriptan (Zomig) for menstrual migraine?
KNOW START & TOTAL DAYS
2.5 mg PO QD-BID
START 2 DAYS BEFORE MENSES
7 DAYS TOTAL
What are differentiating characteristics of a tension type HA?
type of pain?
duration?
mild to moderate bilateral (band like) pressing or tightening, that is not aggravated by activity
lasts 30 mins-7 days
What are differentiating characteristics of a cluster HA?
more common gender?
type of pain?
duration? & frequency?
additional symptoms?
males
severe unilateral orbital, supraorbital and/or temporal pain
lasts 15-180 mins; occur QOD up to 8x a day
additional symptoms
on same side of pain
- conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, forehead/facial sweating, mitosis, ptosis (eye droop)
agitation, restlessness
What are differentiating characteristics of hemicrania continua?
type of pain?
duration?
additional symptoms?
unilateral pain with exacerbations of moderate or greater intensity
lasts > 3 mo
additional symptoms
on same side of pain
- conjunctival injection, lacrimation, rhinorrhea, nasal congestion, eyelid edema, forehead/facial sweating
agitation, restlessness
RESPONDS THERAPEUTICALLY TO INDOMETHACIN*
What are differentiating characteristics of a TBI HA?
type of pain?
onset?
additional symptoms?
resembles migraine-like and/or tension type HA
within 7 days of head trauma
assoc w/ post-concussive symptoms
- fatigue, dizziness, insomnia, concentration impairment, seizures, depression, anxiety
What are differentiating characteristics of psuedotumor cerebri?
what is it?
symptoms?
who is it most common in?
which drugs can induce it?
increased intracranial pressure
HA, papilledema, vision loss
overweight females of childbearing age
growth hormones, tetracyclines, retinoids
What are differentiating characteristics of a brain tumor HA?
type of pain?
additional symptoms?
features vary based on location & tumor type
- common phenotype is tension type HA
- typically bilateral pain or on same side as tumor
assoc w/ neurosymptoms
- seizures, fatigue, cognitive dysfunction, focal weakness
What are differentiating characteristics of a reversible cerebral vasoconstriction syndrome (RCVS)?
what is it?
type of pain?
additional symptoms?
who is it most common in?
what is needed for it to occur?
what meds are associated with it?
reversible multi-focal narrowing of cerebral arteries that can cause permanent brain damage
thunderclap HA
neuro deficits related to brain edema, seizure or stroke
triggering event -> stress, exertion
SSRI, triptans, ergots, cyclophosphamide, tacrolimus, nasal decongestants, illegals drugs
What are differentiating characteristics of a subarachnoid hemorrhage HA?
type of pain?
onset?
additional symptoms?
MAX INTENSITY within seconds (worst pain of life)
sudden or thunderclap onset
N/V, photophobia, neck stiffness, focal neurologic deficit, brief loss of consciousness
LIFE THREATENING EMERGENCY
What agents are used for acute therapy in tension type HA? (3 ish)
- NSAIDs or APAP
- combo analgesics w/ caffeine
- combo analgesics w/ butalbital or codeine
What agents are used for preventative therapy in tension type HA? (6)
TCAs, mirtazapine, venlafaxine
gabapentin, topiramate
trigger point injections (nerve block)
What agents are used for acute therapy in cluster HA? (3)
- O2
- subQ (preferred) or intranasal sumatriptan
- intranasal zolmitriptan
What agents are used for preventative therapy in cluster HA? (6)
GOLD STANDARD: verapamil
- glucocorticoids
- Emgality (galcanezumab)
- lithium
- topiramate
- greater occipital nerve blocks
What is the GOLD STANDARD of cluster HA preventative therapy?
verapamil
What is the GOLD STANDARD of hemicrania continua treatment?
indomethacin
What is the treatment for psuedotumor cerebri?
- D/C offending agents
- weight loss
- carbonic anhydrase inhibitor to dec CSF production
- acetazolamide
- topiramate
What agents are associated with medication overuse headaches? (5)
What are the thresholds of risk for each? (i.e. max days per month)
greater than 10 days/month
1. ergots
2. triptans
3. opioids
greater than 15 days/month
4. non-opioid analgesics
greater than 5 days/month
5. butalbital
Define medication overuse HA:
HA greater than 15 days/month in pt w/ pre-existing HA disorder
with regular overuse for > 3 mo of one or more acute HA therapies
What is the treatment of medication overuse HA?
- D/C (taper off) overused med
- consider bridge therapy during initial period after D/C
- initiate preventative therapy with PRN breakthrough therapy
What are the HA Red Flags?
hint: acronym, think of a famous rapper
SNOOP
S - Systemic signs/symtoms OR Systemic disease
N - Neurologic signs/symptoms
O - sudden Onset (thunderclap)
O - Onset after 40 yo
P - Pattern change
