Headache Disorders (Exam I Cut Off) Flashcards
1
Q
Primary Headaches
A
- 90-98% of cases, Benign
- Chronic recurrent pattern
- +/- lack of neurological findings
- Associated with morbidity
- EX: Migraine, tension headache, cluster headache, etc
2
Q
Secondary Headaches
A
- <10% of cases
- Due to underlying organic etiology
- Acute, progressive
- Present with physical and neurological findings
- Associated with mortality
- EX: head/neck trauma, cranial/cervical vascular disorder, nonvascular intracranial disorder, substance/withdrawal, infection, facial pain (structure related), psychiatric disorder
3
Q
Migraine Triggers
A
- Changes in hormone levels
- Altered sleep patterns
- Weather changes
- Psychological factors
- Sensory stimuli
- Alcohol and/or food
4
Q
Acute Migraine Treatment Goals
A
- Treat migraine attacks rapidly and consistently
- Restore person’s ability to function
- Minimize the use of backup and rescue medications
- Optimize self-care for overall management
- Be cost effective
- Minimal or no AE
5
Q
Long-term Migraine Treatment Goals
A
- Reduce migraine frequency, severity, and disability
- Reduce reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies
- Improve QoL
- Prevent headache
- Avoid escalation of HA med use
- Educate/enable patients to manage their disease
- Reduce HA-related distress and psychological symptoms
6
Q
Migraine Nonpharm
A
- Rest/sleep in dark, quiet environments
- Ice/hot pack
- Headband-like device that stimulates branches of trigeminal nerve
7
Q
Mild Migraine Attack Treatments: Non-Rx
A
- APAP, ASA, NSAIDs
- Also combination products with caffeine
- Risk of GI ADRs and medication overuse HA
8
Q
Mild Migraine Attack Treatments: Rx
A
- Analgesics: NSAIDs
- 5HT Agonists (Triptans): alone or in combinations
- 5HT1F agonist
- Ergots
- CGRP Antagonist
- Butophanol spray, metoclopramide, prochlorperazine
9
Q
Triptans + Half-Lives
A
- Sumatriptan: 1.2-2.3 hr
- Naratriptan: 3-5 hr
- Frovatriptan: 2-4 hr
10
Q
Triptans
A
- MoA: vasoconstriction and reduction of neurogenic inflammation
- Combination of sumatriptan and naproxen available
11
Q
Triptan CI
A
- Ischemic coronary artery disease
- Coronary artery vasospasm
- Peripheral vascular disease
- Ischemic bowel disease
- Uncontrolled HTN
- Recent use of another 5HT agonist or ergot
- History of stroke or transient ischemic attack
- Co-administration with MAO-A Inhibitors (separate by 2 weeks)
12
Q
Triptan Patient Education
A
- First dose take as soon as possible when feeling migraine coming on
- Second dose taken at least 2 hours after initial dose (Naratriptan => 4 hours)
- Inform patients of maximum dose
13
Q
Ergot Pharmacology
A
- Partial alpha-adrenoreceptor/5HT agonists
- MoA: constriction of peripheral and cranial blood vessels
- PO, IV, and intranasal formulations available
- Metabolized by CYP3A4, CI with strong inhibitors of CYP3A4
14
Q
Ergot Warnings
A
- Cardiac valvular fibrosis
- Vasospasm or constriction
- Peripheral vascular ischemia and gangrene
- Pleural/retroperitoneal fibrosis
Associated with chronic use
15
Q
Ergot CI
A
- Hypersensitivity
- Peripheral vascular disease
- Hepatic or renal disease
- Coronary artery disease
- Hypertension
- Sepsis
- Pregnancy
16
Q
CGRP Antagonist
A
- MoA: antagonist of CGRP receptor to prohibit vasodilation
- Used for acute treatment of migraine in adults only
- EX: Ubrogepant (Ubrelvy) and Rimegepant (Nurtec)
17
Q
When to Consider Prophylaxis
A
- Frequent headaches with acute treatment agents (>2 HA/week) Consider overuse HA
- Failure/CI/AE from acute migraine treatment agents
- Patient preference
- Special circumstances: hemiplegic migraine or risk of permanent neurologic injury
18
Q
Migraine Nonpharm Prophylaxis
A
- Wellness program: regular sleep, exercise, limit caffeine, no smoking
- Herbal therapy
- Chiropractic
19
Q
Herbal Therapy + Migraine Prophylaxis
A
- Level A: Petasite (butterbur, fever few)
- Level B: Magnesium,, Riboflavin (B2)
- Level C: Coenzyme Q10
20
Q
Rx + Migraine Prophylaxis
A
- Level A: Valproic acid (Category X), topiramate, beta blockers (propranolol)
- Level B: TCA (amitriptyline), SNRI (venlafaxine)
- Level C: ACE-I (lisinopril), ARB (candesartan)
21
Q
Botox
A
- Onabotulinumtoxin A
- MoA: Neurotoxin that blcoks presynaptic ACh release (reversible)
- Indicated for prophylaxis of chronic migraine headaches (>=15 days/month with >=4 hours/day headache duration)
- Adults ONLY
22
Q
CGRP Antagonist Drugs
A
- Erenumab (Aimovig)
- Fremanezumab (Ajovy)
- Galcanezumab (Emgality)
- Eptinezumab (Vyepti)
23
Q
Tension Headache
A
- Episodic is more common than chronic tension HA
- Females more common patients than male
- Peripheral and central mechanisms at work
- Presentation: bilateral pain, dull pain, nonpulsatile, or pressure
24
Q
Tension HA + Nonpharm
A
- Psychophysiologic therapy: stress reduction, relaxation, biofeedback
- Physical therapy: heat/cold packs, ultrasound, electrical nerve stimulation, stretching, exercise, massage
- Acupuncture
25
Q
Tension HA + Rx
A
- Treatment: NSAIDs (alone or with caffeine)
- Prophylaxis: TCAs, SNRIs (venlafaxine), anticonvulsant (topiramate, gabapentin), muscle relaxant (tizanidine)
26
Q
Cluster HA
A
- Male more common patients than female
- Unknown patho
- Presentation: severe HA that lasts 2 week to 3 months, occur at night, unilateral sharp pain behind the eye
27
Q
Cluster HA + Nonpharm
A
Oxygen!!!!
28
Q
Cluster HA + Rx
A
Treatment
- Ergots
- Triptans
Prophylaxis
- Verapamil
- Lithium
- Ergotamin
- Corticosteroids
- Galcanezumab/Emgality
29
Q
Medication-overuse HA
A
- HA present >= 15 days/mo
- Regular overuse for >3 mo of one or more drugs for acute/symptomatic treatment of HA
- HA has developed or worsened during medication overuse
- HA resolves or reverts to previous pattern within 2 mo of DC overused medication
Treat be reducing doses or selecting appropriate treatment agents
30
Q
Causative Meds + Overuse HA
A
- Ergotamines
- Triptan/Ergots
- Analgesic
- Opioid
- Combination of acute meds for HA treatment
