Headache Management Flashcards
Which medications are implicated in medication overuse headaches?
simple and combination analgesics and opiates
triptans (M w/ high frequency HA)
What is the recommendation for frequency of use of acute migraine therapies?
limit to < 10d/mo
Medication overuse headache: description
gradual onset of an atypical daily or near-daily headache with superimposed episodic migraine attacks
Migraine: description
recurring episodes of throbbing head pain
- unilateral
- 4-72hrs
- w/ N/V, sensitivity to light/sound/movement
What substance is implicated as an important mediator of migraine headaches?
5-HT (serotonin)
Migraines: acute migraine therapies
analgesics (acetaminophen, excedrin migraine)
NSAIDs (ASA, IBU, naproxen sodium, diclofenac)
serotonin agonists (triptans: sumatriptan, zolmitriptan)
adjunctive therapies:
- metoclopramide (prokinetic, antiemetic)
- prochlorperazine (antiemetic)
older:
- ergotamine tartrate
- dihydroergotamine
Ergot: MOA
nonselective 5 HT1 receptor agonist
venous and arterial constriction –> inhibits neurogenic inflammation
central inhibition of trigeminovascular pathway
Triptan: MOA
selective agonist of 5 HT1B and 5 HT1D receptors
- vasoconstriction
- inhibition of vasoactive peptides
- inhibition of transmission
What is first line therapy for patients with mild-severe migraines?
triptans
What drug interacts with rizatriptan?
propanolol (reduce dose of rizatriptan)
What is unique about frovatriptan, in relation to the other triptans?
most triptans can only be repeated once daily
frovatriptan can be taken 3x/d
What should be considered when prescribing ergotamine tartrate?
consider pretreatment with an antiemetic
Triptans: ADEs
triptan sensations:
- tightness
- pressure
- heaviness
- pain in chest/throat/neck
Sumatriptan: clinical applications
migraine HA
cluster HA
Which drug can precipitate serotonin syndrome?
sumatriptan
Serotonin Syndrome: clinical presentation
hyperthermia hyperreflexia tremor clonus hypertension hyperactive bowel sounds diarrhea mydriasis agitation coma
Serotonin Syndrome: treatment
discontinue precipitating drugs sedation (benzodiazepines) paralysis intubation ventilation
Serotonin Syndrome: look alikes
neuroleptic malignant syndrome (longer onset, acute sev parkinsonism)
malignant hyperthermia (quicker onset, muscle rigidity, tachycardia)
What is the first line treatment for migraine prophylaxis?
propranolol
Migraine: indications for preventative therapy
> 2 attacks/wk
sx therapies are ineffective/contraindicated/cause serious ADEs
Migraine: preventative therapy: agents
propranolol timolol divalproex sodium (valproic acid) topiramate CGRP monoclonal antibodies (erenumab, galcanezumab)
When do you see maximal benefits of preventative therapy in migraines?
6 months
CGRP monoclonal antibodies:
- effects
- agents
- benefits
- ADEs
dec migraine frequency
erenumab, galcanezumab
reduce CNS ADEs
long half lives
ADEs:
- form neutralizing antibodies
- constipation
- muscle cramps/spasms
Prophylactic Migraine Therapies
metoprolol
propranolol
timolol
topiramate
valproic acid/divalproex sodium
ibuprofen (menstrual migraines)
ketoprofen
naproxen sodium
Frovatriptan: prophylactic special instructions
take in perimenstrual period to prevent menstrual migraines
Supplemental Prophylactic Migraine Therapies
magnesium feverfew riboflavin melatonin butterbur
you need to know
slide 42
Tension Type Headache: treatment options
CBT (stress management, relaxation training, biofeedback)
simple analgesics (+/- caffeine)(acetaminophen)
NSAIDs (ASA, diclofenac, IBU, naproxen, ketoprofren, ketorolac)
Effective options in tension type headaches
high dose NSAID
+ (ASA or APAP) w/ butalbital or codeine
Tension Type Headaches: limit on acute medications
butalbital containing: 3d
combination analgesics: 9d
NSAIDs: 15d
(per month)
There is no evidence to support the efficacy of _________ in the management of episodic tension type headaches.
muscle relaxants
Tension Type Headaches: preventative therapy
TCAs SSRIs (not effective unless they have depression) SNRIs? topiramate, gabapentin? botulinum toxin?
Cluster Headache: description
excruciating unilateral head pain
lasts wks or months separated by remission periods lasting months or years
accompanied by cranial autonomic sx
hallmark: circadian rhythm of painful attacks
Cluster Headache: abortive therapy
oxygen (100% by non rebreather facial mask)
triptans (sprays or injections)
ergotamine derivatives (IV dihydroergotamine or ergotamine tartrate)
Cluster Headache: prophylactic therapy
verapamil
lithium (monitor thyroid and renal function)
corticosteroids
What is the preferred 1st line treatment for prevention of cluster headaches?
verapamil
Sumatriptan: ADEs
paresthesias
dizziness
chest pain
possible coronary vasospasm
