Headache (R) Flashcards by Anna I

International Headache Society (IHS) classification

-migraine
-tension-type headache
-cluster headache

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tx goals for migraine

-rapid & consistent tx
-restore functional ability
-use lowest, effective dose of abortive therapy
-minimize adverse events

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non-pharmacological interventions: migraines

maintain headache diary to identify potential triggers & practice avoidance
-use of ice, rest, bio-feedback

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urgent medical eval for “red flags”

-new-onset sudden +/- severe pain
-stereotyped pain pattern worsens
-systemic signs (fever, wt loss, accelerated HTN)
-focal neurologic sxs (other than typical visual/sensory aura)
-papillederma
-cough-, exertion-, or Valsalva-triggered headache
-pregnancy or postpartum state
-pts w/ cancer, HIV & other infectious & immunodeficient disorders
-seizures

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if n/v present in migraine headache treat

antiemetic: consider IV, IM, SQ, or nasal formulation

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mild-moderate migraine sxs …Rx

-simple, analgesics NSAIDs

-APAP alone is not recommended

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severe migraine sxs or if no relief from NSAIDs for mild-moderate sxs .. Rx

combo analgesics

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first-line tx choice for mild to moderate attacks or severe attacks that have responded in the past to similar tx

oral NSAIDs

combination analgesics w/ caffeine

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butalbital-containing products

drug class: barbiturates

-limit & monitor use due to overdose
-medication-overuse headache
-withdrawal

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acetaminophen (APAP): dosing & max

1000mg at onset
repeat q4-6h as needed
max=4g/day

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APAP + ASA +caffeine

APAP 250mg + ASA 250mg + caffeine 65mg

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ASA or APAP, caffeine

1-2 tablets q4-6h

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isometheptene + dichloraphenazone + acetaminophen

isometheptene 65mg + dichloraphenazone100mg+ acetaminophen 325mg 2 capsules at onset, repeat 1 capsule every hour as needed

max 6 capsules in 24hr

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ASA

500-1000 mg q 4-6hr; max 4g/day

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ibuprofen: dose & max

200-800 mg q6h; avoid >2.4 g/day

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naproxen sodium

550-825 mg at onset; may repeat 220mg in 3-4h

avoid > 1.375g/day

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first-line therapy for moderate to severe migraines especially when nonspecific (OTC (Excedrin migraine)) are ineffective

triptans

if no response to one, try another

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triptans contraindications

-hx of ischemic heart disease
-uncontrolled HTN
-CAD
-stroke
-PVD
-Prinzmetal’s angina
-MI
-pregnancy

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moderate to severe migraine attacks when other tx failures

ergotamines

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ergotamines: CIs

-pts w/at risk for CAD
-stroke
-PVD
-uncontrolled HTN
-liver/kidney disease
-strong inhibitors of CYP3A5
-pregnancy (cat X)

opioids

moderate to severe infrequent headaches

“last resort” due to contraindications or failed response to conventional therapies

lasmiditan

a selective serotonin 1F receptor agonist that lacks vasoconstrictor activity

for contraindications to triptans due to cardiovascular risk factors

s/e of lasmiditan

decrease HR and/or increase BP
-dizziness, paresthesia, somnolence, fatigue, N

duration 1.5-2h

no driving, operating machinery, engage in hazardous activities for at least 8h after EACH dose

lasmiditan: life threatening

serotonin syndrome

w/ [SSRIs, SNRI, triptans, TCA, fentanyl, lithium, tramadol, buspirone, St. John’s wort, tryptophan) or w/o other drug associates

-impair serotonin metabolism: MAOIs
-other contributing: MAOIs: linezolid and IV methylene blue

serotonin syndrome: s/s

-mental status changes [agitation, hallucination, delirium, coma] -autonomic instability [tachycardia, labile BP, diaphoresis] -neuromuscular changes [tremor, rigidity, myoclonus] -GI sxs [N/V/D] -seizures discontinue tx

CGRP antagonists

pharmacological modulation of calcitonin-gene related peptide (CGRP) activity appears to mediate trigeminovascular pain transmission in migraines

CGRP available for

"gepants" for acute tx of migraine in patients w/ either insufficient response or contraindication (CAD) to tx w/ triptans

ubrogepant & rimegepants

acute migraine tx for adults

adjuvant therapy to relieve N/V & migraine attack

***chlorpromazine, prochlorprezamine*** -IV formulation for refractory, intractable headache -administer 15-30m before abortive therapy ***metoclopramide*** IV (a DA receptor blocker) effective for acute migraine tx

prophylactic therapy considerations

-quality of life, business duties, or school attendance are severely impaired -frequency of attacks are equal/greater than 2/month -migraine attacks do not respond to acute drug tx -frequent, very long, or uncomfortable auras occur

beta-blockers

propranolol ideal for health pts/comorbid HTN, angina, or anxiety ***avoid in reactive airway disease, heart block, bradycardia***

TCAs

**nortriptyline, amitryptiline** comorbid depression/insomnia ***avoid: urinary retention, BPH, glaucoma, anticholinergic effects are problematic***

anticonvulsants

**valproate, topirimate** for comorbid seizure disorder/manic-depressive illness (many drug interactions)

CCBs

**verapamil** generally considered 2nd or 3rd line for migraine headaches ***first for prophylaxis of cluster type of headache***

NSAIDs

use for migraines w/ predictable pattern (eg. menstrual cycle) -initiate 1-2d prior to expected onset of headache -total duration of use limited due to risk of GI events

triptans

use for migraines w/ predictable patter (eg. menstrual cycle) -for pts that are unresponsive to NSAIDs, not considered standard of practice

botox

15 or more headaches a month, each lasting 4h or more

CGRP antagonist

little evidence of use

MOH abbr

medication overuse headache headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute/symptomatic headache medication for more than 3 months

highest risk for MOH

-opioids -butalbital-containing analgesics -acetaminophen-aspirin caffeine combos

prevention of MOH

limit most meds to less than 10 days per month or less than 15d for ASA, APAP, NSAIDs

cluster headache

severe headache on one side of the head w/ recurrent on fixed time intervals

cluster headache s/s

-swollen/drooping eye -smaller pupil in the eye -eye redness/watering -running/congested nose -red/warm face -sweating

cluster headache causes

-smoking -alcohol -disruptions in your circadian rhythm (sleep deprivation, jet lag)

cluster headache tx

-measure to abort the acute episode w/ meds such as **sumatriptan** -o2 (dec severity) -avoid alcohol

cluster headache: acute tx

-submatriptan subq inj -zolmitripan nasal spray -sumatriptan nasal spry -o2 -nVNV (for ECH)

cluster headache: interim tx

-oral prednisolone -greater occipital nerve block

cluster headache: preventative

-verapamil -topiramate -lithium -melatonin -nVNS -SPG microstimulator

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Headache (R) Flashcards

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