Headache Treatment

Question 1

Butalbital AE

Answer 1

• tachycardia
• confusion
• sedation

Question 2

Butalbital CIs

Answer 2

• PUD
• renal dysfunction
• substance abuse

Question 3

What do we need to remember about giving ergot alkaloids IV?

Answer 3

GIVE ANTIEMETIC

• chlorpromazine (thorazine) or metoclopramide (reglan)

Question 4

Ergot alkaloids AE

Answer 4

• abdom pn
• N/V

(rare): ischemia, necrosis, MI

Question 5

Ergot alkaloids CI

Answer 5

• CVD
• renal/hepatic failure
• sepsis
• triptan use c/i 24 hrs

Question 6

What NT do Triptans effect, and why should we care?

Answer 6

5-HT agonists!

= potent vasoconstrictors

Question 7

Triptans AE

Answer 7

• fatigue
• dizziness
• warm sensation
• chest fullness/tightness
• nausea

Question 8

Triptans CI

Answer 8

• CVD (PMH: MI, stroke, uncontrolled HTN..)
• severe sulpha allergy
  (then we use zolmitriptan, rizatriptan, frovatriptan)

Question 9

How do we treat tension headaches?

Answer 9

OTC meds

when OTC failure –> Rx (NSAID, butalbital products

Question 10

How do we treat cluster headahces?

Answer 10

1. high flow O2 x 15 mins
2. if O2 not available: triptans (nasal or SC sumatriptan or zolmitriptan)
3. Octreotide (if ergotamine/triptan is CI)
4. IV to PO taper of steroids

Question 11

How do we treat migraines?

Answer 11

1. remove triggers
2. NSAIDs or APAP
3. triptans/ergotamine prn

• ask about antiemetic need
• -> prochlorperizine (compro)

Question 12

Medication overuse headache tx

Answer 12

1. ergotamine, triptan or opioid use for <9 days/mo
   (NSAID, APAP <14 days/mo)

• opioids for migraine obvi very last line!!

Question 13

Tension headache PREVENTION

Answer 13

TCAs (elderly fall risk!)

- behavioral modification (decr. stress, improve posture, more rest)

Question 14

Cluster headache PREVENTION

Answer 14

1. Verapamil

2. Lithium

Question 15

Important clinical points of verapamil

Answer 15

• caution with CVD
• avoid with eletriptan
  (CYP 3A4 interaction)

Question 16

Important clinical points of lithium

Answer 16

0.4 - 0.8 target range

• caution c/ renal failure & CHF
• long term use = tremor, GI upset, lethargy
• HS dosing for sx improvement

Question 17

Lithium CI

Answer 17

• thiazides

- ACE/ARB

Question 18

What about lithium or verapamil + ergotamine?

Answer 18

Lower doses of lithium and verapamil

Question 19

Migraine PREVENTION

Answer 19

1. Beta Blockers (propanolol)
   (metoprolol, timolol, nadolol, atenolol = 2nd line)
2. if unable to use BBlockers: ACE/ARB, candesartan (Atacand)
3. TCAs (amitriptyline (elavil) > nortriptyline (pamelor))
4. antiepileptics (VPA)
5. topamax
6. Botox inj (chronic migraines, if others are not effective)
7. Calcitonin Gene Related Peptide
8. MABs
9. natural prods (butterbur…riboflavin, Mg, CoQ10)

trigeminal neuralgia use carbamazepine

Question 20

VPA important details:

Answer 20

• cause wt gain

other SE:

• N/V
• GI

caution: liver disease, ETOH use disorder

CI c/ PREGNANCY!!!

Question 21

Topamax details:

Answer 21

• wt loss
• kidney stones

good for: metabolic syndrome, nerve pn

X c/ PREGNANCY

Question 22

Menstrual headache tx

Answer 22

NSAIDs prior to menstruation

-triptans (frovatriptan, naratriptan, zomitriptan) if NSAID fail –> 2-3 days prior

Question 23

Migraine tx: Pediatrics

Answer 23

1. ibuprofen
2. APAP
   (maybe antiemetic (prochlorperazine)
3. triptans (if NSAID fail)

prophylactic:

• topamax if 12+
• remove triggers & try non-pharm
• avoid ASA = Reye Syndrome

Question 24

Migraine tx: pregnancy

Answer 24

#1 = APAP
(prednisone & methylprednisolone are OK)

prophylaxis: beta blockers

avoid:

• NSAIDs 3rd trimester
• opioids

CI:

• triptans
• ergot products