Headaches

Question 1

RED FLAGS FOR HEADACHES

Answer 1

SSNOOP

• Systemic symptoms (fever, lb loss, malaise) OR
• Secondary HA risk factors (HIV, systemic Ca)
• Neuro or abnormal sign (confusion, impaired alertness/consciousness)
• Onset: THUNDER CLAP, sudden, split second, abrupt
• Older: Age 50yo and older for new onset (giant cell arteritis)
• Previous HA history with change in frequency, severity, clinical features

Question 2

Headache Classifications

Answer 2

Primary: benign
- Cluster, Tension, Cluster, Drug Rebound
Secondary: Signs of organic disease

Question 3

Migraines (3 Types)

Answer 3

Migraine with Aura

• focal with neuro symptoms
• visual or sensory symptoms develop over 5-60min
• motor weakness, hemiplegic

Migraine without Aura
- no neuro symptoms

Migraine Variants

• atypical presentation
• some autosomal dominant transmission for rare variants

Chronic 15 or more days q 1 mo for more than 3 mo

Question 4

Abortive Treatment for Migraines

Answer 4

• Works better if you give early onset
• Simple analgesics (high dose) for mild-mod attacks
  > ASA 900-1000mg
  > Ibuprofen 400-600mg
  > Naproxen 275-825mg
• Ergotamine or Ergo Combos (with caffeine) and dihydroergotamine
  > 2nd Line
  > 1st line if cant take triptans
  > contraindicated in pts on CYP3A4’s
  - Cyclosporins, macrolides, antifungals, heparin
  - Raises ergo levels bc reduces metabolism of ergo
• TRIPTANS
  > 1ST LINE for mild-sev attacks
  > Taken no more than 2 doses in 24 hours
  > OR 2-3 doses per week
  > OR 10 doses per month
  > Combos with (NSAID’s) have good efficacy

AVOID:
- Narcotics, Barbs/containing, Caffeine, Benzos
>BC habit forming + long term rebound HA’s

Question 5

TRIPTANS

How it works
Common Side Effects
Availability Form

Answer 5

• 1ST LINE for mild/mod-sev attacks
• Seroton 5ksdfkl Receptor Agonist
  > Appears to work by VASOCONSTRICTION and
  inhibiting neurogenic inflammation
• Common Side Effects
  > Fatigue
  > Flushing
  > Chest/Throat/Jaw tightness
  > Pressure?
  > heaviness or pain
  > paresthesia’s
  > dizziness
  > drowsiness
• Intranasal
  > bad taste and nasal discomfort
  > quicker onset than PO and sometimes better for
  those with n/v
• Chest Symptoms
  > Usually not related to ischemic disease
  > But use with caution in those at risk for CAD, men
  over 40, and postmenopausal women
  > Cardiac eval for these patients prior to use

Available in tablets, injections, ODT, nasal sprays
> ODT can be more convenient bc no water needed

Question 6

TRIPTANS

Contraindications

Answer 6

• Ischemic heart disease
• Cerebrovascular disease
• Uncontrolled HTN
• Hemiplegic or basilar migraine
• Use within 24 HOURS of ERGO/DERIVATIVES

** Opioids and Barbs/Containing (Fiorinal) are not considered to be appropriate abortive agents **

Question 7

Prophylactic Treatment of Migraines

Answer 7

• Indicated when HA occurs more than 1x/week
  OR
• When symptomatic treatment contraindicated or not working
• Beta-Blockers (propanolol, timolol, atenolol, metop)
• TCA (amitriptyline)
• Antiepileptics (topiramate, divalproex, valproic acid)
• Others
  > CCBs: Verapamil
  > SSRI
  > Antiepileptics: gabapentin
  > Botox

Question 8

Tension-Type Headache Treatment + Diagnosis

Answer 8

• No diagnostic testing need, can be clinically diagnosed
  > BE SURE TO RULE OUT SSNOOP
• Important to avoid overuse of caffeine, narcotics, barbs/containing because of risk of rebound HA

Acute Treatment:

• NSAIDs and Acetaminophen
• Combo Analgesics containing caffeine

Preventative Treatment:
- TCA