Headaches Flashcards
Migraine Diagnostic criteria
- > 5 attacks
- 4-72 hrs duration
- > 2: pulsatility, moderate/severe intensity, aggravated by physical activity, unilateral
- > 1 : n/v, photophobia & photophonia, not attributed to another disorder
FDA approved therapies for migraines
- Propranolol
- Timolol
- Divalproex sodium
- Topiramate
- Trial 2-3 months, maxn6 months
- Selection of agent based on SE profile and comorbid conditions
- Often can use lower doses than other indications
- Start low and go slow
- Continue 6-12 months after frequency of headache reduces
- May be able to taper to lower dose or discontinue altogether
First line for mild-mod migraines
- Simple analgesics (APAP & APAP/caffeine/ASA)
- NSAIDS (Aspirin, diclofenac, ibuprofen, ketorolac, naproxen, tolfenamic acid, and combination therapy)
- Metoclopramide = speed absorption of analgesic and alleviate N/V
Pharmacological tx: migraines
- Acetaminophen 1000 mg every 4 hours as needed; max dose 3-4 gm/24 hours
- Excedrin Migraine (ASA/APAP/caffeine) 2 tabs every 6 hours as needed
- ASA 500-1000 mg every 4 hours as needed (max 4 gm/day)
- Ibuprofen 200-800 mg every 4 hours as needed (max 2.4 gm/day)
- Naproxen sodium 550-825 mg at onset, may repeat 220 mg 3-4 hours later
opiates for migraines
-Use is controversial
-CNS sensitization is likely
Increased risk for overuse headache
-Maybe reasonable with moderate to severe infrequent headaches
Ergot alkaloids for migraines
- Useful for moderate to severe attacks
- Nonselective 5-HT receptor agonists
- Constrict intracranial blood vessels and inhibit development of neurogenic inflammation in trigeminovascular system
- Agonist at dopamine receptors
- Contraindications: renal or hepatic failure, coronary dz, cerebral dz, PVD, uncontrolled HTN, sepsis, pregnant or nursing
Ergotamine
- Oral, sublingual, rectal
- Caffeine may be given to enhance absorption and analgesic effects of oral and rectal routes
- Use is limited due to poor efficacy and side effects (nausea), associated with rebound headache
Dihydroergotamine
- Intranasal, IV, IM, SQ routes
- Relatively safe, not associated with rebound headache
- Side effects: Common: N/V, abdominal pain, weakness, paresthesias, muscle pain, diarrhea, chest tightness
- Rare: Severe peripheral ischemia (ergotism), vasoconstrictor effects, gangrene, MI, hepatic necrosis, bowel & brain ischemia
Triptans: First line for mild-severe HAs
- Selective agonists of 5-HT1B and 5-HT1D receptors
- Normalization of dilated intracranial arteries through enhanced vasoconstriction
- Inhibit vasoactive peptide release from perivascular trigeminal neurons
- Inhibit transmission through second order neurons ascending to the thalamus
- Sumatriptan provides relief in 70% of patient at 2 hours; SQ has most rapid onset
- Do not use triptan within 24 hours of ergotamine derivative
- Zolmitriptan
Triptan s/e
-generally mild – moderate, short duration
-Paresthesia’s, Fatigue, Dizziness, Flushing
Warm sensations, Somnolence
-Contraindicated: history ischemic heart dz, uncontrolled HTN, cerebrovascular dz, pregnancy, hemiplegic or basilar migraines
-Postmenopausal women and men over 40 years of age – cardiovascular assessment prior to use; first dose with supervision
Triptan drug interactions
- Avoid sumatriptan, rizatriptan, and zolmitriptan within 2 weeks of MAOIs
- Eletriptan should not be given with CYP3A4 inhibitors: macrolide abx, antifungals, and some antiviral therapies
- SSRI or SNRI + triptan may increase risk for serotonin syndrome
Prophylactic therapies: BB
- Reduce frequency 50%, in greater than 50% of patients
- May raise migraine threshold by modulating adrenergic or serotonergic neurotransmitters in cortical or subcortical pathways
- May be useful if concomitant HTN
- Caution if concomitant CHF, PVD, Atrioventricular conduction disturbances, asthma, depression, diabetes
Prophylactic therapies: Antidepressants
- Amitriptyline and venlafaxine demonstrated effectiveness
- Other agents are controversial; anecdotal evidence
- Watch for serotonin syndrome if using venlafaxine with triptans
Prophylactic therapies: Anticonvulsants
- Enhancement of GABA-mediated inhibition, modulation of excitatory NT glutamate
- Inhibition of Na and Ca channel activity
- Useful with comorbid seizures, anxiety, bipolar
- Sodium valproate or divalproex sodium
- Topiramate is most studied – benefit as soon as 2 weeks possible
Aimovig (erenumab-aooe)
-Monoclonal antibody, inhibits Calcitonin Gene-Related Peptide
-Prevention of episodic and chronic migraines (with and without aura)
-70-140 mg SQ monthly, upper arm
-Side Effects: constipation, hypertension
Can be significant
-Cost and insurance coverage can be a barrier
