Headaches Flashcards
What’s the difference between primary and secondary headaches?
Secondary headaches are attributed to other disorders (ie post-traumatic, vascular disorders, tumors etc); Primary headaches are when headache condition is a disorder unto itself
What is the distribution of migraine sufferers in male vs female?
women affected 3:1 in mid adulthood compared to males (22-55 yrs); prior and post, women and men more evenly affected
What are the four phases of migraine
prodrome, aura, headache, resolution
What happens in migraine prodrome?
(hrs/days before) change in mental status (drowsy, depressed, europhoric, hyperactive ,etc); phono/photophobia, yawning, difficulty concentrating, dysphasia, anorexia, food cravings, thirst, urination, fluid retention, stiff neck, etc
What is a migraine aura?
complex of focal neurologic symptoms (positive or negative) that follows/precedes/accompanies HA. lasts <60min, may occur w/out HA, visual aura most common; paresthesias 2nd most common
What happens during the headache phase of migraines?
unilateral, throbbing, aggravated by physical activity, relieved by rest; can become bilateral, last 4-72hrs, gradual onset/resolution, many assoc symptoms
What happens during the resolution phase of migraines?
headache wanes, person feels tired, washed out, irritable, impaired concentration, scalp tenderness, depression
What is the baseline pathophysiology for why migraines may occur?
1) genetic component (ex: familial hemiplegic migraine due to mutations on chromosome 19), plus twin studies etc
2) “sensitive brain” w/hyperexcitability and exaggerated responses
What is the pathophysiology of the aura phase?
associated w/reduction in cerebral blood flow (NOT a vascular phenomenon though); NOT due to vasoconstriction; more due to cortical spreading depression (neuronal dysfunction)
What is the pathophysiology of the headache phase?
involves activation of trigeminovascular system; where nerve fibers from V11 release vasodilating and permeability promoting peptides to cause sterile inflammation leading to increased sensitivity and pain
What are some behavioral treatments to prevent primary headaches from occurring?
healthy habits (sleep/diet/no smoking etc), stress management, biofeedback, trigger identification and avoidance
What are some examples of nonspecific medications used to treat migraines?
NSAIDs, COX2 inhibitors, combination analgesics, neuroleptics/antiemetics, corticosteroids, opiods
What are examples of specific medications used to treat migraines?
Ergotamines/DHE and Triptans
What are nonspecific medications useful in treating? Where to problems occur?
mild/moderate headaches, special populations (pregnancy, children, cardiovascular risks); caution to avoid overuse (especially with barbiturates)
What is the Rebound headache phenomenon?
symptomatic medications when taken daily can cause rebound phenomenon; medication overuse is MOST COMMON CAUSE OF CHRONIC DAILY HEADACHES (often from caffeine, barbiturates, and narcotics; but also from specific migraine meds)
How do Analgesics help with acute treatment of migraines?
COX-2 inhibitors usually preferred; Acetaminophen preferred in children due to danger of Reye’s; combo of acetaminophen/aspirin/caffeine (ie Excedrin) can be effective w/moderate migraines
When do Barbiturates help with acute treatment of migraines?
Used when more specific migraine meds aren’t available or are contraindicated; but risk of overuse/withdrawal, drowsiness and dizziness; thus limited to 2-3 times use/week
When do Opioids help with acute treatment of migraines?
Only for pts with infrequent headaches or for women that are pregnant (codeine or meperidine w/caution); only use 2 days/wk to avoid rebound
When do Corticosteroids help with acute treatment of migraines?
For pts with prolonged headache symptoms such as chronic daily headache
What is the proposed MOA of Ergotamines and DHE (dihydroergotamine)?
possibly vasoconstriction and/or acting as a 5HT agonist in the trigeminovascular pathway (reducing cell activity)
How is Ergotamine administered and how is DHE administered?
Ergotamine: suppository or tablet; DHE: IM, IV or nasal spray
What are the common side effects with Ergotamines and DHE?
Nausea (*less w/DHE), dizziness, paresthesia, chest pain, abdominal cramps
Who is contraindicated in taking Ergotamines and DHE?
women planning pregnancy, uncontrolled HTN, sepsis, renal or hepatic failure, vascular disease
What are 3 advantages to DHE over Ergotamines?
less likely to cause rebound, have low HA recurrence rate, less likely to cause nausea
What is the mechanism of action of the Triptans (ex:Sumatriptan)
Selective 5HT 1B-D agonists that penetrate the CNS to some extent, constricting extracerebral intracranial vessels and inhibiting the trigeminovascular system
What are the Triptans effective in treating?
**premier migraine abortive drugs! plus effective for photo/phonophobia, N/V; pain relief for 80% taking subcutaneous doses and 60% other routes
What do Triptans not treat?
aren’t helpful during the aura stage
What are some contraindications and side effects in taking Triptans?
Contraindications = vascular disease (including Prinzmetal angina), uncontrolled HTN, complicated migraines
Side effects: flushing, tingling, dizziness, chest discomfort (non cardiac)
What are some examples of adjunctive treatments used to tx acute migraines?
antiemetics and neuroleptics
When would it be useful to use preventive treatment for migraines?
long-term use, preemptive, short term (menstruation), most used at low doses for chronic prevention when recurrent severe migraines >3/month, recurrent mild/moderate >2/wk, special migraine syndromes, etc
What tricyclic antidepressants are used for preventive migraine treatment and what are the side effects?
amitriptyline, protriptyline, nortriptyline
side effects (rare): dry mouth, constipation, weight gain, cardiac toxicity, orthostatic hypotension
What SSRIs are used for preventive migraine treatment and what are the side effects?
fluoxetine, paroxetine and sertraline
side effects: weight gain, sexual dysfunction
What antihypertensives are used for preventive migraine treatment and what are the side effects?
**propanolol most used (FDA approved) and timolol (FDA approved); nadolol, atenolol
side effects: drowsiness, depression, decreased libido, HYPOTENSION; contraindicated w/asthma, diabetes, CHF and Raynaud’s
What Calcium channel blockers are used for preventive migraine treatment and what are the side effects?
Verapamil – useful in patients with prolonged or disabling aura and for complicated migraine syndromes like hemiplegic migraine
side effects: constipation and dizziness
What are some of the antiepileptic drugs used for preventive migraine treatment?
Valproic acid, topiramate (see Dr. Vertino flashcards for more info on these drugs)
How does onobotulinumtoxin A (botox) used as preventive treatment and what are the side effects?
Unknown MOA (might decrease afferent stimulation of trigem, downregulating sensory and parasympathetic receptors, etc)
Side effects: injection site pain, headache, neck weakness, ptosis (distant toxin spread not expected)
What are some characteristics of the tension type headache?
no prodrome or aura, mild to moderate in severity, pain is dull, achy, non-pulsatile, pressure-like; bilateral (band-like), neck or jaw discomfort, scalp tenderness, difficulty sleeping is trigger
What are the IHS Criteria for Episodic tension type headaches?
headaches 30 min-7days w/some of the following: bilateral, no aggravation with physical activity, no nausea or vomiting, and only photophobia or phonophobia (1 or the other)
What are the IHS Criteria for Chronic tension type headaches?
similar to episodic tension type headache but >15days/month for >6months and may be associated with disorders of pericardial muscles?
What are the acute treatments for TTH?
analgesics (possibly in combo with opioids, barbs, caffeine)
What are the preventive treatments for TTH?
TCA (Amitriptyline), SSRIs, muscle relaxants, botox
What is the epidemiology of cluster headaches?
clockwork daily/annual rhythm; men affected 4:1, genetic component, pts w/heavy facial features (possibly due to smoking?)
What is the IHS Criteria for Cluster Headaches?
severe unilateral orbital, supraorbital, temporal pain lasting 15 min-3hrs, associated w/lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, miosis, ptosis, eyelid edema, conjunctival injection, restlessness/agitation
What is the pathophysiology of the cluster headache?
maybe due to dysfunction within hypothalamus interacting with trigeminovascular system
What are the acute treatments for Cluster Headaches?
O2 via non-rebreathing masi, Sumatriptan, DHE (SC or intranasal), lidocaine nasal drops
What are the short term preventive treatments for cluster headaches?
steroids (daily oral prednisone) or DHE daily oral
What are the long term preventive treatments for cluster headaches?
verapamil, topiramate, valproic acid, lithium (which has many side effects and potential toxicity; avoid Na-depleting diuretics)
