Headaches

Question 1

Pathophys of migraine

Answer 1

• activation of the trigeminovascular system
• vasodilating and permeability-promoting peptides released from pervascular nerve endings
• sterile inflammation and central pain processing
• mediated by presynaptic 5HT 1B-D receptors (inhibitory GPCRs)

Question 2

ergotamine

Answer 2

• 5HT 1B-D agonist
• migraine abortive tx and rescue tx for CH
• vasoconstriction and inactivation of trigem system
• SE: N+V, CP, abdominal pain, dizziness
• contraindications: preganancy, uncontrolled HTN, sepsis renal or hepatic failure, coronary, cerebral or peripheral vascular disease
• oral tablet or suppository form only
• **not really used because of the SE

Question 3

dihydroergotamine (DHE)

Answer 3

• 5HT 1B-D agonist
• vasoconstriction and inactivation of trigem system
• migraine abortive tx
• IM, IV or nasal spray
• IV mainly for status migrainosus
• weaker vasoconstriction, less emetic and less effect on uterus than ergotamine
• ** triptans > DHE > ergotamine

Question 4

triptans

Answer 4

• Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan, Zolmitriptan (mostly tablets, except sumatriptan which is IM too)
• 5HT 1B-D agonist; vasoconstriction and inactivation of trigem system
• premiere migraine abortive meds, CH
• also affective at reducing photo/phonophobia, N + V
• avoid use in PTs with vascular disease, uncontrolled HTN and complicated migraines (ie: hemiplegic migraines)
• well tolerated: SE = flushing, tingling, dizziness, chest discomfort

Question 5

Antidepressants

Answer 5

• TCAs: amitriptyline*, nortriptyline, protriptyline
• preventive/prophylactic tx of migraine and TTH
• avoid during pregnancy,
• SE: dry mouth, constipation, weight gain, cardiact toxicity and orthostatic hypotension

Question 6

Propanolol, Timolol

Answer 6

• Beta blockers used for prophylactic tx of migraines
• SE: drowsiness, depression, decreased libido, hypotension, memory disturbance
• contraindicated in PTs with asthma, diabetes, CHF, Raynaud’s

Question 7

Verapamil

Answer 7

• Calcium channel blocker (antihypertensive agent)
• prophylactic tx of migraines and CH, prolonged or disabling aura and for complicated migraine syndromes (hemiplegic migraine)
• SE: constipation and dizziness
• ** it is the weird drug that treats the weird HAs

Question 8

valproate

Answer 8

• AED
• prophlyactic tx of migraines and CH
• SE: sedation, hair loss, weight gain, tremor, changes in cognition, hepatoxicity, blood dyscrasias and pancreatitis (need to monitor CBC and LFTs)

Question 9

topiramate

Answer 9

• AED
• prophylactic tx of migraines and CH
• SE: cogntion, paresthesias, weight loss, kidney stones and acute angle-closure glaucoma, decreased serum bicarb

Question 10

Onabotulinumtoxin A (Botox)

Answer 10

• prophylactic tx of chronic migraine
• mech unknown
• SE: injection site pain, headache post injection, neck weakness and ptosis

Question 11

analgesics

Answer 11

• COX inhibitors
• acetominophen, aspirin, naproxen, indomethacin, indomethacin, piroxicam, ibuprofen
• acute tx of migraine and TTH

Question 12

barbs

Answer 12

• acute tx of migraine
• risk of OD, withdrawal and rebound HA
• use limited to 2-3 days/week
• SE: dizziness, drowsiness

Question 13

Opioids

Answer 13

• acute tx of migraines
• risk of overuse and rebound
• pregnant women may use codeine or meperidine with caution

Question 14

corticosteroids

Answer 14

• acute tx of migraines or prolonged HA syndromes (ie: chronic daily HAs), rescue tx of cluster HA

Question 15

cluster HA

Answer 15

• annual rhythm, occur at same time of day (usually after falling asleep)
• male > females
• leonine facies, smokers
• restlessness (unlike migraine), ipsilateral lacrimation, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis, eyelid edema, conjunctival injection
• involvement of opthalmic division of trigem
• hypothalamic source?

Question 16

acute CH tx

Answer 16

• O2
• sumatriptan (injection! – the other triptans are tablets and work too slowly!)
• DHE (injection!)
• anesthetics (lidocaine nasal drops)

Question 17

prophylactic tx for CH

Answer 17

• oral corticosteroids and ergotamine (short-term while experiencing a cluster)
• verapamil, topiramate, divalproex sodium, Li (long term prevention)

Question 18

Lithium

Answer 18

• prophylactice tx of CH
• alters circadian rhythms
• need to monitor blood levels
• SE: weakness, nausea, thrist, tremor, lethargy, blurred vision, slurred speech
• toxicity: vomiting, anorexia, diarrhea, confusion, nystagmus, EPS and seizures
• avoid indomethacin and Na-depleting drugs since they increase Li toxicity

Question 19

acute tx of TTH/episodic TTH

Answer 19

• < 15 headaches/month
• simple analgesics (naproxen, ketorolac, indomethacin)
• analgesic combo with opioids, barbs, caffeine (but avoid overuse..)

Question 20

preventive tx for TTH/chronic TTH

Answer 20

• CTTH = > 15 HA/month
• indications in episodic TTH: >2 HA/week, duration > 4hrs, HA severity
• amitriptyline –> SSRI –> muscle relaxants –> Botox

Question 21

migraine abortive/acute tx

Answer 21

• analgesics
• barbs
• opioids
• steroids
• ergotamine/DHE
• triptans

Question 22

preventive tx for Migraine

Answer 22

• antidepressants (usually TCA)
• antihypertensives (beta and Ca2+ channel blockers)
• AEDs (valproic acid and topiramate)
• Botox

Question 23

when do you treat prophylactically for migraine?

Answer 23

• > 3 severe migraines/month
• >2 mild/mod migraines/week
• inability to use effective symptomatic tx
• overuse of acute meds