Headaches Flashcards
migraine, tension, cluster
primary headache
head trauma, vascular disorders, substance
use
secondary headache
Recurring severe throbbing unilateral headache interfering with normal functioning
migraine
migraine without aura
common migraine
migraine with aura
classic migraine
migraine prevalence
female, white, lower socio, genetic
neuropeptides released in migraines
Calcitonin gene-related peptide (CGRP)
Substance P
Neurokinin A
Trigeminovascular System regulated by
serotonin
migraine dgx
5+ HA lasting 4-72 hr at least two: unilateral, throbbing, worsened by movement, moderate to severe PLUS nausea or vomiting or photophobia AND phonophobia
migraine with aura dgx
At least one (reversible): -Positive (flickering lights) -Negative (loss of vision) -Speech disorder -CANNOT BE WEAKNESS Develops gradually and lasts less than 1 hr
SNOOP
systemic signs or symptoms neurologic onset old age progression of existing HA disorders
Migraine test
MIDAS (MIgraine Disability Assessment Test)
Scored by 5’s as I, II, III or IV (0-5, 6-10, etc)
Classes used for migraines
Analgesics NSAIDS Ergot Alkaloids Serotonin Agonists (Triptans) Opiates Antiemetics
Use caution with Analgesics/NSAIDs
Ulcer dz
Renal Dz
Cardiac Dz
Hypersensitivity
Analgesic/NSAID DOC for migraines
Ibuprofen and naproxen
Aspirin
Combination: Acetaminophen, aspirin, caffeine
2nd Line:
Acetaminophen, isometheptene, dichloralphenazone
Acetaminophen, butabital, caffeine
Analgesic/NSAID MOA
Inhibition of prostaglandin synthesis
Ergot Alkaloids MOA
5HT1 agonists – constrict intracranial blood vessels
Inhibition of the trigeminovascular system
-Activation of 5-HT1 receptors on sensory nerve endings of
the trigeminal system results in the inhibition of pro-
inflammatory neuropeptide release
-Prevention of neurogenic inflammation
Severity of migraine to use Analgesics/NSAIDs
Mild - Moderate
Severity of migraine to use Ergot Alkaloids
Moderate - Severe
Analgesic/NSAID ADE’s
Renal, GI (bleeding, dyspepsia, nausea), CNS (dizziness)
Ergot Alkaloids used in migraines
Ergotamine Tartrate (more potent arterial constrictor) Dihydroergotamine (DHE) - (less potent)
Ergotamine Tartrate routes
Oral
SL
Rectal
Dihydroergotamine (DHE) routes
Nasal
Parenteral
Ergotamine Tartrate can be combined with:
Caffeine
- Enhances absorption
- Aides in analgesia
Dosing for Ergot Alkaloids
Ergotamine Tartrate has strict dosing to prevent rebounds
-Daily and weekly dose
PR 4 mg/day 10 mg/wk
PO 6 mg/day 10 mg/wk
Ergot Alkaloids ADE’s
Nausea/Vomiting
-Stimulation of the chemoreceptor trigger zone
-Pretreatment with antiemetic needed:
Ergotamine tartrate
IV DHE
Systemic constriction
-Paresthesias, chest tightness, cold hands
Severe systemic constriction – (rarely)
-Ischemia: brain, bowel, heart, extremities (ergotism)
-Less with DHE
Ergot Alkaloids Contraindications
Systemic vasoconstriction
-MI, angina, coronary vasospasm, PVD, hemiplegic migraine, uncontrolled HTN, ischemic CVA, sepsis
Use of triptan within 24 hours
Use of MAOI within 2 weeks
Use with any potent CYP 3A4 inhibitor
-Azole antifungals, PI, macrolide antibiotics
-The risk for vasospasm leading to cerebral ischemia
and/or ischemia of the extremities is increased. Pregnancy
DHE Nasal Pt Education
- Before using each nasal spray vial, prime the pump by spraying 4 times into the air, away from the face
- Use 1 spray into each nostril
- Do NOT tilt your head back, sniff through your nose, or blow your nose while spraying or immediately after. Use another spray into each nostril 15 minutes after the first sprays if needed
- Do not use more than 4 sprays for a single attack
Serotonin Agonists (Triptans) MOA
5HT1 agonists – constrict intracranial blood vessels
Inhibition of the trigeminovascular system
-Activation of 5-HT1 receptors on sensory nerve endings of the trigeminal system results in the inhibition of pro- inflammatory neuropeptide release
-Prevention of neurogenic inflammation
Serotonin Agonists on mkt
Almotriptan Eletriptan Frovatriptan Naratriptan Rizatriptan Sumatriptan Zolmitriptan
DOC for mod - severe migraines
Serotonin Agonists (Triptans)
Selection of Triptans
Onset -Injection vs nasal vs oral -ODT – faster onset? Duration -Prevention of recurrence -Menstrual migraines Drug Interactions - metabolism Patient variability to response -Can not be predicted -Failure on one does NOT mean class -12 week trial
Triptan ADE’s
Usually mild to moderate
Paresthesias, flushing, warm sensation
Local side effects based on route
-Injection site reactions
-Nasal irritation
“chest symptoms”: heaviness, pressure, tightness
-5HT2A receptors within the coronary vessels
-Isolated cases of cardiac events have been reported
-Unlikely in patients with normal coronary vessels
Reason for migraines during menstruation
lowest levels of estrogen during cycle
