Headaches Flashcards
Abortive meds for HAs?
- analgesics
- NSAIDS
- combo analgesics
- antiemetics
- triptans (5-HT agonists)
- ergot alkaloids
preventative meds for HAs?
- BBlockers
- anticonvulsants
- antidepressants
- CCBs
- serotonin antagonists
Analgesics used for tx HA sxs?
- tylenol: 325- 650 q 4-6 hrs not to exceed 3250 mg/day * watch for liver toxicity * 1st choice during PG and breastfeeding
- Aspirin: 325-650 mg q 4-6 hrs - don't exceed 4000 mg/day - inhibits prostaglandin synthesis, reducing inflamm. response and platelet aggregation - CIs: hx of bleeding disorders asthma hypersensitivity
NSAIDS use in tx HA? MOA, SE? BBW?
- MOA: inhibit cox-2 enzyme
- SEs: abdominal cramps, nausea, indigestion, Renal impairment
BBW: CV events - Ibuprofen (motrin):
200-400 mg, don’t exceed 2400 mg/ 24 hrs - naproxen: initial 500 mg then 250 mg q 6-8 hrs, not to exceed 1250 mg/day
- these are first line!!
Combo analgesics used for HA tx? barbiturates
- barbiturates:
fiorinal: butalbital/caffeine/ASA, 50/40/325 dose, give 1-2 tabs q 4hr, max 6 tabs/day - MOA: inhibit prostaglandin, sedation, cerebral vasoconstriction
- preg C
SEs:
drowsiness, N/V, abdominal pain
fioricet: butalbital/caffeine/acetaminophen 50/40/325 dose, 1-2 tabs q 4 hr, max 6/day - preg C - BBW: hepatotoxicity SEs: drowsiness, N/V, and abdominal pain
- habit forming
- can cause overuse HAs
- don’t use more than 3 days/month
Combo analgesics? Midrin
isometheptren/dichloraphenazone/acetaminphen
- 65/100/325 dose
- 1-2 caps q 4 hrs, max 8 caps/day
- MOA: cerebral vasoconstriction, sedation, analgesia
- Preg C
- Ses: drowsiness, N/V, and abdominal pain
- not used as much
Antiemetics - phenothiazines?
BBW?
- promethazine (phenergan) PO, IM, IV, rectal
- prochlorperazine (compazine) PO, IM, IV, rectal, PO sustained release capsule
- MOA: non-selectively antagonizes central and peripheral histamine H1 receptors
- Preg C
- SE: drowsiness, sedation
BBW: resp depression in younger than 2 yo and tissue necrosis with injections (phenergan)
- dementia related psychosis (compazine)
Antemetics - metoclopromide (reglan)? BBW?
- PO/IV/IM
- MOA: antagonizes central and peripheral dopamine receptors
- Preg B
- SEs: drowsiness, restlessness, fatigue
BBW: tardive dyskinesia
Triptans used in HA relief?
- 5-HT1 receptor agonists:
sumatriptan (imitrex): PO at HA onset, SC, nasal
naratriptan (amerge): has higher bioavailability, longer acting, lower rate of HA recurrences
rizatriptan (maxalt): early onset of action (30 min)
zolmitriptan (zomig): PO/nasal/disintegrating tablet onset of migraine
Frovatriptan (Frova): half life 26 hrs, works well for menstrually related migraines
2 day miniprophylaxis
MOA, CI, Preg, and SEs of triptans?
MOA: agonist effect on serotonin 5-HT1 receptors in cranial bood vessels and subsequent inhibition of pro-inflammatory neuropeptide release
- CIs:
CAD, PVD, stroke, hemiplegic and basilar migraine
use of SSRIs (serotonin syndrome)
MAOI use
Preg C
Don’t use for more than 9 days/month
SEs: nausea jaw, neck, or chest pressure or tightness fatigue burning sensation of the skin increased BP
Onset of sxs and triptans use?
- all efforts should be made to initiate therapy as soon as possible after first sxs of attack, since success is proportional to rapidity of tx, and lower dosages will be effective with less SEs
ergot alkaloids use? MOA? preg? BBW?
- first migrain specific drug
- have fallen out of favor d/t unpredictable pt response
- dihydroergotamine (DHE) and Ergotamine
MOA: nonspecific 5-HT agonist, antagonist, or both types of activity for serotonergic, dopaminergic and alpha-adrenergic receptors
- results in constriction of peripheral and cranial vessels
preg X
BBW: life threatening peripheral ischemia
- effects are woorse with admin with potent CYP 3A4 inhibitors, protease inhibitors and macrolide abx
Admin of ergotamine tartrate (ergots, ergomar) and SEs?
- PO, SL, PR
don’t exceed 6 mg/attack - SEs:
rebound HA, vascular occlusion, dependence
Admin of DHE 45 (migranal)? Adverse effects?
- IM/SQ and IV - al max 6 mg/week
- nasal 1 spray each nostril, repeat q 15 min to max 4-6 sprays/day, max: 8 sprays/ week
Adverse effects - more common: burning or tingling sensation dry mouth dryness, soreness or pain in nose runny or stuffy nose, change in sense of taste, diarrhea, dizziness, fatigue, HA, increased sweating, N/V, muscle stiffness
less common:
anxiety, blurred vision, cold clammy skin, confusion, congestion in chest, cough, decreased appetite, pounding heartbeat, depression, nervousness
Recommendations in HA care?
- tx with safest, least expensive drug during first attack
- progress to more expensive and specific therapies for subsequent attacks if initial tx unsuccessful
- stratified care: tx assigned based on severity of HA
Narcotic analgesics?
- meperidine (demerol)
- morphine
- oxymorphone
- hydromorphone (dilaudid)
- Norco
- percocet
- oxycodone
- hydrocodone
- fentanyl
- in general NOT recommended for tx of HAs
- use in migraines for:
rescue med for severe migraine, and infrequent migraines with CIs to other agents
Combo therapy in HA relief tx?
- Triptan+OTC naproysn (aleve) 220 mgx1 with onset of HA
- NSAID with antiemetic
- moderate narcotic with antiemetic
When should preventative therapy be initiated?
Goals of preventative therapy?
- recurring HA that significanly interferes with daily routine in pt’s opinion
- CIs or failure of overuse of acute therapies
- adverse reaction with acute therapies
- pt preference
goals of preventative therapy:
- decrease attack frequency and duration
- improve responsiveness to tx of acute attacks
- improve fxn and decrease disability
Meds used for preventative therapy?
- BBlockers: propranolol (inderal)
- anticonvulsants: valproic acid (depakote), topramax (topiramide)
- antidepressants: TCAs, SSRIs
- CCBs - Calan (verapamil)
BBlocker use as preventative therapy? Caution in? SEs?
- propanolol (Inderal) and TImolol have been approved by FDA for migraine prophylaxis
- *** Considered FIRST line for prophylactic tx of migraines
- propanolol stary 40 mg bid daily
- timolol: 5 mg once daily
- used with caution: baseline bradycardia asthma 2nd or 3rd degree AV block CHF
SEs:
- fatigue, depression, impotence, hypotension
CCBs - MOA, CI, Meds, SE?
- MOA: inhibition of serotonin release
- CI: bradycardia, heart block, a-fib
- meds: verapamil (calan): start at 40-80 mg tid daily, considered 2nd or 3rd line tx, but ** 1st for cluster HA
- SEs: flushing dizziness constipation peripheral edema
Anticonvulsants? Depakote
- valproic acid (depakote)
- may decrease HA frequency by as much as 50%
- effects seen within first 4 weeks of therapy
- dose ranges: 250 mg bid
- SEs:
wt gain, tremor, nausea, hair loss - preg: D
Anticonvulsants? topiramate (topamax)
SEs?
CI?
- FDA approved in 2004
- dose 25 mg qhs for 1st week
- increase weekly by 25 mg
- SEs:
concentration and memory impairment
fatigue
wt loss
nausea
preg C
CIs: liver and renal impairment
Antidepressants use in preventative therapy? Most effective?
- TCAs most effective:
Elavil (amitryptiline) only TCA with proven efficacy, start at 10 mg/hs
SNRI venlafaxine (Effexor): effective starting 37.5 mg once daily
- insufficient data regarding SSRIs and HAs:
Prozac
zoloft
paxil
SEs: main limiting factor - sedation, dry mouth, constipation, wt gain
Recommendations for prevention of HAs and migraines?
- for most pts with episodic migraine
- choice of agents depends on individual situation, assoc medical problems
- start low, give adequate time for tx to take effect
- avoid overuse of abortive therapy
- lifestyle measures
Goals for prevention?
- improve pt’s quality of life
- initiate with meds that have highest level of effectiveness and lowest SEs
- may take 2-6 months
What is a HA? Causes?
-(cephalalgia) is pain anywhere in region of the head or neck
- HA is a non-specific sx, but has many causes:
sleep deprivation
stress
effects of meds/drugs
infections
Primary HA?
- 90% of HAs
- usually start b/t 20-40
- most common types are migraines and tension-type HAs
- cluster is also a primary HA
Secondary HAs?
- caused by underlying disease
- can be harmless or dangerous
- red flags indicate the HA may be dangerous!
Causes of secondary HAs?
- trauma: subdural hematoma, epidural hematoma
- SAH
- meningitis
- brain tumor
- temporal arteritis
PP of a migraine?
- primary neurovasular dysfxn that leads to a sequence of change intracranial and extracranial that account for the migraine
- HA results from dilation of blood vessels innervated by trigeminal nerve caused by a release of neuropeptides from parasympathetic nerve fibers
How common are migraines?
- affect 12% of pop
- 17% women, 6% men
- most common ages: 30-39
- can be familial
- most common type is migraine w/o aura
Precipitating and exacerbating factors - migraine?
- emotional stress (80%)
- hormones in women (65%)
- not eating (57%)
- weather (53%)
- sleep disturbances (50%)
- odors
- smoke
- light
- alcohol
Migraine 4 phases -
1. migraine prodrome?
- 60% people with migraines have prodrome
- sxs appear 24-48 hrs prior to onset
- sxs include:
euphoria, depression, irritability, weird food cravings (apple)
Migraine 4 phases -
2. migraine aura?
- only 25% suffer from this
- involves positive and negative sxs
- positive:
visual, auditory, somatosensory, motor - negative:
loss of vision, hearing or feeling, inability to move a part of the body - most often visual
- begins as small area of vision loss just lateral to pt of fixation
- aura usually moves out to periphery
- sensory aura:
usually follows visual aura, but can be without, begins as tingling of one limb or side of face, usually lasts up to an hour - language aura: less common, difficulty with speech
Migraine 4 phases -
3. migraine HA?
- usually unilateral
- pain tends to be throbbing or pulsatile quality
- can experience N/V
- pts will have photophobia or phonophobia: most will have to lie down in dark quiet room
- can take hrs or days to go away
Migraine 4 phases - migraine postdrome?
- pts often feel drained or exhausted
- some report a feeling of mild elation or euphoria
Subtypes of migraines?
- migraine with brainstem aura
- hemiplegic migraine
- retinal migraine
- vestibular migraine
- menstrual migraine
Migraine with brainstem aura characteristics?
- uncommon
- females more than males
- onset: 7-20
- consist of:
vertigo
dysarthria
tinnitus
diplopia
ataxia
decreased level of consciousness - needs two of above to make dx
Hemiplegic migraine charcteristics?
- motor weakness, usually distinguishes from other migraines
- typicall unilateral weakness
manifestations:
- severe HA
- scintillating scotoma
- visual field defect
- numbness. parasthesia, aphasia
- fever
- lethargy
- coma and or seizures
Retinal migraine characteristics?
rare condition which involves repeated attacks of monocular scotomata or blindness lasting less than one hour
- assoc with or followed by HA
Vestibular migraine charactersitics?
- episodic vertigo in pts with hx of migraine
- no confirming test
- must exclude other brainstem disease
Menstrual migraine?
- migraine that occurs before and throughout menstruation
- usually 2 days before through 3 days after onset of bleeding
Dx test for migraines?
- no test available
- neuroimaging only for:
pts with unexplained abnormal finding on neuro exam, or atypical HA features or don’t fit definition of migraine
What are red flag indications for neuroimaging?
- neuroimaging usually isn’t necessary unless abnorm neuro findings
red flags:
- worst or first HA
- sig changes in severity, frequency, or pattern
- new or unexplained neuro sxs
- HA always on same side
- new onset HA after 50 (tumor?)
- HAs not responding to tx
- new onset HA in pts with HIV/cancer
- S/S: stiff neck, fever, papilledema, cognitive impairment, or personality change.
Dx criteria for migraine w/o aura?
- - at least 5 attacks fulfilling criteria B-D B) HA attacks lasting 4-72 hrs C) HA has at least 2 of the following: unilateral location pulsating quality mod or severe pain intensity avoidance of routine physical activity D) during HA at least one of following: N/V or both, photophobia or phonophobia
Dx criteria for migraine with aura?
- at least 2 attacks fulfulling criteria B and C
B) one or more of following reversible aura sxs:
visual
sensory
speech
motor
C) at least 2 of following: - at least 1 aura sx spreads gradually over 5 min and or 2 or more sxs occur in succession
- each individual aura sx lasts 5-60 min
- at least one aura sx is unilateral
- aura is accompanied or followed within 60 min by HA
Tx for migraines?
- first line: NSAIDs or ASA
- 2nd line: triptans
first tier: sumatriptan, almotriptan, rizatriptan, eletriptan
2nd tier: slower effect -
naratriptan, frovatriptan - 3rd line: triptans + NSAID
- opiods and barbiturates: shouldn’t be used for tx of migraines unless last resort
Pharm migraine prophylaxis selection?
- first line agents: amitriptyline, Depakote, propranolol or timolol, topiramate, if not effective after 2-3 months adjust dose until effective and if still not effective at max dose or adverse effects - try a diff first line agent
Tension type HA (TTH)?
subtypes?
- most common form of primary HA disorder
- has mild-mod intensity
- bilateral non-throbbing HA w/o other assoc features
- subtypes:
infrequent episodic: less than 1 day/month
frequent episodic: 1-14 days/month
chronic: 15 or more days/month
PP of TTH?
- peripheral activation of sensitization of myofacial nociceptors that migrate through pain pathways in the central nervous center
Epidemiology of TTH?
- one of most common HA for neuro consult
- usually peaks in 40s
- women more common than men
Clinical features of TTH?
- mild-mod intensity
- bilateral non-throbbing HA described as:
dull
band like or vise like
tight cap
pressure - pericranial muscle tenderness: muscle tenderness in head, neck and shoulders
- poor concentration
- no aura, if there is, then it isn’t a TTH
Precipitating factors of TTH?
Dxs?
- stress or mental tension most common, fatigue, and noise
- no dx test, based on clinical impression
episodic TTH dx criteria?
- typically bilateral, lasting minutes to days. Pain doesn’t worsen with physical activity, not assoc with nausea, but photo or phonophobia may be present/
A. at least 10 episodes of HA fulfilling criteria B-D, infreq and freq episodic subforms distinguished as follows:
infrequent TTH: HA occurring on less than 1 day/month on average
frequent: occuring on 1-14 days per month for longer than 3 months
B. HA lasting from 30 min to 7 days
C. At least 2 of the following 4 characteristics:
bilateral location
pressing or tightening quality
mild or mod intensity
not aggravated by routine physical activity such as walking or climbing stairs
D. both of the following:
no N/V
no more than one of photophobia or phonophobia
Chronic TTH dx criteria:
A. HA occurring on more than 15 days/month on avg for more than 3 months and fulfilling B-D
B. lasting hrs to days or unremitting
C. at least 2 of following characteristics:
bilateral location
pressing or tightening
mild or mod intensity
not aggravated by routine exercise
D. both of following:
no more than one of photophobia, phonophobia, or mild nausea
2. neither moderate or severe nausea or vomiting
Tx of TTH?
- techniques to induce relaxation:
massage
hot baths
biofeedback
- acute initial tx first line: ASA 600-1000 mg tylenol 1000 mg ibuprofen 200-400 mg naproxen 220-550 mg
- 2nd line: above meds with caffeine 64-200 mg
- adjunct therapy:
3rd line: butalbital (fioricet or fiorinal) - used when NSAIDs and caffeine isn’t working or CI (3rd trimester) - used when CI to NSAIDs/ASA: stomach ulcers, renal failure, and liver failure
- parenteral options: ketorolac (toradol) 30 mg IM
- opioids/muscle relaxants not recommended
Cluster HA? Sxs?
- characterized by recurrent severe HA on one side of the head, typically around the eye
- sxs assoc with eye:
watering of the eye
nasal congestion
swelling of the eye
rhinorrhea
lacrimation
PP of cluster HAs?
-characterized by hypothalamic activation with secondary activation of trigeminal-autonomic vascular system via the trigeminal hypothalamic pathway
Epidemiology of cluster HAs?
- predominantly middle aged men
- male-female ratio: 4.3:1
- prevalence 124/100,000
Clinical features of a cluster HA? S/S’s?
- usually unilateral
- can have 8 episodes/day and last from 7 days to 12 months
- many pts sit and rock back and forth or pace about
- S/S:
ipsilateral nasal congestion
rhinorrhea
lacrimation
Horner’s syndrome:
ptosis of eyelid
meiosis of pupil
anhidrosis (inability to sweat)
Cluster HA triggers?
- ETOH
- stress
- glare
- ingestion of specific foods
Neuroimaging for cluster HAs?
- MRI w/ or w/o contrast prefered
- non contrast CT
Dx criteria for cluster HA?
A. at least 5 attacks fulfilling criteria B through D:
B. severe or very severe unilateral orbital, suborbital pain lasting 15-180 min whne untx,
C. either or both of the following:
1. at least one of the following sxs or signs ipsilateral to HA:
a. conjunctival injection or lacrimation
b. nasal congestion and or rhinorrhea
c. eyelid edema
d. forehead and facial sweating
e. forehead and facial flushing
f. sensation of fullness in ear
g. miosis or ptosis
2. sense of restlessness or agitation
D. attacks have freq b/t 1 q other day and 8/day for more than half of time when disorder is active
Tx of cluster HAs?
- 1st line: subQ sumatriptan 6 mg and 100% O2
- oxygen helps abort HA
- O2 given through nonrebreathing mask with flow rate of at least 12 L/min in sitting upright position: continue for 15 min to prevent attack reoccurring
- other options:
intra-nasal lidocaine
ergotomine
Prevention of cluster HAs?
- verapamil: DOC
240 mg daily
can titrate up to 480-960 mg - benefit is seen w/in 2-3 weeks
What is a SAH? Most common in? PP?
- bleed in subarachnoid space
- can occur spontaneously, ruptured aneurysm, stroke or trauma
- most common from 40-65
- PP: blood in subarachnoid space causes chemical meningitis that increases ICP
- a 2nd rupture sometimes occurs within 7 days
Clinical features of SAH?
- severe thunderclap HA or worse HA of your life
- N/V
confusion - heart and RR abnormal
Dx of SAH?
- noncontrast CT
- if neg CT then LP
Tx of SAH?
- ABC’s
- surgical clipping or coiling of aneurysms
- Nimodipine for vasospasm
- nicardipine if mean arterial pressure is greater than 130 mmHg
goals of tx: BP control prevention of seizures tx of nausea management of intracranial pressure
What is temporal arteritis?
- chronic vasculitis of large and medium size vessels
- usually never occurs below age of 50, with mean onset at 70
- more common in Scandinavian descent
- women affected more than men
- most feared complication is vision loss
PP of temporal arteritis?
- affects arteries containing elastic tissue
- mononuclear cells infiltrates the adventitia from granulomas containing activated T cells and macrophages
Clinical features of temporal arteritis?
systemic complaints:
- fever
- HA: new onset in temporal region, scalp tenderness
- jaw claudication
- visual manifestations: amaurosis fugax (transient monocular loss of vision)
- polymyalgia rheumatica: morning stiffness of shoulders, hips, neck and torso
- aortic dissections or aneurysms (thoracic)
Dx of temporal arteritis?
- temporal artery bx (GOLD Standard)
- CBC, CMP, ESR, CRP
Tx of temporal arteritis?
- initiation of corticosteroid therapy:
prednisone 40-60 mg daily
taper over 2-3 months, requires 1-2 years of tx - low dose aspirin
- once vision loss is present, rarely resolves with tx, so TX FIRST then bx
Causes of IICP?
- increase rise in pressure of CSF
- can be a devastating complication of neuro injury
causes:
- subdural/epidural hemorrhage from trauma
- ruptured aneurysm
- CNS infection
- ischemic stroke
- neoplasm
- hydrocephalus
PP of IICP?
- normal ICP is less than 15 mm Hg, increased ICP is above 20 mmHg
- homeostatic mechanism stabilizes ICP
- intracranial component is surrounded by skull which holds 1400-1700 ml
brain= 80%
csf = 10%
blood= 10%
increase in spinal fluid or intracranial mass will increase volume inside
Clinical features of IICP?
- HA (worse with cough/sneeze)
- N/V
- ocular palsies
- altered Level of consciousness
- back pain
- papilledema
Dx of IICP?
- CT scan head
- MRI brain
- LP - only if no risk of herniation!
CIs to LP: SAH, infection, mass, bleeding disorders
Tx of IICP?
ICP monitoring:
- intraventricular (Gold standard)
- intraparenchymal
- subarachnoid
- epidural
Infectious HAs causes?
- meningitis
- encephalitis
- brain abscess
