Headaches

Question 1

Name some medicines that may trigger migraines.

Answer 1

OCPs, nitrates, nifedipine

Question 2

What is the 1st line of choice for mild to moderate migraine?
Which patients may this not be appropriate for?

Answer 2

NSAIDS and acetaminophen/caffeine/ASA combo

- PUD, renal dz, MI or stroke patients

Question 3

Why aren’t opioids used as often as other meds for abortive therapy of migraines?
When might you consider them?

Answer 3

1. Dependency
2. Rebound HA risk
3. Not has effective and may render other meds ineffective
   - refractory cases during pregnancy

Question 4

In patients who do not respond to first line treatment of migraines, what is your first choice of therapy? How do they work?

Answer 4

Triptans - serotonin agonist that vasoconstricts intracranial arteries and blocks pain pathway in brainstem.

Question 5

What are the AEs of triptans?

Answer 5

1. Paresthesias, fatigue, dizziness
2. Chest symptoms
3. Should not be combined with other serotonin agonists

Question 6

Name the contraindications for triptans.

Answer 6

1. Vasoconstriction - hx of MI, uncontrolled HTN, stroke

2. Cannot be combined with MAOIs.

Question 7

What is the longest acting triptan?

Answer 7

Frovatriptan

Question 8

T or F. Sumatriptan comes in a variety of forms.

Answer 8

T - SQ, Nasal, PO

Question 9

Name another migraine abortive therapy other than triptans. How do they work?

Answer 9

Ergot alkaloids and derivatives.

Similar mechanism to triptans - serotonin receptor agonist.

Question 10

What is the rare AE for ergots?

Answer 10

Ergotism - peripheral ischemia that can lead to gangrene

Question 11

Contraindications to ergots?

Answer 11

1. Hepatic and renal failure
2. PV disease
3. Sepsis
4. Pregnant or nursing
5. use of triptan in last 24 hr

Question 12

What is the most common ergot?

Answer 12

Dihydroergotamine (DHE) - nasal spray

Question 13

When might steroids be used to treat migraines?

Answer 13

Status migrainosis

To avoid recurrence

Question 14

What antiepileptic is used as abortive therapy for status migrainosis?

Answer 14

IV VPA

Question 15

What are 5 options for preventative therapy for migraines? What are the contraindications to each?

Answer 15

1. . Propranolol/Timolol - asthma or depression
2. Amitriptyline - mania
3. Ca Channel Blockers (Verapamil) - depression
4. Antiepileptics - liver disease
5. Botox

Question 16

What are the abortive options for tension HA?

Answer 16

NSAIDs - mainstay
Acetaminophen
ASA
Combos
Triptans

Question 17

What are the preventative therapy options for tension HA?

Answer 17

Antidepressants - Amitriptyline (1st)

Venlafaxine (2nd)

Question 18

What are the abortive therapy options for cluster HA?

Answer 18

1. O2 is 1st line, but not patient friendly
2. Triptans - Sq or intranasal
3. DHE

Question 19

What are the PPX options for cluster HA?

Answer 19

1. Ca Channel blocker (verapamil), but must wait 4-6 weeks for full effect
2. Lithium - keep in mind may have AE and need to monitor liver, thyroid and renal function
3. Steroids - not recommended long term

Question 20

What should you do for a patient who is experiencing medication overuse HA?

Answer 20

1. D/C overused med or taper
2. Prednisone for steroid burst
3. DHE