Headaches

Question 1

What % of office and ER visits involving headaches have serious pathology?

Answer 1

< 2%

< 4%

Question 2

How do we classify headaches?

Answer 2

Primary (no other cause)

Secondary (some other cause)

Question 3

What are some red flags of secondary headaches?

Answer 3

Change/progression in headache pattern
Abrupt onset
Neurological sx > 1 hour

Question 4

How do you describe the pain of a tension headache?

Answer 4

Mild-moderate dull ache

Question 5

What are tension headaches usually lacking?

Answer 5

Signs of serious underlying conditions
Visual disturbances
Generalized pain. fever, stiff neck, recent trauma
Bruxism

Question 6

What are the OTC analgesics that pts often self treat tension headaches with?

Answer 6

Acetaminophen (56%)
Aspirin (15%)
Ibuprofen (12%)
Other agents (17%)

Question 7

What NSAIDS and acetaminophen agents are more effective than placebos 2 hours after tx? What is their dosage?

Answer 7

Ibuprofen 400 mg po
Acetaminophen 1000 mg po
Ketoprofen 25 mg po

Question 8

What should you limit analgesia intake per week to? Why?

Answer 8

2-3x/week

Prevent medication overuse headaches

Question 9

What can you augment tension headache (TH) tx with? Give some examples.

Answer 9

Sedating antihistamines
Diphenhydramine
Promethazine

Question 10

If augmented TH tx isnt working, what should you try?

Answer 10

Acetaminophen/ asprin w/ caffeine and butalbital

Question 11

How often can you use the acetaminophen/caffeine/butalbital combination?

Answer 11

< 2xs weekly

Question 12

What might the use of the combo TH therapy precipitate?

Answer 12

Chronic daily headahce

Question 13

What are some things to worry about with the TH combo therapy? What do we do to deal with this?

Answer 13

Sedation

Limit alcohol

Question 14

What are two drugs that are used as prophylaxis for TH?

Answer 14

Amitriptyline

SSRIs

Question 15

How long might SSRIs take to be effective for TH?

Answer 15

1-2 months

Question 16

What are some examples of SSRIs used for TH?

Answer 16

Paroxetine
Venlafaxine
Fluoxetine

Question 17

What are the most painful of primary headaches?

Answer 17

Cluster headaches

Question 18

What are some associated sx with cluster headaches (CH)?

Answer 18

Aura
Photophobia
Phonophobia
Osmophobia

Question 19

What is a key feature of CHs?

Answer 19

Recurrent bouts of near daily attacks

Question 20

How long may CHs last?

Answer 20

Weeks-months

Question 21

When do CH attacks usually begin?

Answer 21

W/ REM phase sleep

Question 22

What to pts susceptible to CHs fear?

Answer 22

Going to sleep

Question 23

List some precipitants of a CH:

Answer 23

Hypoxia (sleep apnea)
Vasodilators
Alcohol
CO2

Question 24

How are CHs dx?

Answer 24

Hx

Question 25

Is CH pain UL or BL?

Answer 25

Unilateral

Question 26

Where is the CH pain usually localized?

Answer 26

Orbital Supraorbital Temporal

Question 27

CH pain is accompanied by >1 of:

Answer 27

Ipsilateral conjunctival injection or lacrimation Ipsilateral nasal congestion or rhinorrhea Ipsilateral eyelid edema, forehead & facial sweating Ipsilateral miosis or ptosis, or A sense of restlesness or agitation

Question 28

What is the dual strategy for CH?

Answer 28

Acute attacks must be aborted or subdued | Prophylaxis used to suppress remaining CH

Question 29

What is the tx of choice for CH? What is the dosage?

Answer 29

O2 | 7 L/min x 15 min

Question 30

What is the medication commonly given for CH? What is the dose?

Answer 30

Sumatriptan 6 mg SQ 20 mg NS

Question 31

What is an under prescribed combo therapy for CH?

Answer 31

O2 and sumatriptan

Question 32

Give some other examples of CH tx:

Answer 32

Dihydroergotamine Lidocaine Capsaicin

Question 33

What is a tx for CH that is not effetive for CH prophylaxis?

Answer 33

Sumatriptan

Question 34

List the prophylactic drugs for CH:

Answer 34

``` Verapamil Prednisone Valproic acid Topiramate Ergotamine ```

Question 35

How do we classify migraines?

Answer 35

By their clinical features

Question 36

What is one major feature of migraines?

Answer 36

Aura

Question 37

What can aura present with? How is that classified?

Answer 37

Visual distortions Positive (scintillations, photopsia) Negative (visual field defects)

Question 38

Describe migraine pain:

Answer 38

Unilateral Throbbing Temporal Incapacitating

Question 39

How do you minimize migraine pain?

Answer 39

Dark, quiet location

Question 40

What are other sx that accompany migraines called?

Answer 40

Prodromal sx

Question 41

What are some common triggers for migraines? Give some examples.

Answer 41

Food (alcohol, caffeine, chocolate, MSG, tyramine, nitrate) Behavioral/physiologic (changes in sleep, skipped meals) Environmental (flickering lights)

Question 42

How quickly do we need to treat migraines?

Answer 42

Rapidly

Question 43

What are the goals of migraine tx?

Answer 43

Reduce frequency/severity of attacks | Avoid escalation of medications

Question 44

What should mild-moderate or unresponsive severe migraine attacks use for tx?

Answer 44

Oral NSAIDS Combination analgesics containing caffeine Isometheptene combinations

Question 45

What should mod-severe or mild mod unresponsive to NSAIDs migraine attacks use?

Answer 45

``` Migraine specific meds Combo tx (APC = aspirin, APAP, caffeine) ```

Question 46

What two things are not part of migraine tx?

Answer 46

Sedatives | Acetaminophen monotherapy

Question 47

Which is the superior care approach for migraines?

Answer 47

Stratified care (based on severity of disability)

Question 48

What are two abortive txs for migraines?

Answer 48

Ergotamine | Dihydroergotamine

Question 49

What is ergotamine?

Answer 49

Nonselective 5-HT1 agonist

Question 50

What is an advantage of dihydroergotamine?

Answer 50

Less overuse headache (replace ergotamine)

Question 51

What are some drawbacks of the abortive meds?

Answer 51

Both are oxytocic Contraindicated in pregnancy Peripheral vasoconstriction (short term use)

Question 52

What are triptans?

Answer 52

Specific 5HT1 receptor agonists

Question 53

What are triptans usually reserved for?

Answer 53

Mod-severe migraines unresponsive to other meds

Question 54

When are triptans contraindicated?

Answer 54

Uncontrolled HTN Ischemic vascular conditions Vasospastic CAD

Question 55

How quickly does subQ sumatriptan peak?

Answer 55

15 minutes

Question 56

How quickly does oral rizatriptan peak?

Answer 56

60-90 minutes

Question 57

What triptan has the longest half life? What might happen with this?

Answer 57

Naratriptan | Decrease chance of recurrence HA

Question 58

What are the principles of triptan therapy?

Answer 58

Try for 2-3 headache episodes before changing If one is ineffective try another Match drug characteristics to patient's needs

Question 59

When do you consider prophylaxis for migraines?

Answer 59

> 2 attacks/month w/ disability > 3 days/month Contraindications to/failure of abortive therapy Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura)

Question 60

What is an uncommon tx for migraines?

Answer 60

OnabotulinumtoxinA

Question 61

What is the MOA of botox?

Answer 61

Neuromuscular blocking agent

Question 62

How many different sites do you inject with botox?

Answer 62

31 total sites

Question 63

What are CGRP antagonists for migraines?

Answer 63

Potent vasodilators of cerebral vessels

Question 64

What two things do CGRP antagonists do?

Answer 64

Block CGRP receptors | Inhibit CGRP directly

Question 65

What is CGRP receptor antagonist?

Answer 65

Monoclonal antibody

Question 66

What is the MOA of CGRP receptor antagonist?

Answer 66

Bind CGRP receptor blocking activation

Question 67

How much do CGRP receptor antagonists reduce migraines?

Answer 67

To 1-2 episodes/month

Question 68

How do you administer CGRP receptor antagonists?

Answer 68

SC injection once monthly

Question 69

When are CGRP receptor antagonists indicated?

Answer 69

Pts who fail other drugs | Prophylaxis of migraine

Question 70

What is the MOA of CGRP antagonists?

Answer 70

Prevents receptor activation by binding directly to CGRP

Question 71

How much do CGRP antagonists reduce migraine frequency?

Answer 71

1-2 episodes per month

Question 72

How do you administer CGRP antagonists?

Answer 72

SubQ injection once monthly

Question 73

When are CGRP antagonists indicated?

Answer 73

Prophylaxis when other drugs fail