Headaches & Migraine Management Flashcards
types of HA and locations
patho
tension HA: band-like squeezing sensation
Migraine: unilateral, throbbing sensation =/- aura and photophobia
Cluster: behind 1 eye, sharp stabbing and boring pain with autonomic disfunction
Secondary HA: of other cause
post-tramuatic: temples, forehead and neck
medication overuse: any location
sinus HA: forehead, cheeks and nasal cavity
Patho
- dilation = increased pressure on the structures around the vessel
- leading to neuronal firing/desensitization
- goal of thearpy: vasoconstrict to decrease pressure
SNOOP2 Critera for a seondary HA
S: systemif findings = fever, chills, WL
N: Neurologic = changes in behavior or personality, motor weakness
O: Onset = sudden = peak within 1 minute - SAH
O: onset = age = new before age 5 or after 65
P: Pattern = progressive or changing
P: Pregnancy = new onset or changing in character
Medication Overuse HA
definition by type of med used
Analgeisic Induced: max 14days/month
- acetaminophen
- NSAID
Combination INduced: max 9 days/month
- caffeine
- codeine
- butalbital
- things like excedrin and fioricet
Managment
- stop the medication or taper down the dose
- expect a withdrawl for 2-10 days (nervousness, restlessness, insomnia)
- caninitiate a bridge therapy to help here: corticosteroid or dihydrergotamine
Common Causes (trigger) for HA
- alcohol
- caffeine/withdrawal
- chocolate
- nitriate containing food
- weather changes
- skipping meals/fasting
- mestration
- stress or post stress
- tyramine containing
nonpharm treatment of HA
CBT
relaxation
sleep hygeine
regular meals
avoid food triggers
smoking cessaion
(less evidence)
heat/cold packs
stretching
exercise
Tension Headaches
- etiology
- diagnosis
Tension HA
- most commony type; women > men
- episodic in nature via environmental influences
- skipping meals, insomnia, stress and smoking
Diagnosis
- no nausea/vomiting
- only one of: photophobia or phonaphobia
- and TWO of the following
- bilateral location (entire head)
- pressing/tightening (non-pulsitile) quality
- mild/mdoerate intensity
- not aggrevated by physical activity
chronic = > 15 HA days/month for > 3months
Acute Treatment of Tension HA
(think abortive treatment)
First line
Second Line
Acute: Abortive Treatment for Tension HA
First Line: analgesics
- NSAIDS (ibuprofen, asprin, naproxen)
- acetaminophen
- parenteral options like IV ketorolac
Second Line (still have symptoms?) = Combination Meds
- Caffeine/acetaminophen (excedrin)
- acetaminophen/asprin/caffeine (excedrin ES)
- acetaminophen/caffeine/Butabital (try to avoid butalbital) because of the ADRs (drowsy, dependence)
Prophylatic Treatment of Tension HA
(prophylatic only approved for CHRONIC tension HA)
First line
Second Line
Prophylatic Tension HA Treatment
chronic tension HA only
First Line
- amitriptyline: (TCA) most common; watch drowsy SE
- if amitriptyline doesnt work can try nortryptline (less SE)
Second Line
- mertazapine (atypical antidep.)
- venlafaxine: SNRI (SSRI wont be effect to treat tension HA if no concurrent depression)
Amitriptyline (TCA) for prophalytic chronic tension HA treatment
ADR
contraindications
DDI
when to see effects and how long to use
Amitriptyline: TCA medication
first line choice for prophylatic treatement for chronic tension HAs
ADR
- anticholenergic effects; CNS depression!! watch this
- bleed risk
- hyponatremia
- ortostati hypotension
D-D interactions
- triptans: they will concurrently cause serotonin syndrome
Contraindications
- cannot give within 14 days of MAOI (serotonin syndrome)
Timing
- take 6 months to work
- must contineu treatment for > 6 months before tapering off
Second Line Agents for Prophylatic Chronic Tension HA
Mirtazipine
Venlafaxine
ADR
Rx. Pearls
Mertazapine
- give at bedtime: makes you dissy/drowsy and sedated
- helps with insomnia
- weight gain
Venlafaxine
- good for concominent anxiety and PTSD
- GI distress
Cluster HA
- etiology
- diagnosis
- episodic v chronic
Etiology
- men > women; rare
- genetic predisposition
- linked with sunlight and seasonal changes
Diagnosis
- 5 attacks of the following
- severe UNILATERAl orbital or temporal pain for 15-180 minutes
- can have 8-10 a day
- autonomic symptoms ipsilateral to the HA: tearing, redness, edema, sweating, ptosis, miosis, rhinorrhea/congestion
- restlessness and agitation
Episodic
- 2+ cluster HA lasting a minimum of 7 days, separated by 3months or more of remission
Chronic
- occuring so frequently the remission period lasts < 3 months to 1 year or less
Acute: Abortive Treatment for Episodic and Chronic Cluster HA
First Line
Second
adjuct
last line
for abortive acute treatment of cluster HA
First Line
- 100% O2 6-12L/min for 15 mins : decreases neurogenic inflammation
- Triptans: serotonin agonists (vasoconstrict intracranially) - Sumatriptan or Zolmitriptan
- Dihdryoergotamine : serotonin agonist (less selective) - Migranal
Second Line
- Octreotide
Adjunct Thearpy
- intranasal Lidocaine
Last Line: IV glucocorticoids (better than PO taper)
Acute: Abortive Treatment for Episodic or Chronic Cluster HA : First Line
Triptans
names
dosing pearl
ADR
Contraindications
D-D interactions
Triptans: abortive treatment for cluster HA (first line)
no more than 2 doses in 24 hours
Names
- Sumpatriptan
- Zolmitriptan
ADR
- dizzy
- QTc prolongation monitor EKG with the first dose if giving to someone with high CV risk
- chest discomfort
Contraindications
- those with CVD (MI, PVD) or uncontrolled HTN (because these vasoconstrict and can worsen BP)
- do not use within 24 hours of another triptan or ergotamine (since same MOA)
- do not use within 2 weeks of MAOI (serto. syndrome)
ACute Abortive Treatment for Episodic or Chronic Cluster HA : First line
Ergotamine
ADR
contraindications (big ones to know)
ergotamines are first line acute aborptive treatment for chronic or episodic cluster HA
Ergotamine Derivatives: dihydroergotamines
ADR
- gangrene!!!: ergotism: since these are fungally derieved? (so much vasoconstriction)
- MI or CVA
Contraindications
- those with CVD: MI, CVA, angina, PVD
- uncontrolled HTN
- renal/hepatic failure
D-D Interactions
- cannot use within 24 hours of a triptan
- cannot use with anything that is a strong CYP3A4 inhibtor: will impact this drug
- no pregnant/BF
Prophylatic Cluster HA Treament
- Criteria
- First line
- Second Line
can be chronic or episodic cluter HA
Criteria
- occuring for > 4 weeks
- remission lasting less than 3 months
First Line
Verapamil (CCB)
- blocks calcium channels in the smooth muscles of the vessels; inability to dilate (???) they dont know why it works but it does so moving on…..
Second Line
- Lithium
- Toperiamate
Prophylatic Treatment for Cluster HA
First Line : Verapimil
ADR
Contraindications
Monitoring & Counceling
Verapimil: CCB (nondihydro.)
ADR
- hypotension
- bradycardia
- edema
Contraindications
- those with severe LV dysfunction
- those hypotensive or in caridogenic shock
- those with 2nd/3rd heart block
Monitor
- BP, HR, LFTs and EKG
- educate= takes 1 week to start, 4-6 weeks to peak
Prophylatic Treatment of Cluster HA: seoncd line = Lithium
ADR
CI
Lithium
ADR (think low and slow)
- cardiac arrythmias, bradycardia
- CNS depression
- N/V/D
- hypothyroid
- weight gain
CI
- thoe with severe CV disease or reanl disease
- dehydrate, sodium depleted
- cant use if on a diuretic (will increase levels)
- dont use with MAOI or NSAIDS or ACE = serotonin syndrome
drug level monitoring = 0.4-0.8 toxicit > 1.5
Prophylatic Treatment Cluster HA: Second Line = Toperimate
ADR
Monitor
this is preferred second line over lithum: if verapimil doesnt work
ADR
- cognitive dysfunction + suicidal ideation
- nephrolithiasis (stones)
- less sweat = over heat easy
- weight loss
Monitor = mood
Prophylatic Cluster HA treatment: Last Line= CGRP
ADR and use
CGRP: Galcanezumab
Pearls
- expensive
- watch injection site reactions
- keep in fridge and rotate injection site
Transitional Treatmelt for Cluster HA
those who need to add prophlyatic treatment onto of the acute– takes time to kick in so …
Corticosteroids
Ergotamine
taken to bridge the waiting time for prophylatic treatment to kick in
Corticosteroids
- IV methlyprednisone
- oral prenisolone
Ergotamine
- dose before bedtime to help wiht bedtime attacks
Migraines
Etiology
characteristics
diagnosis
chronic is…..
assessment of disability
Migraines
- can be with or without aura
- very common
Characteristics
- Prodrome
- aura
- HA (4-72 hours)
- postdrome
Diagnosis
- 5 attacks of
- lastin 4-72 hours each
- unilateral location
- pulsitile
- moderate/severe pain
- aggrevated by physical activity
with episodes during migriane of
- nausea/vomiting
- photophobia/phonophobia
chronic = 15+ days/month for > 3 months
Aura
- can be + or - symptoms
MIDAS : can be used to scale severity of the migraine and amount of disability
ACUTE migraine Treament by severity
first and second line treatment
- mild/moderate
- moderate/severe
- refractory
Acute Treatment = Migraine
If Mild/Moderate
- first line = NSAIDS/acetaminophen
- second line = triptans
If Moderate/Severe
- first line = Triptans
- second line = NSAIDS/acetaminophen (add on)
Refractory Migraines (despite above treatment)
- dihydroergotamines
- Lasmiditan
- CGRP’s
add-on = antiemetics for N/V
Acute Migraine Treatment : Mainstay = Triptans
Picking a med in the class
ADR
CI
DD interactions
Monitoring
Counceling
Triptans
can try multiple meds within the class to find which is best for pt.
Sumatriptan (comes in most preparations)
Zolmitriptian
Frovatriptan (for menstral)
Frovotriptan and Naratriptan = longes duration
ADR
- cardiac: TIA, Afib, angina, CVA
- increased BP
Contraindcations
- those with CAD (MI, Angina)
- CVA history or PVD
- uncontrolled HTN
- dont use within 24 hours of ergotamine
Monitoring
- cause use in those with high CV risk: get EKG when giving 1st dose
- no more thant 10 days per month can thse be used = risk of medication overuse HA
DD Interactions
- SSRI/SNRI = serotonin syndrome
what antiemetics should be used for migraine add on therapy
- what other med to add on
- ADR
- CI
- monitoring
Antiemeitcs: to help with nausea/vomiting of migraine
Meds
- Metoclopramide
- Proclorperazine
- when using these: consider adding in dipehnhydraine: since these are dopamine antagonist: can get EPS so diphenhydra. will help
ADR
- CNS depression
- EPS
- increased BP
CI
- dont use if there is GI obsturction
- those who already on DA antagonists: can increase EPS
Monitor
- watch mental alertness, EPS
- only IV and IM can be conisdered monotherapy: if using oral you need two meds
Refractory Migraine : Acute treatment options: lasmiditan
MOA
ADR
caution and monitoring
Lasmiditan: for refractory migraines (can also use ergotamine)
MOA: serotonin agonist: to decrease stimulation of teh trigeminal nerve
ADR
- dizzy
- decreased HR and increased BP (monitor HR and BP)
Caution
- dot use more thatn 4 times 1 month
- liver issues = monitor LFTs
- can cause driving impairment
CGRPS
- role for refractory migrianes acute treatment
- names
- MOA
- ADR
CGRPs: refracotroy migraine acute treatment
MOA
- the CGRP is noramlly released in pain response- the trigeminal nerve causes vasodilation: these meds are antagonists so they will vasoconstict
Names
ubrogepant: only acute treatment
rimegepant: can be used acute and prophylatically (cant use in hepatic faillure)
Zavegepant: intranasal,
Prophylatic Treatment of Migraines
when to use (?)
first lines for the following concurrent conditions
HTN
Depression
insomnia
seizure
obestiy
those who have failed 2+ meds
When to use prophylatic treatment
- no clear guidelines
- 4+ a month, 8+ HA days
- debiliating
- med overuse
For those with Concurrent…..
- HTN: use beta blockers metoprolol or propranolol
- Depression: use amitriptyline or venlafaxine
- INsomina: amitryptlyine
- Seizures: toperimate
- obestiy: toperimated
- failed 2+ drugs: CGRPs
takes 4 weeks to work = up to 6 months
pregnant pt. prophlayitc migriane
first seond and other meds
First = bblockers or CCB (verapimil)
second = TCA, SNRI
consider: magnesium or riboflavin
BetaBlocker pearls for prophlayic migraine use
Metoprolol
- cardioselective
propranolol
- noncadrdioselective
wathc out
- mask hypoglycemia symptoms
- wathc COPD/asthma
- ED, bradycarida
Antiseizure meds for prophlatic migraines
toperimate or valproic acid
Valproic Acid
- weight gain
- throbocytopenia
- hepatotoxicity
- cant use in pregnant
role of botx in migraine prevention
failed 2-3 other meds = can try
watch
- hypersensitivity
- infection
- can spread = dysphagia
follow PREEMPT protocol
stop if no repsonse 2-3 times: getting < 30% reduction in HA
menstrual migrianes
first line = frovotriptan
start 6 days before menstratuion
