IC 5 - Headaches Flashcards
What are the three types of primary headache?
- Tension
- Migraine
- Cluster
Tension type headaches are _____ in nature.
bilateral
Migraine can be ________ or ________.
unilateral, bilateral
Which of the primary headaches is affected by routine activities of daily living?
Migraine
Mr Lee has a headache where the pain is bilateral. He explains that he feels a band liked tightness around the head and it does not worsen with activity. What kind of headache does Mr Lee has?
Tension type headache
What are the symptoms of migraine?
N/V
Sensitivity to light or sight
Aura (e.g. visual, sensory, speech disturbance)
Cluster headache confers pain which is _______ in nature.
unilateral (around eyes or face)
What are some symptoms accompanying cluster headaches?
Red, watery or swollen eye, nasal congestion/ runny nose, sweating
Differentiate between infrequent, frequent episodic and chronic TTH in terms of frequency.
Infrequent episodic: <1 ep/month
Frequent episodic: 1 to 14 days/month
Chronic: 15 or more days/month
What can trigger TTH?
Physical/ emotional stress
Poor posture (especially neck flexion)
Alcohol, caffeine
Cold/flu or sinus infections
Dehydration
Hunger
What are the typical clinical presentation of TTH?
No aura, premonitory symptoms
Bilateral
Non-pulsatile
Tightness or pressure
Mild/Mod intensity
Pericranial or cervical muscles tenderness
What are some non-pharmacological methods that can relieve TTH?
CBT, biofeedback, relaxation
Physical and/or occupational therapy
Lifestyle modification (include sleep hygiene)
What are the three medications that can be given as prophylaxes for TTH?
Amitriptyline (1st line)
Mirtazapine
Venlafaxine
What are the three medications for acute TTH?
Paracetamol (alone or with caffeine)
Aspirin
NSIADs: Ibuprofen, Naproxen, Diclofenac, Ketoprofen
What are the 4 phases of migraine?
Prodrome, aura, headache, postdrome
________is involved in the prodrome phase.
Hypothalamus
________ is involved in the aura phase.
Cortex
Briefly explains the pathophysiology of migraine.
- Bodily changes in prodrome stage due to effects of hypothalamus
- Leads to involvement of cortex, leading to “aura” (sensory and motor changes)
- CGRP and PACAP is then released, leading to symptoms of headaches
- After episode, there will be a post period of “energy being drained”, leading to tiredness
Differentiate between chronic and episodic migraine.
Episodic: ≥ 5 migraine attacks lasting 4 to 72 hours
Chronic: ≥ 15 monthly headache and ≥ 8 monthly migraine day, > 3 months
List 3 non-pharmacological method to manage migrane.
Identify triggers
Headache diary
Healthy lifestyle
What are the medications that have established efficacy for migraine?
Triptans
Ergotamine derivatives
Gepants
Lasmiditan
NSAIDs (aspirin, celecoxib oral solution, diclofenac, ibuprofen, naproxen)
Combination Analgesic (Acetaminophen, aspirin, caffeine)
How does NSAIDs help with migraine?
Inhibit prostaglandin synthesis
Which population should NSAIDs be avoided in for migraine?
Hypersensitivity, previous ulcer, renal disease and severe CVS
What are the adverse effect of NSAIDS?
Hypersensitivity, GI (N/V etc), CNS (dizzy etc)
What is the indication of NSAIDs in migraine?
Mild to moderate
How does triptans help with migrane?
Selective agonists at 5HT-1B and 1D
1. Vasoconstrict intracranial extracerebral blood vessels
2. Inhibit vasoactive peptide release by trigeminal neurons
3. Inhibit nociception neurotransmission within trigeminocervical complex
When is triptan used for migraine?
Mild pain
Which group of patients with pre-existing conditions should not be given triptans and Ergotamine and dihydroergotamines?
- Stroke/ TIA
- Ischemic coronary artery
- Coronary artery vasospasm
- Uncontrolled HTN
- Peripheral vascular disease
- Gastrointestinal ischemia
- History of hemiplegic or basilar migraine
Triptans should not be given to people who are on __________ as medication.
- Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation
- Concomitant use of ergotamine-containing or ergot- type medication within 24hours
Ergotamine derivatives should not be used in patients on ______ medication.
- Triptans (within 24 hours)
- Potent CYP3A4 inhibitors e.g. macrolides and proteases inhibitors (increase vasospasm risk)
How does the 2 components in cafergot works for migraine?
Ergotamine: Induce vasoconstriction and inhibit norepinephrine uptake and alpha adrenoreceptors
Caffeine: Adenosine A1, A2A, A2B receptor antagonist, vasoconstrict cerebral vasculature and increase ergotamine GI absorption
Describe medication overuse headaches.
Use of too much medications and results in headaches ≥ 15 days/mths in PT with preexisting headaches
What causes medication overuse headaches?
- Panadol or ≥1 NSAID on ≥15 days/months for 3 months
- Triptan or ≥1 opioid on ≥10days/months for 3 months
What is the criteria for assessment for migraine preventive measures?
No of days + disability degree
What are the oral drugs that can be used for migraine preventive measures?
Candesartan
Valporate
Frovatriptans
Metoprolol/ Propranolol/ Timolol
Topriamte
Divalproex sodium
What are the parental drugs that can be used for migraine preventive measures?
- Eptinezumab
- Fremanezumab
- Galcanezumab
- Erenumab
A minimum of _____ weeks should be given to patients to determine if the drug is effective or a switch is needed.
8
What should be done to monitor patients with migraine?
Headache diary
Disability Assessment
Adverse effects from medication
