IC5: Headache Flashcards
What is SNNOOP10 used for?
red flags for secondary HA
What does SNNOO stand for?
- systemic sx (fever)
- neoplasm hx
- neurologic deficit
- onset of HA sudden
- older age (over 50)
What does P10 stand for
- pattern of change or recent onset
- positional HA
- precipitated by sneezing or exercise
- papilledema
- progressive HA with atypical presentation
- pregnancy
- painful eye
- post-traumatic onset of HA
- pathology of immune system
- painkiller overuse or new drug at HA onset
Differentiate TTH and migraine in terms of pain location
TTH - bilateral
Migraine - unilateral usually
Differentiate TTH and migraine in terms of pain quality
TTH - tightening
Migraine - pulsating, throbbing
Differentiate TTH and migraine in terms of pain intensity
TTH - mild to moderate
Migraine - moderate to severe
Differentiate TTH and migraine in terms of effect of/on routine activities
TTH - not aggravated by routine activities
Migraine - aggravated by or causes the avoidance of routine activities
Differentiate TTH and migraine in terms of duration
TTH - 30mins to 7 days
Migraine - 3 to 72h
What is the key to NPM in TTH management?
Patient education to identify triggers, recommend a headache diary (take note of events and quality of HA)
What are pharmacological management options for TTH? (3 + 3)
acute - paracetamol (w/wo caffeine), aspirin, NSAIDs (ibuprofen, naproxen)
prophylactic - amitriptyline, mirtazapine, venlafaxine
What are non-pharmacological management options for TTH?
CBT, biofeedback, lifestyle modification (including sleep hygiene)
What are the 5 migraine phases?
Prodrome
Aura
HA (ictal)
Postdrome
Interictal
Which symptoms are experienced in most of the phases? (5)
Photophobia, phonophobia, fatigue, neck discomfort, nausea
What actions outline the prodrome phase? (2)
Hypothalamus activation
Neuropeptides involved in homeostatic functions
What action outlines the aura phase?
Cortical spreading depression (CSD) resulting in slow-spreading depolarisation within the grey matter that inhibits cortical activity
CSD may also activate the trigeminovascular system, driving aura symptoms
What action outlines the ictal phase?
neuropeptides (including CGRP) sensitise the trigeminovascular system and create a state of hypersensitivity
What action outlines the postdrome phase?
Similar to prodrome:
hypothalamus activation and neuropeptide release
What action outlines the interictal phase?
Some regions of the brain remain abnormally activated after headache cessation, including the olfactory regions, the midbrain, and the hypothalamus
How is episodic migraine diagnosed
during a lifetime, ≥ 5 migraine attacks lasting 4-72 hours
How is chronic migraine diagnosed
≥ 15 MHDs and ≥ 8 MMDs over > 3 months
What is an MHD
monthly HA day
a day with migraine-type or tension-type headache
What is an MMD
monthly migraine day
at least 2/4: unilateral, pulsating, mod/severe, avoid physical activity
if no aura, at least 1/2: photo/phonophobia, n/v
Which two classes of medications are specifically implicated in medication overuse HA?
Opioids and barbituates
What is the first line and second line for acute migraine treatment?
First line: analgesics like NSAIDs or paracetamol/aspirin if NSAIDs are contraindicated
Second line: triptans
What are the triptans’ MOA and what do they inhibit? (3)
Triptans are agoists of 5-HT(1B) and 5-HT(1D) receptors, decreasing trigeminal neuron activity
they inhibit 3 things:
- cerebral blood vessels,
-vasoactive peptide release by trigeminal neurons
- nociception
Which agents can be used for CGRP receptor blockade? (2)
erenumab, gepants
Which agents can be used for CGRP blockage? (1)
monoclonal antibodies like eptinezumab
Which agents stimulate 5-HT (1B/1D) receptors
triptans
Which agents stimulate 5-HT (1F) receptors
ditans
What can be used for adjunctive treatment?
Metoclopramide for nausea
What are the contraindications to cafergot use? (4)
CVD, CHD, recent stroke, uncontrolled hypertension
(due to vasoactive effect)
What does AHS recommend for when to start preventative treatment?
in terms of HA days / month, start if
≥ 6 days w no disability
≥ 4 days w some disability
≥ 3 days w severe disability
What 2 classes of drugs can be given for preventative treatment of migraines? (2 + 2)
ASM (topiramate, valproate)
BB (propranolol, metoprolol)
