IC5 Headache Flashcards
What are the 3 main primary headaches?
- Migraine
- Tension type headache (TTH)
- Trigeminal Autonomic Cephalgias (TACs)
What are the 6 common secondary headaches?
- Trauma to head and/or neck
- Cranial or cervical vascular disorder
- Non-vascular disorders
- Infection
- Homeostasis disorder
- Psychiatric disorder
What is the name of the guideline that shows red flags for secondary headaches?
SNNOOP10 Guide
Systemic sx
Neoplasm
Neurological deficit or dysfunction
Onset of headache is abrupt
Older age (>50yo)
Pattern change or recent onset of headache
Positional headache
Precipitated by sneezing, coughing, exercise
Papilledema
Progressive headache w atypical presentation
Pregnancy
Painful eye w autonomic features
Post traumatic onset of headache
Pathology of immune system - e.g HIV
Painkiller overuse
What are the 5 clinical presentation of tension type headaches (TTH)?
- No prodrome
- Pain is bilateral
- Non-pulsatile tightness or pressure
- Mild/moderate intensity
- Peri cranial or cervical muscle tenderness
What are the 2 risk factors of TTH?
- Peaks at 40 years old
- Female > male
What is considered infrequent episodic TTH?
<1 episode/month
What is considered frequent episodic TTH?
1-14 days/month
What is considered chronic TTH?
15 or more days/month
What are the 7 things that can trigger TTH?
- Stress
- Alcohol
- Caffeine
- Cold/flu or Sinus infections
- Dehydration
- Hunger
- Activities that cause the head to be held in one position for a long time
What are the 2 goals of therapy for TTH?
- Pain relieve
- Prevent progression to chronic TTH
What are the 2 acute treatment options for TTH?
- Paracetamol
- NSAIDs (Aspirin, ibuprofen, celecoxib & etc.)
What can be used as prophylactic treatment for TTH?
1st line - Amitriptyline
2nd line - Mirtazapine, Venlafaxine
What are the 6 clinical presentation of migraine?
- Unilateral or bilateral pain
- Pulsating
- Moderate/severe
- Aggravation by, or causing avoidance of routine physical activity
- Photophobia / phonophobia
- N&V
How to diagnose a pt w migraine wo aura?
Fill in the blanks below:
Criteria:
a. At least __ attacks fulfilling criteria B to D
b. Headache attacks last ___ to ___ hours
c. Headaches has 2 of the 4 characteristics:
- Bilateral or Unilateral?
- Pulsating or Non-pulsating?
- Mild/moderate or Moderate/severe?
- _________________ of physical activity
d. During headache at least one of the following:
(specific to migraine w no aura)
1. __________
2. __________
a. 5 attacks
b. 4-72 hours
c. Unilateral, pulsating, moderate/severe, aggravation or avoidance of physical activity
d. N&V, Photophobia/phonophobia
Criteria:
a. At least 5 attacks fulfilling criteria B to D
b. Headache attacks last 4 to 72 hours
c. Headaches has 2 of the 4 characteristics:
- Unilateral
- Pulsating
- Moderate/severe
- Aggravation or avoidance of physical activity
d. During headache at least one of the following:
(specific to migraine w no aura)
1. N&V
2. Photophobia/phonophobia
How to diagnose a pt w migraine w aura?
Fill in the blanks below:
Criteria:
a. At least __ attacks fulfilling criteria B and C
b. At least __ of the following fully reversible aura:
1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal
c. At least __ of the 6 characteristics:
1. At least 1 aura symptoms spread gradually over ≥5 minutes
2. 2 or more aura symptoms occur in succession
3. Each individual aura symptom last 5-60mins
4. At least 1 aura symptom is unilateral
5. At least 1 aura symptom is positive
6. The aura is accompanied, or followed within 60mins, by headache
Criteria:
a. At least 2 attacks fulfilling criteria B and C
b. At least 1 of the following fully reversible aura:
1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal
c. At least 3 of the 6 characteristics:
1. At least 1 aura symptoms spread gradually over ≥5 minutes
2. 2 or more aura symptoms occur in succession
3. Each individual aura symptom last 5-60mins
4. At least 1 aura symptom is unilateral
5. At least 1 aura symptom is positive
6. The aura is accompanied, or followed within 60mins, by headache
What are the 6 acute treatment goals of migraine?
- Rapid relief from pain & associated symptoms
- Restore ability to function
- Minimal need for repeat dosing or rescue medication
- Optimal self-care
- Minimal or no ADR
- Cost-effective
What can we use to treat a migraine patient w N&V?
Anti-emetics
What is the MOA of triptans?
They are selective agonist at 5-HT1b & 5-HT1d receptors.
They cause vasoconstriction of the intracranial extracerebral blood vessels
At which stage of a migraine should triptans be taken?
Triptans should be taken early in the course of a migraine attack.
What DDIs are associated w triptans?
Triptans cannot be used together with:
1. Ergotamine containing medications
2. MAOIs or within 2 weeks after discontinuing MAOIs
What is a special SE of triptans?
Paraesthesia - pins & needles / numbness
What is the MOA of cafergot?
Cafegot has:
1. Ergotamine
2. Caffeine
Ergotamine - 5-HT1b and 5-HT1d agonist
Caffeine - a-adrenergic receptor antagonist
Both helps in vasoconstriction of the cerebral vasculature.
What DDIs are associated with ergotamines?
Ergotamines should not be used with
- Triptans within 24hrs
- Potent CYP3A4 inhibitors (e.g macrolides & protease inhibitors)
Are opioids recommended for use in pt w migraines?
Opioids are not recommended for routine use in migraine due to lack of evidence & risk of abuse.
E.g of opioids - codeine, tramadol
What is the definition of medication overuse headache?
Headache occurring 15 or more days/month in a pt w:
1. Pre-existing primary headache
2. Overuse of acute headache medications:
- Paracetamol or ≥1 NSAID for >15days/month, for 3 months
- Triptan or ≥1 opioid on ≥10days/month, for 3 months
Medication overuse headaches usually develops in pt w migraine of TTH.
What agents do we use if a triptan does not work?
We can use another type of triptan. The failure of one triptan does not mean other triptans will not work.
However, if ≥2 triptans fail to work, or pt cannot tolerate triptans, we can use:
- Gepant & ditans
For severe headaches, -mabs can be used as last resort. Name 3 -mabs that can be used in migraine prevention?
- Erenumab
- Eptinezumab
- Fremanezumab
What is the MOA of -mabs in migraine prevention?
They are CGRP inhibitors.
CGRP - calcitonin gene-related peptide
Erenumab is a CGRP receptor inhibitor
Eptinezumab acts on the CGRP molecule itself
What are the rules to follow in preventive treatment?
- Start high and titrate down? OR Start low and titrate up?
- For oral treatments, we stop titration of dose if ______ dose or ______ dose have been reached.
- For oral treatment, we need to give a drug for __ weeks before we can determine lack of effectiveness.
For CGRP mAbs, we give at least __ months for treatment
- Start low and titrate up
- For oral treatments, we stop titration of dose if maximum dose or therapeutic dose have been reached.
- For oral treatment, we need to give a drug for 8 weeks before we can determine lack of effectiveness.
For CGRP mAbs, we give at least 3 months for treatment
What methods can we use to assess headache efficacy?
- Headache diary
- Disability assessment (e.g MIDAS)
- ADR from medications
