IDT - Headaches, Ishmael Flashcards
What are recognized as the primary types of headache?
Cluster
Tension
Migraine
What is a cluster headache?
A headache where pain is in and around one eye
What is a tension headache?
Pain is like a band squeezing around the head
Most common Primary Headache
Normally associated w/ stress/anger/fatigue
What is a migraine headache?
A chronic headache disorder, it is Characterized by pain and at least one associated symptom:
Nausea/ Vomiting
Photophobia and Phonophobia
Pain is generally unilateral and pulsing/moderate to severe intensity that is aggravated by physical stimuli
What is the definition of a secondary headache?
Headache that occurs as a result of another health problem
What are some common causes of secondary headaches?
Infection Head injury Vascular Condition Tumor GI disorder
What are some non-pharmacologic treatments for tension-HA?
Palpation of pericranial or cervical muscles Stress management (behavioral/relaxation/biofeedback)
What are some pharmacological treatment options for tension-HA?
Simple analgesics (w or w/o caffeine) High dose NSAIDS Combination analgesics w/ butalbital or codeine
Why should pharmacological treatment options for tension HA be limited in it’s use?
may cause medication overuse headache
Who are more common to suffer from migraine headaches?
6% of men
18% of women
5-10% of children
Both Migraine and cluster headaches can further classified as what?
Vascular Headaches
Why might migraines be more common in women?
Rising and falling estrogen levels
Menstrual cycle beginning
incidence
might improve after menopause
What are the different types of migraine headaches and how are they distinct?
Migraine w/o Aura
Migraine w/ Aura - preceded 10-30min by sensory warning signs. (pain onset usually occurs within 60min)
What are the symptoms of a migraine “aura”?
Reversible visual symptoms
Reversible sensory symptoms
Reversible speech distubrances
Cortical spreading depression = aura
What are the four recognized phases of a migraine attack?
Prodrome Premonitory (hours/days)
Aura (60min)
Pain + Symptoms (4-72hrs)
Postdrome (not everyone experiences)
What are the symptoms during prodrome premonitory phase of migraine attack?
Fatigue, irritability, cravings, mood changes and muscle tension
What are the symptoms during postdrome phase of migraine attack?
Fatigue, irritability, scalp tenderness, refreshed, lightheaded
What are the vascular and neurogenic components of migraines?
- Blood vessels within the meninges
- The Trigeminal Nerve
- Serotonin
What is the pathophysiology of migraine?
Trigger initiates a nociceptive response --> Dilation of blood vessels --> Neurogenic inflammatory response --> Pain--> Further nerve activation
What is the most likely reason for migraine?
Channelopathy - disturbed ion transport
What mutation do sufferers of familial hemiplegic migraines have in common?
Mutation in the alpha-subunit of voltage gated P/Q-type calcium channels
What are mutant Ca(V)2.1 channels often associated with?
Hyperexcitability
Headache pain generally comes from?
dilation and distention of cerebral blood vessels?
What are the membranes that cover the brain and how do they cause headache?
Meninges, have a lot of blood vessels that are sensitive to pain.
What cranial nerve is responsible for innervation of blood vessels in meninges?
Trigeminal Nerve (Cranial nerve V)
How is pain from headache perceived?
Impulses are relayed to thalamus and cerebral cortex where pain is perceived.
What is Trigeminal Neuralgia and how is it treated?
A condition characterized by sudden attacks of facial pain, usually treated with use-dependent Na+ channel blocker such as carbamazepine.
What does depolarization of trigeminal nerve cause?
Release of neuropeptide transmitters (CGRP, substance P, Tachykinin) which cause vasodilation.
What is the role of vasodilation in migraines?
Vasodilation causes migraines, as the vessels dilate and expand, they are more prone to protein and fluid escape, causing inflammation and tissue damage.
What 5HT receptors are targeted by Triptans? What does their activation trigger?
5HT- 1A, 1B, 1D, 1E, 1F
Gi/Go Inhibition of adenylyl cyclase
What presynaptic 5HT receptors does the trigeminal nerve express?
5HT 1D/F
Where are the receptors targeted by triptans located?
Within the trigeminovascular system
How do Triptans differ from simple analgesics in mechanism for treating headache/Migraine?
Analgesics mask pain
Triptans, target TGVS to trigger vasoconstriction and reduce the inflammation causing pain.
Sumatriptan
- Brand
- mechanism
- formulation
- sig
- Imitrex or Imigran
- Selective 5HT 1B/1D agonist
- Injection/tablet/nasal spray
- Has an abortive effect
- not intended for prophylactic use.
Is Sumatriptan’s action dependent on CNS penetration?
No, it targets 5HT-1D on presynaptic vessels to decrease release of neuropeptides to constrict cranial vasculature
Is a selective 5HT-1D agonist able to completely effective in migraine?
They were deemed non-effective in clinical trials
What is the advantage of second generation triptan drugs over sumatriptan?
Generally have higher oral bioavailability and longer half-life
All selective 5HT 1B/1D/1F agonists
What is the possible advantage of 5HT-1F agonists?
Will be CNS penetrating and non-constricting in migraine management (still in Phase III trials)
Describe the strength and sig of Sumatriptan :
Oral
SQ
Nasal
Take 25-100mg oral tablet as soon as experiencing migraine onset, unless vomiting. repeat in 2hrs as needed, but do not take more than 2 per day or 4 per week
SQ one dose, can repeat once in 24hrs, no more than 2 per week
Nasal (5-20mg) 15min onset,
When should Triptan drugs be avoided?
In some patients due to vasoconstriction (ischemic heart disease/Stroke)
In patients using
- another Triptan
- an Ergot derivative
Serotonin Syndrome
caused by concurrent use of serotonin modulating agents, can cause confusion, temperature changes, diarrhea.
Many physicians don’t think its actually thing.
Ergot Alkaloids
- Origin
- Mechanism
- advantages
- Disadvantages
- Derived from fungus (can cause gangrene of limbs)
- Has affinity to 5HT receptors
- low cost, historical use
- nausea, vomiting, muscle pain and weakness, numbness, itching
Ergotamine
- Brand
- mechanism
- formulation
- sig
- Ergomar
- Partial agonist at 5HT receptors (affinity for 5HT-1) that may cause emetic effect
- Oral sublingual dose 2mg repeated every 30min up to 6mg/day or 10mg/week
- poor bioavailability, caffeine increases absorption
Adverse effects of Ergot Alkaloids
Nausea Leg Weakness, Muscle Pain Numbness, tingling of fingers Transient Tachycardia/Bradycardia Localized Edema Ergot Poisioing (can be fatal)
Contraindications of Ergot Alkaloids
Pregnancy Peripheral Vascular Disease Coronary Artery Disease HTN Impaired renal or hepatic function Sepsis Should not be used concurrently with triptans or any other drug causing vasoconstriction
Response of ergotamine on coronary arteries vs Triptans
Cause persistent contractile response, unlike triptans which diminish over time
What is a Medication Overuse headache?
Rebound headache due to overmedication, it can only be stopped by decreased use of the medication, and can be caused by any medication used for headache. Can be exacerbated by caffeine.
What is a Complex Migraine?
Atypical unusual aura for migraine that presents as a stroke.
It causes severe reversible neurological symptoms that precede the headache such as
- slurred speech
- sensory problems
- movement problems
How is a complex or atypical migraine treated?
Combination analgesics such as Fioricet
Why is anti-nausea medication often taken with migraine headaches, when is the best time to take it?
one of the biggest side effects
Best taken earlier into feelings of nausea
What are some commonly prescribed anti-emetic medications taken with migraine meds?
Promethazine Metoclopramide Prochlorperazine Chlorpromazine Trimetho-benzamide
If acute migraine specific therapy does work, what other treatment is used and why?
Prophylactic, to reduce frequency, severity and length of migraine attacks
What are some commonly prescribed prophylactic treatment meds?
Beta Blockers - atenolol, propranolol, metoprolol
Tricylclic antidepressants - amitriptyline, nortriptyline
AEDs - Valproic acid
What OTC dietary supplements may be taken as prophylactics for migraine?
Riboflavin (B2) and/or Magnesium
What treatment options exist for cluster headaches?
Acute and Abortive: - High-flow oxygen therapy - Triptans - Ergotamines Prophylaxis - Corticosteroids - Verapamil - Lithium
What is the preferred procedure of high-flow oxygen therapy?
For cluster headache treatment
12L/min for 15-30min
What is the most effective triptan and dosage form in treatment of cluster headaches?
SQ sumatriptan
What Ergotamines are used for cluster headaches?
Dihydroergotamines, may be repeated for 3-7 days
What is the preferred 1st line treatment for cluster headache prophylaxis?
Verapamil (360-720mg)
What is Chronic Daily Headache?
- A headache that occurs daily, within 4-5% of adults
- Resembles a daily tension-type headache.
- Usually occurs in people who have suffered from migraine or tension headaches for a long time.
