Lecture 4-Headache

Question 1

What are primary and secondary headaches? How do we treat both?

Answer 1

Primary headache = intrinsic, headache is the illness itself so treat headache

Secondary headache = due to another ilness, so treat that ilness first to get rid of headache

Question 2

Migrane more common in men or women?

Answer 2

Migrane 3x more common in women.

Question 3

Migrane prevalence is highest in?

Answer 3

Prevalence is highest in the 25-55 group

Question 4

Is migrane common?

Answer 4

Migraine is more common than other common diseases (OA, asthma, diabetes).

Question 5

State the 4 migrane phases & what they mean.

Answer 5

1. Prodrome: change in mental status, phono/photophobia
2. Aura (visual distortion most common). Due to decreased cerebral blood flow.
3. Headache: unilateral or bilateral, lasts from 4 - 72 hrs, with nausea/ vomitus, & osmo (smell)/photo/phonophobia
4. Resolution: tired, depressed, or euphoric.
   mnemonic: PAHRRR

Question 6

What is the most common migrane?

Answer 6

Migraine Without Aura

Question 7

Describe the genetic and neurological basis of migrane.

Answer 7

There is a strong familial influence.

People with migraines have hyperexcitable brains. PPL with migranes have exaggerated responses to normal stimuli.

Question 8

Describe the pathophysiology of the headache phase.

Answer 8

There is Activation of the trigeminovascular system (meninges) innervated by V1. This is sterile inflamation, not meningitis.

Inflammatory peptides cause increased intracranial mechanosensitivity and hyperalgesia to previously innocuous stimuli (coughing, head movement). This peptide release is blocked by Triptans.

Question 9

Use of _____ containing medications for acute migranes is discouraged for risks of overuse.

Answer 9

barbituarate

Question 10

Most symptomatic medications when taken daily may cause “rebound” phenomenon = taking the medication actually _____ the headache.

______ & _______-containing medications and narcotics are the leading culprits.

Answer 10

causes; Caffeine & barbiturate

Question 11

NSAIDS & COX 2 inhibitors are effective in control of _____ migrane.

Acetaminophen, aspirin & caffeine (Excedrin) is effective in _____ migraine.

Answer 11

acute; moderate (acute)

Question 12

Barbiturates are used for _____ migrane. Side effects & risks?

Answer 12

acute;

Risk of overuse and withdrawal

Frequent side effects: drowsiness & dizziness

Question 13

Opiates are used for _____ migrane. What is the specific dosing protocol to avoid overuse & rebound?

Answer 13

acute;

To avoid overuse & rebound, only used for pts with infrequent headaches

Question 14

Corticosteroids are used for the treatment of ______ migranes.

Answer 14

acute

Question 15

Ergotamines and Dehydroergotamine (DHE) are used for _____ treatment of migranes & they act by vaso_____ and reducing cell activity in the ______ pathway.

Answer 15

acute; constriction; trigeminovascular

Question 16

What is the main side effect Ergotamine & Dehydroergotamine (DHE)?

Answer 16

Main side effet = chest pain so EKG prior!

Adverse reactions: Nausea, dizziness, paresthesia, chest pain (EKG prior), abdominal cramps, etc

Dehydroergotamine (DHE) has fewer side effects, less likely to cause nausea.

Question 17

Tripans are the premier migrane abortive drugs. They act as selective Selective ____ & _____ receptor agonists. All can penetrate the CNS to some extent, _____ extracerebral intracranial vessels and inhibiting the trigeminovascular system

Answer 17

5-HT 1B & 5-HT 1B 1D; constricting

I too Eletriptan (Relpax)!

Question 18

Triptans in general, also effective for ___/__phobia. There is ____ evidence that supports use during aura.

Answer 18

photo/phono; no

People with aura should take the triptan when they get the aura to get a headstart, even though the aura is not treated (headache only).

Question 19

Antidepressants like Tricyclic antidepressants (TCAs), SSRIs, & MAOIs. Antihypertensives like propranolol, Timolol, & veramamil (a Ca2+ channel blocker). Antiepileptic drugs like Divalproic acid, Topiramate, & Gabapentim all are useful for what?

Answer 19

Migrane prophylaxis/ prevention

Question 20

What is are the common & major side effects of Topiramate?

Answer 20

Common side-effects include changes in cognition, paresthesias and weight loss

Serious side effect include kidney stones (3% in clinical trials) and acute angle-closure glaucoma (extremely rare)

Question 21

OnabotulinumtoxinA (Botox) has been FDA approved for what?

Answer 21

Chronic migrane prevention

Question 22

Tension type headaches (TTH) are the most ______ headaches. They have _____ prodrome or aura. _____ is dull, pressure like, & with neck/ jaw discomfort.

Answer 22

common; no; Pain

Question 23

What is the most common treatment for TTH?

Answer 23

TCAs: Amitriptyline

Question 24

Cluster headache is the ____ type of headache. It is unique in that it works around _____ clockwork. It is more often seen in ____.

Some pts have typical _____ facial features (leonine facies in men, masculine in women) may be due to the fact lot of these pts are _____.

Answer 24

worst; daily; men; heavy; smokers

Question 25

The following are symtoms of what type of headache?

Unilateral, temporal headache; sympatheric symtoms: lacrimation, rhinorrhea, ptosis, & miosis, horrible headaches & people have committed suicides during these headaches.

Answer 25

Cluster Headache

Question 26

In cluster headache, the _______ (circadian rhythm, REM sleep) is likely the basic site of dysfunction and interacts with the trigeminovascular system

Answer 26

hypothalamus

Question 27

Name 4 treatments for cluster headache.

Answer 27

Attacks peak quickly, therefore Rx has to be fast acting

O2 via non-rebreathing mask (safe and cost effective)

Sumatriptan (also other triptans have proven effective)

DHE Subcutaneus & intranasal

Lidocaine nasal drops

Question 28

Name 2 short term prophylactic treatments for cluster headaches.

Answer 28

Steroids: daily oral prednisone or methylprednisolone

DHE: daily oral

Question 29

Name 2 long term prophylactic treatments for cluster headaches.

Answer 29

Verapamil (Ca2+ channel blocker)

Topiramate

Valproic Acid

Lithium (circadium rhythms)

Question 30

What are major side effects of lithium? Toxicity? What medicines are contraindicated?

Answer 30

Side-effects include weakness, nausea, thirst, tremor, lethargy, blurred vision and slurred speech

Toxicity may lead to vomiting, anorexia, diarrhea, confusion, nystagmus, extrapyramidal signs and seizures;

Indomethacin and sodium-depleting diuretics should be avoided since they increase lithium levels.