Lecture 4-Headache Flashcards
What are primary and secondary headaches? How do we treat both?
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
Migrane more common in men or women?
Migrane 3x more common in women.
Migrane prevalence is highest in?
Prevalence is highest in the 25-55 group
Is migrane common?
Migraine is more common than other common diseases (OA, asthma, diabetes).
State the 4 migrane phases & what they mean.
- Prodrome: change in mental status, phono/photophobia
- Aura (visual distortion most common). Due to decreased cerebral blood flow.
- Headache: unilateral or bilateral, lasts from 4 - 72 hrs, with nausea/ vomitus, & osmo (smell)/photo/phonophobia
- Resolution: tired, depressed, or euphoric.
mnemonic: PAHRRR
What is the most common migrane?
Migraine Without Aura
Describe the genetic and neurological basis of migrane.
There is a strong familial influence.
People with migraines have hyperexcitable brains. PPL with migranes have exaggerated responses to normal stimuli.
Describe the pathophysiology of the headache phase.
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.
Use of _____ containing medications for acute migranes is discouraged for risks of overuse.
barbituarate
Most symptomatic medications when taken daily may cause “rebound” phenomenon = taking the medication actually _____ the headache.
______ & _______-containing medications and narcotics are the leading culprits.
causes; Caffeine & barbiturate
NSAIDS & COX 2 inhibitors are effective in control of _____ migrane.
Acetaminophen, aspirin & caffeine (Excedrin) is effective in _____ migraine.
acute; moderate (acute)
Barbiturates are used for _____ migrane. Side effects & risks?
acute;
Risk of overuse and withdrawal
Frequent side effects: drowsiness & dizziness
Opiates are used for _____ migrane. What is the specific dosing protocol to avoid overuse & rebound?
acute;
To avoid overuse & rebound, only used for pts with infrequent headaches
Corticosteroids are used for the treatment of ______ migranes.
acute
Ergotamines and Dehydroergotamine (DHE) are used for _____ treatment of migranes & they act by vaso_____ and reducing cell activity in the ______ pathway.
acute; constriction; trigeminovascular
What is the main side effect Ergotamine & Dehydroergotamine (DHE)?
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.
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
5-HT 1B & 5-HT 1B 1D; constricting
I too Eletriptan (Relpax)!
Triptans in general, also effective for ___/__phobia. There is ____ evidence that supports use during aura.
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).
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?
Migrane prophylaxis/ prevention
What is are the common & major side effects of Topiramate?
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)
OnabotulinumtoxinA (Botox) has been FDA approved for what?
Chronic migrane prevention
Tension type headaches (TTH) are the most ______ headaches. They have _____ prodrome or aura. _____ is dull, pressure like, & with neck/ jaw discomfort.
common; no; Pain
What is the most common treatment for TTH?
TCAs: Amitriptyline
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 _____.
worst; daily; men; heavy; smokers
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.
Cluster Headache
In cluster headache, the _______ (circadian rhythm, REM sleep) is likely the basic site of dysfunction and interacts with the trigeminovascular system
hypothalamus
Name 4 treatments for cluster headache.
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
Name 2 short term prophylactic treatments for cluster headaches.
Steroids: daily oral prednisone or methylprednisolone
DHE: daily oral
Name 2 long term prophylactic treatments for cluster headaches.
Verapamil (Ca2+ channel blocker)
Topiramate
Valproic Acid
Lithium (circadium rhythms)
What are major side effects of lithium? Toxicity? What medicines are contraindicated?
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.
