Migranes Flashcards
What is the prevelance of headaches? who tends to experience them msost often?
lifetime prevalence of headaches if 66%
- tends to decline as reach 40 years old
- affects women more than men
*accounts for 20% of work absences
What are the types of primary head aches?
Primary head ache = Not associated with underlying illness
*90% of headaches
- ex: TTH, Cluster, Migrane (vascular, benign external, cold- stimulus)
what are secondary headaches
symptom of an underlying condition
- ex: medication overuse heachache, sinus headache
what are the disease causes of headaches
Infection
temporal arteritis
subdural hematoma
subarachnoid haemorrhage
cerebral ischemia (stroke)
Transient ischemic attack (TIA)
- systemic/CNS vasculitides
- space occupying lesions
What are the drugs hat cause heachaes as a side efect
ACEIs
BBs
CCBs
H2 antagonists
Nitrates
NSAIDs
Oral contraceptives & HRT
Other antihypertensives
SSRIs
What drugs are associated with Intracranial hypertension?
*intracranial hypertnesion = high pressure around brain
**refer immediately
Antibiotics • Corticosteroids • Other
what characteristics define a heachache
Location of pain
Nature
Onset
Duration
Non-headache symptoms
what are the 4 major types of heachaes and where is each located?
Sinus: behind browbone and/or cheekbones
Cluster: prain is in and around one eye
Tension: pain is like a band squeezing the head
Migrane: pain, nausea and visual changes are typical (full head)
Describe TTH
(nature, severity of pain, location, onset, frequency, duration, aggrevation by physical activity, and non heachae assocaited symptoms)
Nature/Quality: Pressing/tightening (non pulsating)
Severity of painL mild - moderate
Location: bilateral
Onset: gradual
Frequenccy: episodic or chronic
DUration: 30 min - 7 days
Aggrevated by physical activity: No
Associated symptoms: muscle pain radiating along trapezius muscles and scalp
Describe Migrane
(nature, severity of pain, location, onset, frequency, duration, aggrevation by physical activity, and non heachae assocaited symptoms)
Nature/quality: trobbing (pulsating)
Sevarity: moderate - severe
location: unilateral (fronto-temporal)
Onset: sudden
Frequency: episodic or chronic
Duration 4-72 hours
aggrevated by physical acitivty: yes
assocaited symptoms: Either N/V or photophobia, phonophobia
Describe Cluster heachache
frequency, duration, aggrevation by physical activity, and non heachae assocaited symptoms)
Nature/quality: Penetrating/stabbing
Sevarity: excurciating
location: unilateral, orbital or temporal
Onset:
Frequency: episodic or chronic
Duration 15- 180 min
aggrevated by physical acitivty: no
assocaited symptoms: Elacrimation, nasal congestion, forehead/facial sweating, eyelid edema
Describe Sinus headache
(frequency, duration, aggrevation by physical activity, and non heachae assocaited symptoms)
Nature/quality: Pressue behind eyes or face
Sevarity: full, worse in AM
location: bilateral: face, forehead periorbital area
Onset: simultaneous with sinus sx
Frequency: N/A
Duration days
aggrevated by physical acitivty: no
assocaited symptoms: occur w/ sinus sx: purulent nasal discharge/congestion
What is the mosst common type of headache
TTH (stress headache)
- pathophysiology not known
*manfiest bc of mental stress, anxiety, depression, emotional conflicts and other stimuli
*Diagnosed by the absense of features found in other types of headache (no N/V)
characteristics of migrane headaches
- recurrent - occur w/ or wi focal neurologica symptoms (aura)
( migrane with aura occurs twice as frequently as migrane with aura )
*when aura is present (15%) is usually precedes the Ha
- 70% of patients have family histories of migrane
Pain sevarity >> TTH (80% will say the apin is severe)
- ass symptoms: nausea and/or vomitting, photophobia and/or phonophobia
- can cause vertigo, tinnitus light headedness and irritabiliy
What are the 4 phaes of migrane type headaches?
- Prodrome: burtsts of energy, fatigure 48hr before heachache
- Aura: visual or auditory (15% of patients)
- Heache
- Postdrome
what symptoms can migrane headaches cause
- Neasuea and/or vomiting, photo and/or phonophobia
Tinnitus,light headedness, vertigo, irritability
* can be aggrevated by or cause avoidance of routine physical activity
What factors will trigger a migrane headache?
What medications can trigger a migrane headache?
Stress, fatigue, oversleeping, fasting/missing a meal, vasoactive substances in food (MSG), caffeine, alcohol, menses, changes in barometric pressure & altitude
Certain Medications: Reserpine, Nitrates, Oral contraceptives, Postmenopausal hormones
describe the characteristics of a sinus type headache
usually reported in patients with acute sinusitis
*if pain si mroe intense when you bend over/ blow nose it acn indicate sincus HA
- assosicated symptoms: upper teeth toothache, facial pain, nasal stuffiness, nasal discharge
*Prevalance is low: 90% of patients who believe they have sinus HA may actually be experiencing migraine headache
describe the characterisitcs of a cluster headache?
uncommone (0.2%)
- onset 25-50 years old
*• Will have several attacks over a period of time, and then goes into remission for months or years
- Associated symptoms: can cause tearing, nasal congestion, rhinorrhea, forehead/facial swelling, miosis and headahe
* if suspect patient of a cluster headache must refer
how are head aches assessed?
- differential diagnosis: rule out seonccdary cause of HA (need to make sure its priamry)
- no diagnostic tests exist for primary HA- its based on symptoms
- pateitns with occasional TTH do not req futher assessment unless headaches become chronic
How should patients decribe head ache?
SCHOLAR
- S: symptoms
- Red flags: fever, cahnges in vision, sensation and consciouesness
- C: characteristics: quality/sevarity (relative)
- is ti worst pain ever
- History of headaches
- how often do you get?
- age of onset?
- how does it compare to past HA
- change in freq, intensity, duration, location, progression
- Response to prev treatments if any
- family histroy of HA?
- O: onset
- L: Location
- A: aggrevating/ previpitating factors/ triggers
- any relationship with food .alc
- Remitting/ releiving factors
What info should you gather on the patient?
- H: health condations
- HTN? recent rrauma? changes in health/activ
- A: allergies
- M: mediactions
- S: Social: smoking, acl use etc
conditions for emergent head ache referral?
SSNOOPP
S: systemic s/s: fever, N/V, appears ill
S: severe (worse HA of life)
N: neurologic s/s: seizures, stiff neck, changes in vision, mental status, impaired consciouness
O: onset is abrupt of new
O: other ass conditions (trauma)
P: prior HA history: sig change in pattern of HA, inc freq and or progressive severity
P: Pain (unilateral eye), fixed and dilated pupil or diminied vision
Conditions for non emergent HA referral?
- an secondary cause of HA
- chronic TTH or freq migranes
- >8 headaches/month - prophilactic therapy
- Suspected MOH or mediaction-induced headache
- 1st HA ever
- occurance at ngiht or on awakening in morning
- potential signal of brain tumor
- patient >50 with new undiagnosed HA
- Patient >50 and HA assocaited with tenderness in the temporal artery
- ONsert w/ excersie or sexual acitivty
- uncrontolled HTN
- Shingles or post- herpetic neuralgia
- inusitis, otitis media or denal abscess
- pain >6
if a patient presents with headache and says it is:
1st/worst HA, sudden onset, changes in balance, consciousness, mental status, reflexes or sensations, vision fever, one sided weakenss
- refer to ER or urgent care
if pateint present with HA and sas:
chronic or progressive or significant change in HA pattern
- will require medial assessment asap
(not emerge tho)
if patient present with head ahces and says
recurrent or intermittent pattern
- primary headache disorder
- potential candidate for self care
if patient present with tension type headache, what do you do for a intermitent vs chronic HA?
- Intermittenet (<15 days/month)
- nonpharmacologic therapy
- simple analgesics
- Chronic >15 days/month
- evaluate for possible medication overuse headache
if patient presents with migrane, what do you do if it is mild vs moderate/severe?
- Mild
- Non pharmacologic theray
- simple analgesics
- Moderate/Severe
- non pharmacologic therapy
- analgesics, antimetics, ergot derivatives, triptans
- If severe headache has sudden onset/accompanies by severe vomiting or neuologic changes sent to ER
- Reasses if acute therapy not effective
*If HA interefore w/ QOL desipe appropriate use of abortive medications evalute pat for possible prophylactic therapy
what to do is patient presents with cluster type HA
- req medial assessemnt for daignosis
what is patient presents with a medication overuse headache?
- consider management strategies w/ patient
- refer to neurologist/ headache specialist if appropriate
if a patient has a head ache with 2 or more of
- Neasea, light sensitivity, interference with activites
- migrane HA
- if mild/mod and prev diagnosed by physician then self care candidate
* migranes are typically underdiagnosed, consider migrane diagnosis for recurring “sinus” headache
if patient does not have 2 or more of: neasure, light sensitivity, interference w/ activites
but DOES have a bilateral HA, non pulsating pain, mild to moderate pain, not worsened by activity
- tension type head ache
- if episodic in frequency then self care candidate
- if not then refer
what head ahces are self care candidates?
- intermittent TTH
- dianosed, mold-moderate migrane
- sinus headache in diagnosed sinus infection
when shoud you prescribe for a HA?
- mild to moderate TTH not relieved by optimal non rx/self care measures they laready tried -> Rx dose of an NSAID
- Mild to moderate migrane not relieved by optimal nonR/Self care measures already treid -> Rx dose of NSAID or Triptan
* make sure give OTC product a shot
- *if pat have >8/ month strongle consider referral to MD for prophylactic therapy
What are the goals of HA therapy?
- identify the HA source and its severity
- relieve or abolish pain and assoicated symptoms
- prevent recurrent HA symptoms
- prevent complications of mediaction usage/overuse
what are non pharmacologic measures to treat head ache?
- patient education and reassurance
- rest in dark, quiet rom
- Apply cold cloth / ice pack to head
- Avoid bright lights and loud sounds
- Stress management
- Stretching and strengthening of head & neck muscles
- Lifestyle modifications
migrane triggers
food, environmental, chemcial hormonal, drugs or other
8Maintain a headache diary to receord freq of HA, intensity, suspected triggers and effect of treatment
What is the list line of HA treatment (Episodic TTH)
Ibuprofen: 400mg (max dose 1200mg/day)
Aspirin: 100mg (caution Reye’s
Naproxen Sodium: 550 mg
Acetaminophen: 1000mg
Prophylactic HA treatment (episodic TTH)
1st line:
- Amitriptyline: 10-100mg/d
- Nortriptyline: 10-100mg/d
- Mirtazapine: 30 mg/d
- Venlafaxine: 150 mg/d
*dont need to know dosing
What is the treatment for Chonric TTH?
Acute: *all these are 1st line treatment
- Ibuprofen: 400 mg
- aspirin 100mg
- naproxen 500 or 845
- acetaminophen 1000mg
Chronic
- TTH can be treated same way as episodic TTHA but should also be reffered to MD for investiagetion and/or strong consideration of prophylactic treatment
what to prescribe for patient with migrane and severe attacks requring bed rest?
- Triptan
- treat approximately 3 separate attacks befor ejudging effectivenes
- try at least 3 triptans in diff atacks before next step
- *do not use 2 different tripants in the same 24 hours period, do NOT use triptan and DHE in same 24 hours period
- Triptan plus NSAID
- add rescue med if occasional treatment failture: acetaminophen w/ codeine, corticosteroid, prochlorperazine
- *use NSAIDs w/ caution in pat with GI/ cardiovascular disorder
- if that doesnt work: DHE +/- metoclopramide
- if that oesnt work: opiods
- do NOT reccomend for routine use - monitor freq carefully
what to prescribe for patient with migrane but not severe attaches that often require bed rest?
- Acetaminophen, ASA, diclofenac potassium, iburpofen, naproxen
- add triptan as rescue medication if occasional treatment failure or moderate-severe attacks
- triptan
- triptan+ NSAID
- DHE +/- metoclopramide
- opioids
what could you teat refractory migranes with?
combi NSAID + triptan
Summary of treatment of acute migrane
1st line: same as chonic TTH treatment
- Ibuprofen 400 mg
- aspirin 1000mg
- maproxen 500 or 825
- acetaminophen 1000
Second line
- triptans
- domperidone or metoclopramide
Third line
- Naproxen + triptan
Fourth line:
- fixed dose combination analgesics
treatment for mild TTH
moy not be reuqired
when to take mediaction for episodic TTHA & mild-mod migrane attacks
- often respond well to simple analgesics or NSAIDS
- should be taken as soon as HA starts
if can predict occurance (ie during menstration_ take analgesic before and throughout event know to trigger
how can you help to relieve sinus HA
Decongestants facilitate drainage of the sinuses
Concomitant use of nonprescription analgesics and decongestants can relieve the pain of a sinus HA
how do you treat coexisting tension and migrane HA
- treamtent of initiating HA can abort the mixed HA - dont always need to treat both
*review if patient taking suboptimal doses of NDAIDS first before reccommenind congo agent
patients who encounter significant disability during __ or more of their attacks and/or vomiting in ___ of attacks are poor candidates for exclusive nonprescription therapy
patients who encounter significant disability during 50% or more of their attacks and/or vomiting in >20% of attacks are poor candidates for exclusive nonprescription therapy
how long should non prescription analgesics be used for treatment of HA
Use for ANY type of headache should be limited to 3 days per week
* freq/ cont use of non rx analgesics can inc adv side effects and potentially cause medication overuse head aches
what are MOH?
what agents are assocaited?
medication overuse headaches can occur in migrane or TTHA sufferers
- cont HA assocaied with use of analgesic medication for >3 months
- occur within hours of stopping agent
Agents: Acetaminophen • Some NSAIDs • Aspirin • Caffeine • Triptans • Opioids • Butalbital • Ergotamine formulations
*symptomatology shifts from baseline HA to nearly cont HA, particularly noticable on wakening
How to prevent MOH?
- use simple analgesics <15 days/month
- use combo analgesics or opiods < 10 days/month
use ergotamine or tripan meds <10 days/month
* when MOH is suspected use of offending agent(s) shoudl be tapered and subsequently eliminated
*Rx thrapies may be needed to combat inc HAs that temp ensue during withdrawal
DO NOT ABRUPTLY WITHDRAWAL MAY INDUCE SEIZURES
how would you diagnose/ initially assess a MOH
- ergots, triptans, combo analgesics, or coedine or other opiods for 10 days or more
OR
acetaminophen or NSAIDS for 15 or more days
to manage:
- educate patient
- consider prophylactic medication
- provie effective acure med for severe attacks with limitations on freq of use
- fradual withdraw of opioids if used or combo analgesic w/ opidof or barbiturate
- abupt or gradual withdrawal of acet, NSAIDS or triptans
Ha and pregancy/lactation
*1st line would be non pharmacologic measures
- migrans usually improve during pregnancy: if needed occasional acetaminophen
*triptans are contraindicted during pregnancy (do not take)
- TTH do not lessen during pregnancy
*non pharma and occasional acetaminophen is treatment of choice
- Breastfeeding tends to reduce migrane freq
* same as above, but also sumatriptan is comtabible with breastfeeding infrants two or more months of age (data lakcing for toher triptans)
HA in children and adolescents
- acetaminophen and ibuprofen are effective and safe
- triptans can be used: only nasal sumatriptan and almotriptan are officially approved for use in over 12 years of age (but good safety data for all triptans)
^ should be reserved for moderate to severe headaches unresponsive to conventional analgesitcs
when is counselling required for HA
- non pharmacolig management: maintenance of HA dairy
- optimal administration of mediactions: laoding dose for NSAIDs, triptan use and timing if aura present
- TTHA or migrane should be aborted wtihin 2-6 H
- avoidance of MOH
- side effects of chosen treatment
- when initiating prophylactic treatment
Monitoring & follow-up
- TTHA or migraine should be aborted within 2-6 hours of treatment
- Follow up with patient, if possible, 2 hours after medication administration
- Was there significant relief 2 hours after taking the medication?
- Was the medication well tolerated?
- Was only one dose required?
- Could you resume normal activity after taking the medication?
- If prompt follow-up is not possible, ask the above questions when initiating future treatment for new episodes
- If there was no improvement, choose a different treatment option
- Advise patient to report all significant adverse effects
- potential triptan side effects: Chest discomfort or tightness (unrelated to CV issues), Nausea, Facial flushing, Tingling and paresthesia, Dizziness, fatigue, drowsiness
- Encourage patient to keep a headache diary
- Monitor monthly usage of acetaminophen, NSAIDs and triptans to help prevent MOH
When should you monitor for severe, chornic or episodic HA
Severe; within 2-10 days
Chornic: after 4-6 weeks
Episodic: after 6-12 weeks
