Pharm U3 headaches Flashcards
How are headaches diagnosed?
detailed history - attack onset, duration, location, frequency, timing, quality and severity, associated features, aggravating/precipitation factors, ameliorating factors, family history, social history, impact on daily living
what is the most common primary headache?
tension-type
who most commonly presents with migraines?
women
what are the four phases of a migraine?
- prodrome (psychological, neurologic, constitutional, or autonomic features) - hours to days before onset
- aura (5-20 min but less than 60)- complex focal neurological symptoms precedes, accompanies, or follows
- headache
- resolution
features of a migraine headache
unilateral, throbbing, moderate-severe, aggravated by physical activity and relieved by rest - usually 5-12noon, 4-72 hours and associated anorexia, nausea, vomiting, osmo/photo/phonophobia
features of the resolution of migraine headache
headache wanes, person feels tired, washed out and irritable
genetic locus that could be associated with migraines
19p13
aura phase of migraine mechanism
reduction of cerebral blood flow that moves across the cortex at a rate of 2-3mm/min. NOT due to vasconstriction and doesn’t respect cerebral vascular territories
oligemia result of neuronal dysfunction called cortical spreading depression
headache phase of migraine mechanism
activation of trigeminovascular system (constituted by the trigeminal nucleus and sensory nerve fibers from the OPHTHALMIC division of CNV - innervates meningeal blood vessels, large cerebral vessels and venous sinuses
how does the trigeminovascular system cause pain in a migraine?
release vasodilating and permeability-promoting peptides (substance P, calcitonin gene-related peptide) from perivascular nerve endings promoting a sterile inflammation leading to pain
what is the migraine attack mediated by?
presynaptic serotonin (5HG1B-D) receptors (inhibitory G protein linked receptors
migraine treatment choices
non-pharmacological (regular meals, exercise and rest, avoiding provoking factors) then acute or preventive
migraine-specific medications
ergots and triptans
non-specific medications for migraines
analgesics, antiemetics, NSAIDs, steroids, anxiolytics, opiods
analgesics examples for migraines
aspirin, acetaminophen, naproxen, indomethacin, piroxicam, diclofenac, ibuprofen
opiods for migraine - examples and risks
codeine, meperidine, oxycodone, hydromorphone, morphine, methadone, butorphanol - high risk for overuse and development of chronic daily headaches = contraindicated in pregnancy
barbiturates for migraine
never been shown effective - frequent side effects of drowsiness and dizziness - risk for overuse and withdrawal
steroids for migraine
not known how they may work - used for brief periods in prolonged headache states
ergotamine and dihydroergotamine (DHE)
derived from rye fungus, alpha-adrenergic and serotonergic agonist activity (DHE weaker arterial vasoconstrictor) - reduce cell activity in the trigeminovascular system (5HT1 b-d agonists)
side effects of ergotamine and DHE
nausea, vomiting, chest pain, abdominal pain, dizziness - avoided
ergotamine and DHE contraindicated in who?
pregnant women, uncontrolled hypertension, sepsis, renal or hepatic failure, coronary, cerebral or peripheral vascular disease
what is the premier migraine abortive medication?
triptans (all end in triptan)
triptans mechanism
5HT 1b-d agonists that penetrate the CNS causing casconstriction of extracerebral intracranial vessels and inactivation of the trigeminovascular system
triptans side effects and avoided in which patients?
SE: flushing tingling, dizziness, chest discomfort
avoided in: vascular disease, uncontrolled hypertensions and complicated migraine syndromes (hemiplegic migraine)
