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)
what is the injectable triptans?
sumatriptan
what are the nasal spray triptans?
sumatriptan and zolmitriptan
what are the orally disintegrating triptans?
zolmitriptan, rizatriptan
preventive/prophylactic pharmacological therapies for migraine - when and why are they taken?
taken every day to reduce the frequency, duration and severity of migraine. recommended for patients with more than 3 sever headaches per month, 2 mild-moderate headaches per week
what are the major preventive medications for migraine? what are most of these medications?
antidepressants, antihypertensives, antiepileptics
most are off label
antidepressants in migraine treatment (which ones)
TCAs amitriptyline, nortriptyline, protriptyline (amitriptyline best); SSRIs fluoxetine, paroxetine, sertraline for coexistent depression and chronic daily headavhe
side effects from TCAs
dry mouth, constipation, weight gain, cardiac toxicity, orthostatic hypotension
antihypertensives in migraine treatment (which ones)
beta blockers (propranolol, nadolol and atenolol, timolol) and calcium channel blockers (verapamil)
which drug is most useful in patients with prolonged or diabling auro and complicated migraine syndromes?
verapamil (calcium channel blocker)
antiepileptic drugs in migraine treatment
divalproex sodium and topiramate
side effects for divalproex sodium and SE for topiramate
divalproex sodium: sedation, hair loss, weight gain, tremor and changes in cognition (also hepatotoxicity, blood dyscrasias, pancreatitis)
topiramate: changes in cognition, paresthesias, weight less, kidney stones
which drugs is used for treatment of chronic migraines?
botox (onabotulinumtoxinA) - 15+ days a month for more than 3 months in absence of medication overuse
tension type headache symptoms
no prodrome, aura. pain is dull, achy, non-pulsatile, pressure-like, bilateral and mild-moderate in severity - rare photo/phonophobia
what is a known trigger of tension type headaches?
poor sleep
acute pharmacological therapies in tension type headaches
simple analgesics alone or in combination with caffeine, codein, or anxiolytics (careful of medication overuse headache) NSAIDS most effective are naproxen, ketorolac and indomethacin
preventive pharmacological therapies for tension type headache
if frequency is 2+ per week, duration is 4+ hours, severity is terrible. antidepressants are preferred with TCAs followed by SSRIs
most effective preventive pharmacological therapy for tension type headache
amitriptyline (TCA)
cluster headache
annual rhythm, same time of day, usually after falling asleepm more males. severe, unilateral, in the temporal, orbital, or supraorbital area, patients are restless and associated with ipsilateral lacrimation, nasal congestion, forehead/facial sweating, miosis, ptosis, eyelid edema, conjunctival injection. onaverage 60-90 minutes
episodic cluster headaches
periods lasting 7 days to 1 year separated by pain-free periods lasting 1 month
chronic cluster headaches
more than 1 year without remission or remissions lasting less than 1 month
pathophysiology of cluster headaches
ophthalmic division of trigeminal nerve - sympathetic dysfunction and parasympathetic overaction - hypothalamic source
acute therapies for cluster headaches
02, sumatriptan SC first line, DHE IM and nasal spray, lidocaine (intranasal agent)
prophylactic therapies for cluster headaches: short term
corticosteroids and daily ergotamine
prophylactic therapies for cluster headaches: long term
verapamil, topiramate, divalproex sodium and lithium
