Pharm U3 headaches

Question 1

How are headaches diagnosed?

Answer 1

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

Question 2

what is the most common primary headache?

Answer 2

tension-type

Question 3

who most commonly presents with migraines?

Answer 3

women

Question 4

what are the four phases of a migraine?

Answer 4

1. prodrome (psychological, neurologic, constitutional, or autonomic features) - hours to days before onset
2. aura (5-20 min but less than 60)- complex focal neurological symptoms precedes, accompanies, or follows
3. headache
4. resolution

Question 5

features of a migraine headache

Answer 5

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

Question 6

features of the resolution of migraine headache

Answer 6

headache wanes, person feels tired, washed out and irritable

Question 7

genetic locus that could be associated with migraines

Answer 7

19p13

Question 8

aura phase of migraine mechanism

Answer 8

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

Question 9

headache phase of migraine mechanism

Answer 9

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

Question 10

how does the trigeminovascular system cause pain in a migraine?

Answer 10

release vasodilating and permeability-promoting peptides (substance P, calcitonin gene-related peptide) from perivascular nerve endings promoting a sterile inflammation leading to pain

Question 11

what is the migraine attack mediated by?

Answer 11

presynaptic serotonin (5HG1B-D) receptors (inhibitory G protein linked receptors

Question 12

migraine treatment choices

Answer 12

non-pharmacological (regular meals, exercise and rest, avoiding provoking factors) then acute or preventive

Question 13

migraine-specific medications

Answer 13

ergots and triptans

Question 14

non-specific medications for migraines

Answer 14

analgesics, antiemetics, NSAIDs, steroids, anxiolytics, opiods

Question 15

analgesics examples for migraines

Answer 15

aspirin, acetaminophen, naproxen, indomethacin, piroxicam, diclofenac, ibuprofen

Question 16

opiods for migraine - examples and risks

Answer 16

codeine, meperidine, oxycodone, hydromorphone, morphine, methadone, butorphanol - high risk for overuse and development of chronic daily headaches = contraindicated in pregnancy

Question 17

barbiturates for migraine

Answer 17

never been shown effective - frequent side effects of drowsiness and dizziness - risk for overuse and withdrawal

Question 18

steroids for migraine

Answer 18

not known how they may work - used for brief periods in prolonged headache states

Question 19

ergotamine and dihydroergotamine (DHE)

Answer 19

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)

Question 20

side effects of ergotamine and DHE

Answer 20

nausea, vomiting, chest pain, abdominal pain, dizziness - avoided

Question 21

ergotamine and DHE contraindicated in who?

Answer 21

pregnant women, uncontrolled hypertension, sepsis, renal or hepatic failure, coronary, cerebral or peripheral vascular disease

Question 22

what is the premier migraine abortive medication?

Answer 22

triptans (all end in triptan)

Question 23

triptans mechanism

Answer 23

5HT 1b-d agonists that penetrate the CNS causing casconstriction of extracerebral intracranial vessels and inactivation of the trigeminovascular system

Question 24

triptans side effects and avoided in which patients?

Answer 24

SE: flushing tingling, dizziness, chest discomfort

avoided in: vascular disease, uncontrolled hypertensions and complicated migraine syndromes (hemiplegic migraine)

Question 25

what is the injectable triptans?

Answer 25

sumatriptan

Question 26

what are the nasal spray triptans?

Answer 26

sumatriptan and zolmitriptan

Question 27

what are the orally disintegrating triptans?

Answer 27

zolmitriptan, rizatriptan

Question 28

preventive/prophylactic pharmacological therapies for migraine - when and why are they taken?

Answer 28

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

Question 29

what are the major preventive medications for migraine? what are most of these medications?

Answer 29

antidepressants, antihypertensives, antiepileptics

most are off label

Question 30

antidepressants in migraine treatment (which ones)

Answer 30

TCAs amitriptyline, nortriptyline, protriptyline (amitriptyline best); SSRIs fluoxetine, paroxetine, sertraline for coexistent depression and chronic daily headavhe

Question 31

side effects from TCAs

Answer 31

dry mouth, constipation, weight gain, cardiac toxicity, orthostatic hypotension

Question 32

antihypertensives in migraine treatment (which ones)

Answer 32

beta blockers (propranolol, nadolol and atenolol, timolol) and calcium channel blockers (verapamil)

Question 33

which drug is most useful in patients with prolonged or diabling auro and complicated migraine syndromes?

Answer 33

verapamil (calcium channel blocker)

Question 34

antiepileptic drugs in migraine treatment

Answer 34

divalproex sodium and topiramate

Question 35

side effects for divalproex sodium and SE for topiramate

Answer 35

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

Question 36

which drugs is used for treatment of chronic migraines?

Answer 36

botox (onabotulinumtoxinA) - 15+ days a month for more than 3 months in absence of medication overuse

Question 37

tension type headache symptoms

Answer 37

no prodrome, aura. pain is dull, achy, non-pulsatile, pressure-like, bilateral and mild-moderate in severity - rare photo/phonophobia

Question 38

what is a known trigger of tension type headaches?

Answer 38

poor sleep

Question 39

acute pharmacological therapies in tension type headaches

Answer 39

simple analgesics alone or in combination with caffeine, codein, or anxiolytics (careful of medication overuse headache) NSAIDS most effective are naproxen, ketorolac and indomethacin

Question 40

preventive pharmacological therapies for tension type headache

Answer 40

if frequency is 2+ per week, duration is 4+ hours, severity is terrible. antidepressants are preferred with TCAs followed by SSRIs

Question 41

most effective preventive pharmacological therapy for tension type headache

Answer 41

amitriptyline (TCA)

Question 42

cluster headache

Answer 42

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

Question 43

episodic cluster headaches

Answer 43

periods lasting 7 days to 1 year separated by pain-free periods lasting 1 month

Question 44

chronic cluster headaches

Answer 44

more than 1 year without remission or remissions lasting less than 1 month

Question 45

pathophysiology of cluster headaches

Answer 45

ophthalmic division of trigeminal nerve - sympathetic dysfunction and parasympathetic overaction - hypothalamic source

Question 46

acute therapies for cluster headaches

Answer 46

02, sumatriptan SC first line, DHE IM and nasal spray, lidocaine (intranasal agent)

Question 47

prophylactic therapies for cluster headaches: short term

Answer 47

corticosteroids and daily ergotamine

Question 48

prophylactic therapies for cluster headaches: long term

Answer 48

verapamil, topiramate, divalproex sodium and lithium