Pharmacologic Treatment of Headache

Question 1

Triptans: Uses: MOA: Routes of Administration:

Answer 1

Triptans: 1st line treatment during acute attacks Uses: Acute/Abortive treatment of migrane MOA- 5HT 1D/1B agonist (inhibits the release of serotonin and pro-inflammatory neuropeptides) and mediate vasoconstriction through 5 HT-Rreceptors on blood vessels DECREASE cAMP all triptans are given ORALLY. Sumatriptan also has Nasal, SC, and patch routes.

Question 2

Triptans:

Adverse Reactions:

Contraindications:

Answer 2

Triptans:

Adverse Reactions: altered sensations, dizziness, muscle weakness/fatigue, neck pain, chest pain, transient MI (arrthyhmias- in patients with risk factors) and acute increase in BP

Contraindications: Severe hepatic disease, Peripheral vascular disease, Renal Disease

Question 3

Ergot Alkaloids:

Uses:

MOA:

Routes of Administration

Answer 3

Ergot Alkaloids:

highly specific for migrane pain. most helpful when given during the prodrome

Uses: acute/abortive treatment of migrane- 2nd line after triptans

MOA: partial agonist, and antagonist properties at alpa-adrenergic receptors, dopamine, and serrotonin receptors

Routes of Administration: sublingually- can be combined

with caffine for greater absorption. DHE (dihydroergotamine) can also be given via nasal spray, IV, SC, or IM. it has a more mild adverse effect profile

Question 4

Ergot Alkaloids:

Adverse Drug Reactions:

Contra Indications:

Answer 4

Ergot Alkaloids:

Adverse Drug Reactions: GI N/V/D most common, lead weakness and muscle pain, numbness and tinglinging in extremities. PERIPHERAL ISCHEMIA. prolonged vasospasm→gangrene (in overdose).

**remove drug and treat with anticoagulants, low-molecular weight dextran and potent vasodialators

Contra Indications: Coronary artery disease, peripheral ascular disease, HTN, impared hepatic or renal function, Sepsis, PREGNANCY (will induce premature uterine contractions)

Question 5

NSAIDS

Use:

Prolems associated with prolonged use:

Answer 5

NSAIDS

Use: Use if the frequency of migrane isn’t enough to warrent a prescription for triptans

Prolems associated with prolonged use:

Medication Overuse Headache- headache that occurs 15+ times/month as a consequene of regular use of acute or symptomatic headache medication . Treatment: stop the offending medication

Question 6

Anti-emetics

Answer 6

anti-emetics can be administered parenterally as a monotherapy for acute migraine. They can also be administered in the ER to treat the N/V symptoms associated with migraines.

Anti-emetics can also be administered as adjunctive therapy in combination with NSAIDs, or Sumatriptan

Question 7

Botulinium Toxin A

use:

MOA:

Route of administration

Answer 7

Botulinium Toxin A

use: FDA approved for PROPHYLAXIS of Chronic Migraines

MOA: (if anyone looking at these knows this please add it here)

Route of administration: IM injections every 12 weeks. 31 injections in 7 areas.

Question 8

Beta Blockers

use:

Contraindications:

Answer 8

Beta Blockers:

• olol
  use: prophylaxis of migrane (not FDA approved)

Contraindications: smoking, erectile dysfunction, PVD, Reynaud’s disease, Low BP, Asthma, Diabetes

**Can take up to 3 months to see improvement

Question 9

Chronic Migraine:

Treatment:

Answer 9

Chronic Migraine is defined as 15+ headache days/month lasting more than 4 hours

Treatment:

Botox

propranolol

amitriptyline (anti-depressant)

topiramate (anti confulsant)

Question 10

Cluster Headache:

Treatment:

1. First Line
2. 2nd Line
3. Preventative

Answer 10

Cluster Headache: pain is often around the eyes and patient may wake up often in the middle of the night

Acute Treatment:

1. First Line:
   
   1. Triptans (SC) and 100% oxygen (hospital setting)
2. 2nd Line
   
   1. Octreotide (somatostatin analog)
   2. Lidocaine
   3. Ergotamine/DHE
3. Preventative
   
   1. Verapamil (DOC)

Question 11

Tension Headache:

Treatment:

1. Acute
2. Preventative

Answer 11

Tension Headache: bilateral, may be once or a few times a week or continuous for several days

Treatment:

1. Acute: Analgesics/NSAIDS
   
   1. +/- caffine **risk of developing overuse headache
2. Preventative
   
   1. Amitriptyline
   2. Venlafaxine
   3. Topiramate

**the use of antidepressants is most likely also treating the underlying stress/anxiety that brings on the tension headache